Taking Steps to Control and Prevent Diabetes Zaida Belendez, ND, RN

Taking Steps to Control and Prevent Diabetes Zaida Belendez, ND, RN Diabetes is a common, serious, and costly disease condition of elevated blood glucose (high blood sugar) that causes significant illness and early death in the general population. People with diabetes are two to four times more likely to have a stroke or heart attack. Recent research indicates that lifestyle change may be a powerful tool in managing and preventing this serious disease. Is it Type 1 or Type 2? Diabetes mellitus is disease caused by the body s inability to produce or properly use insulin. Insulin is a hormone, produced by the pancreas, required by the body to convert sugar, starches, and other food into energy. There are three types of Diabetes mellitus: Type 1 diabetes is a disease in which the body does not produce any insulin. This form occurs frequently in children and young adults and accounts for 5%-10% of all diabetes cases. Persons with type1 diabetes must take daily insulin injections to stay alive. Onset is generally abrupt. Type 2 diabetes is a disorder resulting from the body s inability to make enough, or properly use insulin. This is the most common form of diabetes, accounting for 90%-95% of all cases. Onset is often gradual, and symptoms can be difficult to distinguish from other illnesses. People may have had diabetes for 10 years and may have serious complications before actually being diagnosed. Symptoms of Type 2 diabetes usually develop gradually and may include: o Fatigue or nausea o Frequent urination o Unusual thirst o Weight loss o Blurred vision o Frequent infection o Slow healing of wounds o Or no symptoms at all Primary interventions are a healthy diet and exercise. Gestational diabetes is a form of glucose intolerance that is often diagnosed in women during the 24 th to 28 th week of pregnancy. Treatment varies, in some cases insulin is required to normalize maternal blood glucose level, in others, diet and frequent monitoring of blood glucose levels is recommended. Treatment prevents both infant and maternal complications. Approximately 5-10% of women with gestational diabetes are diagnosed with Type 2 diabetes after pregnancy, and 20-50% develop Type 2 diabetes within the next 5-10 years. AGRICULTURE & NATURAL RESOURCES FAMILY & CONSUMER SCIENCES 4-H/YOUTH DEVELOPMENT RURAL & ECONOMIC DEVELOPMENT

In the United States, 17 million people (6.2 % of the population) have diagnosed diabetes and in Kentucky, the number most currently reported is 198,052 (6.5%). In addition, 5.9 million people in the US may not be diagnosed and therefore do not receive medical attention. For Kentuckians, the number of undiagnosed cases is 99,026 (3.2%). (Kentucky Diabetes Control Program) In 1999, diabetes was the sixth leading cause of death listed on US death certificates. (Diabetes Information Clearing House) Reducing early deaths and illness and improving the quality of life for people with diabetes is a major public health goal. The impact of adult onset diabetes is currently increasing; the average age of onset of Type 2 diabetes is 51 years, but during the 1990s, many people in their 20s and 30s were diagnosed with Type 2 diabetes. Even more disturbing is that there has been a ten-fold increase of the number of children with Type 2 diabetes in the last five years. This reflects a modern lifestyle with less physical activity and more food consumption than in the past. Kentucky as a whole is embracing this modern dilemma of too many calories and too little activity and our statistics reflect it. Kentucky s statistics paint a sobering picture: Kentucky ranks 1 st in the nation in percentage of adults who report no physical activity in the last month. Kentucky ties for 2 nd in the nation in the percentage of overweight adults based on reported height and weight. One in every two Kentuckians (1,523,475) is at increased risk for developing diabetes because of the risk factors of age, obesity and sedentary lifestyle. Kentucky ties for 15 th in the United States in terms of diabetes prevalence. One in every 10 adults in Kentucky has diabetes, one third of who are undiagnosed. (BRFSS, 2000) (Kentucky Diabetes Control Program) Diabetes disproportionately affects special populations such as Native American, African Americans, and Latinos. In Kentucky, 8.5% of African Americans had diagnosed diabetes compared with only 5.9% of white Kentuckian. o African American woman are estimated to be at even greater disadvantage when compared with males of both races and white females. o Diabetes in Kentucky is the fourth leading cause of death in African American females. o One out of every five black women age 55 or older in Kentucky is thought to struggle with diabetes. (KY Diabetes Control Program) For Latinos, the prevalence nationally is two times higher than non-latino whites. o About 24% of Mexican Americans in the US and 26% of Puerto Ricans between the ages of 45-74 have diabetes. Although local statistics are not available for Latinos in Kentucky, it is a rapidly growing population in the state. Large numbers are settling permanently, will become older, and need access to information and medical services. Many barriers exist for these special populations, including lack of insurance and cultural and linguistically appropriate services. (ADA) Diabetes was once viewed as inevitable. One was doomed to having diabetes if a parent or close relatives had been diagnosed. Once diagnosed, all the accompanying consequences of shortened lifespan, blindness, limb amputations, cardiovascular, and kidney disease were sure

to follow. Recent research has changed this grim outlook. Two major studies, the Diabetes Control and Complications Trial (DTTC) and the United Kingdom Prospective Diabetes Study (UKPDS) have established the benefits of tight control of blood glucose levels for prevention of complications. Prevention of complications has emerged as critical in managing the future disease burden of this chronic and economically costly disease. Making the Link with Cardiovascular Disease Cardiovascular disease poses the greatest threat to people with diabetes, killing 75% of diabetics. Traditional means of diabetes treatment have tended to focus on the management of blood glucose only. Diabetic patients tend to treat heart disease as a separate concern. Cardiovascular risk may be ignored even though high blood pressure and lipid abnormalities are present in the majority of people with diabetes. This means that people with diabetes are two to four times more likely to have a stroke or heart attack than are people without diabetes. Because diabetes can cause severe nerve damage to the heart, diabetics often experience painless heart attacks that are harder to diagnose and more likely to be fatal. Moreover, diabetes is a major reason for the higher incidence of cardiovascular disease in American minority groups. Controlling blood glucose levels and concurrent cardiovascular risk factors, such as abnormal lipid profiles, high blood pressure and tobacco cessation will lead to reducing risk for heart disease and strokes in all type 2 diabetes patients. (Closing the Gap) Diabetes can be Prevented! The previous studies on diabetes that demonstrated the positive effects of strict blood glucose control led to a major clinical trial to prevent diabetes, the Diabetes Prevention Program (DPP). Study participants in the DPP were overweight (A body mass index (BMI) over 25) and had blood glucose levels above normal but not at diabetic levels. This study demonstrated that modest weight loss (7% weight loss) and physical activity (150 minutes per week) can delay and even prevent the onset of diabetes in persons who demonstrate risk, but are not yet diagnosed. (National Diabetes Information Clearing House) The DPP determined that glucose levels above normal, but below diabetic indicate the likely future occurrence of diabetes. This condition of near diabetic blood glucose levels is called prediabetes. People with pre-diabetes are at high risk for Type 2 diabetes. About 16 million people in the US, ages 40 to 74, have pre-diabetes. Since this includes the baby boomers, a large demographic group that is in the 45-55 age range, the issue is getting critical. About 11% of people with pre-diabetes develop Type 2 diabetes during an average 3 years of follow-up. Most people with pre-diabetes develop Type 2 diabetes within 10 years. (ADA) (NDICH) Just 30 minutes a day of moderate physical activity, coupled with a 5-10% weight loss, produced a 58% reduction in diabetes. All men and women over the age of 45, particularly those who are overweight, should be screened on a yearly basis for diabetes and pre-diabetes. Those overweight and under the age of 45 should be assessed if they have any of the following risk factors: o A family history of diabetes o Low HDL cholesterol and high triglycerides, o High blood pressure o History of gestational diabetes

o Gave birth to a baby who weighed more than 9 pounds o Belong to a racial minority group. If any of the above risk factors are present, screening should be carried out as part of a health care office visit. The laboratory screening tests for diabetes or pre-diabetes are the same: A fasting plasma glucose test (FPG). This blood test is usually done in the morning after you have not eaten for at least 12 hours. If your blood glucose level is abnormal (above 110 mg/dl or less than 126 mg/dl) following the FPG, you have impaired fasting glucose (IFG). Or a 2-hour oral glucose tolerance test (OGTT). You fast for eight hours before the test and are given a specially formulated sweet drink at the doctor s office. Blood is drawn at one hour and then at 2 hours after consuming the drink. If results indicate your blood glucose level are abnormal (greater than or equal to 140mg/dl and less than 200 mg/dl), you have impaired glucose tolerance (IGT). Both conditions are considered pre-diabetic. DIABETES 126 mg/dl DIABETES 200 mg/dl <126 mg/dl 110 mg/dl <110 mg/dl PRE- DIABETES NORMAL <200 mg/dl 140 mg/dl <140 mg/dl PRE- DIABETES NORMAL FPG OGTT Individuals who test positive for either diabetes or pre-diabetes should be re-screened on another day to confirm the diagnosis. If the results are in the normal range, individuals should be re-screened every three years. If the individual is diagnosed with pre-diabetes: They should be given counseling on weight loss and increasing physical activity. Monitoring for development of diabetes should be done every 1-2 years. Close attention and appropriate treatment given for cardiovascular risk factors. These include tobacco use, elevated blood pressure, and high lipid profiles. (Diabetes Care, volume 25, number 4, April 2002.) Healthy Kentuckians 2010

In spring 2000, Healthy Kentuckians 2010, the state prevention initiative to increase the years of healthy lives and eliminate health disparities in Kentucky, was published. It set many goals for slowing the rise of diabetes and preventing complications. The umbrella goal that would affect all others is as follows: 18.2 Decrease the rate at which the prevalence of diagnosed diabetes is climbing so that it reaches no more than 6 percent of the population 18 years and older. Implementation Strategy for the Department of Public Health Collaborate and participate with state cardiovascular programs and partners such as American Heart Association, Department of Education, and Kentucky Diabetes Association to implement activities in the areas of nutrition, physical activity, and tobacco control. Stay informed about, and be prepared to assist Kentucky in implementing the findings of the diabetes prevention trials now in progress. The Diabetes Prevention Trial - 1(DPT-1) is attempting to prevent the onset of Type 1` diabetes. The Diabetes Prevention Trial- 2 (DPT-2) is attempting to prevent the onset of Type 2 diabetes. This goal is currently not being met. Current prevalence of diagnosed diabetes in Kentucky is 6.7%, well over the proposed ceiling of 6% for the year 2010. (BRFSS, 2001) In spring of 2000, when Healthy Kentuckians 2010 was published, results of the Diabetes Prevention Trial- Type 2 (DPT-2) were not in. With that study completed, there is conclusive evidence that simple lifestyle intervention of modest weight loss and daily physical activity can delay and possibly prevent the onset of diabetes for people who are at high risk of developing diabetes. We can roll back the epidemic of diabetes with awareness and prevention. Just 30 minutes a day of moderate physical activity, coupled with a 5-10% weight loss, produced a 58% reduction in diabetes. What Can Extension Do? County Extension agents are positioned to work as leaders and with partners to: Increase awareness about diabetes risk factors and understanding about pre-diabetes Promote health care access through infrastructure development o promote the need for more certified diabetes educators o promote use of lay community health workers (such as the SkyCap or HomePlace programs) to link patients to health care services and insurance Promote environmental community programs to increase physical activity Develop individual lifestyle programs that help promote weight loss and physical activity Demonstrate the benefit of individual fitness through our own commitment to better health for ourselves and fellow Kentuckians. What is your Story? The key to motivating individuals to move beyond denial and apathy is to personalize the issue. Take the ADA Risk Assessment Test and see if you need to be working with your healthcare team to reduce your risk of diabetes. Be part of the process both personally and as part of the community.

Take steps to reduce your risk of Type 2 diabetes. Just 30 minutes a day of moderate physical activity, coupled with a 5-10% weight loss, produced a 58% reduction in diabetes. Keep your eyes open for the following state and national campaigns: University of Kentucky Extension will be developing a video called What is your story? about the risks for and prevention of diabetes. We will also target development of programs that can address minority, low resource and limited English proficiency audiences. The Kentucky Diabetes Control Program located at the State Department of Public Health has now become the Diabetes Prevention and Control Program. DPCP has developed and will soon release a curriculum called The Power of Prevention which includes multimedia presentations and brochures. Extension s role could be to partner with the health departments to present this curriculum and provide or promote lifestyle change classes, including support groups, physical activity groups and events, cooking classes. The National Diabetes Education Program will release a program called Small Steps, Big Rewards. Providing yet another opportunity for Extension to partner with the health departments, state and local diabetes coalitions for wrap around events and classes. Take steps to promote wellness and prevent diabetes and its complications. References American Diabetes Association. About Pre-Diabetes. Available online at: http://www.diabetes.org/main/info/pre-diabetes.jsp?wtlpromo=search_diabetes_prediabetes American Diabetes Association. Complete Guide to Diabetes, 3 rd Edition. Port City Press. 2002. National Diabetes Education Program. Diabetes Overview Fact Sheet. Available online at http://ndep.nih.gov or http://www.cdc.gov/diabetes. Kentucky Department of Public Health. Kentucky Diabetes Fact Sheet. Diabetes Control Program. American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases Position Statement. The Prevention or Delay of Type 2 Diabetes. Available online at: http://care.diabetesjournals.org/cgi/reprint/25/4/742.pdf National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes Prevention Program (DPP). National Diabetes Information Clearinghouse. Available online at: http://www.niddk.nih.gov/health/diabetes/summary/dpp/dpp.htm. National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics. National Diabetes Information Clearinghouse. Available online at http://www.niddk.nih.gov.healht.diabetes/pubs/dmstats/dmstats.htm Office of Minority Health. Closing the Gap: Recognizing the Link Can Save your Life. Diabetes and Health Disease. Available online at http://www.omhrc.gov/ctg/ctg-oct-2002.pdf

Zaida Belendez, ND, RN, is an Assistant Professor and Extension Health Specialist with the University of Kentucky department of Family & Consumer Sciences and the Kentucky School of Public Health, Lexington, Kentucky. Educational programs of the Kentucky Cooperative Extension Service serve all people regardless of race, color, age, sex, religion, disability, or national origin. Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, M. Scott Smith, Director of Cooperative Extension Service, University of Kentucky College of Agriculture, Lexington, Kentucky. Copyright 2003 for materials developed by the University of Kentucky Cooperative Extension Service. This publication may be reproduced in portions or its entirety for educational or non-profit purposes only. Permitted users shall give credit to the author(s) and include this copyright notice. Publications are also available on the World Wide Web at: http://www.ca.uky.edu. Issued 3-2003, last printed, XXXX copies, xxxx copies to date.