Diabetes Mellitus

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Diabetes Mellitus

• PRESENTED BY
• Folasade Adesina
• Michael Itidiare
• Nicole Lafortune
• Sophia Laguer
• Lauren Young
• Ali Zaidi
• SPECIAL THANKS TO
• Dr. Aliya Brown

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• Diabetes mellitus is a disease characterized by
  persistent hyperglycemia (high blood sugar
  levels). It is a metabolic disease that requires
  medical diagnosis, treatment and lifestyle
  changes.

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Problem

• Although many resources and programs have been
  established to decrease the prevalence of
  diabetes, diabetes is still increasing in the
  African American community

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Question

• Is the prevalence of diabetes within the African
  American community more linked to their
  socioeconomic status or genetics?

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What Are the Two Types of Diabetes

• Type I Diabetes
• Type II Diabetes

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• Type I Diabetes An autoimmune disease in which
  the pancreas makes little or no insulin,
  resulting in an abnormally high blood sugar
  level. Formerly known as insulin-dependent
  diabetes or juvenile diabetes
• Type II Diabetes insulin is present but doesn't
  work adequately. Usually occurs over the age of
  30 and is controlled by diet and medication or
  diet and insulin. Also known as non insulin
  dependent and maturity onset diabetes.

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Comparison in Type I and Type II Diabetes
Type I Type II Type I Type II Type I Type II
Onset primarily in childhood and adolescence Onset predominantly after 40 years of age
Often thin or normal weight Often obese
Prone to ketoacidosis No ketoacidosis
Insulin administration required for survival Insulin administration not required for survival
Pancreas is damaged by an autoimmune attack Pancreas is not damaged by an autoimmune attack

Absolute insulin deficiency Relative insulin deficiency and/or insulin resistance
Treatment insulin injections Treatment (1) healthy diet and increased exercise (2) hypoglycemic tablets (3) insulin injections

Increased prevalence in relatives Increased prevalence in relatives
Identical twin studies lt50 concordance Identical twin studies usually above 70 concordance

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Diagnosis

• Diagnosed and undiagnosed diabetes in African
  Americans, U.S, 1996 2006.

Mortality rates in African American and white
diabetic men and women
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Risk Factors

• A family history of diabetes. If a parent or
  sibling in your family has diabetes, your risk of
  developing diabetes increases.
• Age over 45
• Race or ethnic background. The risk of diabetes
  is greater in Hispanics, blacks, Native Americans
  and Asians.
• Being overweight. If you are overweight, defined
  as a body mass index (BMI) greater than 25.
• Hypertension. High blood pressure increases the
  risk of developing diabetes.
• Abnormal cholesterol levels. HDL ("good")
  cholesterol levels under 35 mg/dL (milligrams per
  deciliter) and/or a triglyceride level over 250
  mg/dL increases your risk

A person with some or all of the above listed
risk factors may never develop diabetes, but your
chances increase the more risk factors you have.
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Obesity is a factor!!!

• To determine whether or not a patient is
  overweight or obese doctors use the body mass
  index.
• body mass index (BMI) provides a relative measure
  of weight adjusted for the respective height.
• More and more people are becoming affected with
  diabetes because nations are switching to a
  westernized (American) lifestyle that emphasizes
  rich foods and sedentary living
• In the U.S. one of three Americans are obese
  33, and two of three, 67 of teenagers are at
  risk of becoming obese and developing diabetes
  because of little or no vigorous physical
  activity.

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Affect of Obesity on Diabetes

• In the normal process of food metabolism, sugar
  called glucose enters the bloodstream.
• Glucose is a source of fuel for the body.
• An organ called the pancreas makes insulin. The
  role of insulin is to move glucose from the
  bloodstream into muscle, fat, and liver cells,
  where it can be used as fuel.
• When an individual is obese food metabolism is
  slowed down because of lack of exercise causing
  the sugar production to be produced and a large
  quantity is built up within the body more than
  the human body can handle
• Making it difficult for the pancreas to regulate
  the normal amount of blood sugar needed in the
  body, resulting in type II diabetes.
• THE MORE OVERWEIGHT OR OBESE YOU ARE, THE GREATER
  YOUR RISK OF DIABETES!!

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Prevalence of Diabetic Patients and Obesity

• In 2003 the Journal of American Medical
  Association reported statistics that show the
  correlation between obesity and diabetes within
  the United States.
• They reported that obesity climbed from 19.8 in
  American Adults to 20.9 between 2000 and 2001.
  Within that same time frame the diagnosed cases
  of diabetes increased from 7.3 to 7.9.

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Obesity Vs. Diabetes
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Diabetes in Impoverished Communities

• Poverty has been under recognized as a
  contributor to the prevalence of type 2 diabetes
• Low socioeconomic status within minority
  populations appear to particularly be affected by
  overweight and obesity
• -- this is due to low education of proper
  nutrition and the dangers of disease
• -- with little or no knowledge of a proper
  diet, poorer people are more likely to eat high
  calorie junk food and exercise less.
• Also in such communities, they cannot afford
  proper health care and do not seek regular
  physician assistance.
• -- increasing the risk of the development of
  obesity leading to diabetes, hypertension,
  heart disease and much more.
• People with less than a high school education had
  higher rates of both obesity 27.4 and diabetes
  13 than people who had a high school education
• Information from Behavioral Risk Factor
  Surveillance System (BRFSS), a state-based
  telephone survey that collects information from
  adults aged 18 years or older. For this survey,
  participants were asked about their height and
  weight and if they had ever been told by a doctor
  that they had diabetes.

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Diabetes is Also Genetic
Diabetes is a hereditary disease. The genes
that make an individual susceptible to get
diabetes is passed from one generation to the
next. However, the risk of getting diabetes is
passed on NOT the disease itself. First
generation relatives have a higher risk of
developing type I diabetes than people whom do
not have any past history of diabetes in their
respective families. In type II diabetes
studies have shown that the first generation are
at about 3X more likely to get diabetes than
those without. Also with identical twins,
rates of diagnosing diabetes within sets range
from 60-90, which is significantly higher than
fraternal twins , proving a strong genetic
correlation.
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Genetic Statistics
KEY
Female Male Female Diabetic Male Diabetic
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African-Americans and Community

• Most African Americans with diabetes have Type 2,
  which develops in adulthood and requires
  treatment with some combination of exercise,
  proper diet, medication and injected insulin
• African Americans are 1.8 times more likely to
  have diabetes than other ethnicities.
• Obesity has reached near epidemic proportions in
  the United States. The prevalence of obesity is
  high among African Americans, particularly
  African American women, making them at high risk
  for developing diabetes.
• The proportion of African American women who are
  obese is 80 percent higher than the proportion of
  men who are obese. When compared to non-Hispanic
  white women, 69 percent of African American women
  are overweight or obese.
• The prevalence of obesity increases up to age 60
  after which there is a decline
• Klauer, J., Aronne, L. J., (2002). Managing
  Overweight and Obesity in Women. Clinical
  Obstetrics Gynecology, 45(4), 1080-1088.
• American diabetes association

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African Americans Diabetes Genetics Theory

• Some researchers believe that African Americans
  inherited a "thrifty gene" from their African
  ancestors. Such a gene might have initially
  enabled Africans to use energy more efficiently
  when food was scarce. The theory is that today,
  without "feast and famine" cycles, the thrifty
  gene may make African Americans more likely to
  develop type 2 diabetes.
• Other study results found that African Americans
  had the highest rates of both obesity 31.1 and
  diabetes 11.2 compared with other ethnic
  groups.
• National Diabetes Information Clearinghouse,
  "Diabetes in African Americans,"
  (http//www.niddk.nih.gov/health/diabetes/pubs/afa
  m/afam.htm).

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Prevalence of Diabetes by Race

• Whites 13.1 million, or 8.7 of all non-Hispanic
  whites aged 20 years or older have diabetes.
• Blacks 3.2 million, or 13.3 of all non-Hispanic
  blacks aged 20 years or older have diabetes.
  After adjusting for population age differences
• Non-Hispanic blacks are 1.8 times as likely to
  have diabetes as non-Hispanic whites.
• Diabetes results in death for 20 percent more
  African American men and 40 percent more African
  American women than whites.
• Twenty-five percent of African Americans between
  the ages of 65 and 74 have diabetes.
• One in four African American women over 55 years
  of age has diabetes.

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Comparison of Diabetes Frequency by Race and Age
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Hunterdon and Camden County

• Type I diabetes affects 5-7.5 of the US
  population in Camden County, New Jersey.
• Diabetes affects the members of Hunterdon County,
  New Jersey at a rate of 5.4.

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Diabetes in The United States
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Type I in the United States
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Type II in the United States
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Diabetes in South Africa Genetics Vs Culture

• Projected statistics for South Africa reveal a
  rapid increase in the incidence of diabetes
  especially with urbanization of the African
  populations.
• For the people of South Africa the increase in
  the rate of diagnosed diabetes is because of
  people opting to live a lifestyle similar to that
  of the United States, which emphasize more eating
  habits and little to no exercise.

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By 2025, the number of people with diabetes is
expected to more than double in Africa, the
Eastern Mediterranean and Middle East, and
South-East Asia, and rise by 20 in Europe, 50
in North America, 85 in South and Central
America and 75 in the Western Pacific.
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FACTS

• 7.8 million (8.3) of all men in the US have
  diabetes
• 9.1 million (8.9) of all women in the US have
  diabetes
• About ½ of all diabetes cases occur in people
  over the age of 55
• -- The risk for Type 2 increases with age
• 2.8 million (13) of African Americans have
  diabetes
• 105,000 Native Americans and Alaska Natives
  (15.1) have diabetes

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Diabetes - "The Silent Killer"

• Heart disease leading cause of diabetes
  related deaths
• -- 2 to 4 times higher in adults with
  diabetes
• Stroke risk is 2 to 4 times higher among
  people with diabetes
• 73 of adults with diabetes have high blood
  pressure or hypertension
• Leading cause of blindness among adults 20-74
  years old
• Diabetic nerve related disease
• -- leads to lower-extremity amputations
• Complications during pregnancy

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Prevention

• TYPE 1 - Juvenile Diabetes
• No known methods to prevent Type 1 diabetes
• TYPE 2
• Lifestyle Changes
• - - Diet, physical activity

AFRICAN AMERICANS ARE AT A HIGHER RISK FOR TYPE 2
DIABETES AND BEING OVERWEIGHT INCREASES THEIR
RISK.
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Managing Type 1

• Proper diet
• -- lots of fruits, vegetables, whole grains
• -- broils meats (poultry and fish)
• Exercise
• -- varies with age

-- proper diet and exercise must be balanced to
avoid risk of hypoglycemia (low blood sugar) and
hyperglycemia (high blood sugar)

• Insulin Injections
• Home sugar monitoring

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Keys to Healthy Diet

• Balance and moderation
• Reduce portion size
• -- Split restaurant meals or have the other
  half wrapped to go
• Physical Activity
• -- 60 mins every day for children
• ex hopscotch, basketball, dance
• -- 30 mins every day for adults
• ex. walk, dance

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Is Money a Problem?
MAKE A HEALTHY LIFESTYLE A FAMILY AFFAIR

• Plan ahead. Make a list of meal ideas for the
  coming week
• Buy in season fruits and vegetables
• -- Prefer local farmer markets (foods
  fresher and cheaper)
• Purchase canned frozen fruits and vegetables
  when fresh ones are not affordable
• Stock up on sale items
• Assemble snacks at home in small baggies and
  use foods healthy foods
• -- nuts seeds
• -- low fat cheese
• -- fresh fruits vegetables

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Diabetes Related Services
Weigh to Go -- 4 wk. weight management group
for kids age 10-14 (fee 90) Smart Cart --
Personal Grocery Shopper (fee 30) Shapedown
Childrens Weight Management Program (6-18 years
of age) -- 10 wk. program that promotes
changes in food habits, exercise, self-esteem and
weight Diabetes Fitness Program -- 6 sessions
over a 2 wk. period (fee 164) Yoga
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Diabetes Education Programs
CAMDEN COUNTY VS
HUNTERDON COUNTY
Facility Hunterdon Medical Center Program
Diabetes Health Center
Facility Virtua Health Program Virtua Camden

• Diabetes Self-Management Education Group
• Individual Nutrition Counseling
• Pregnancy Diabetes Counseling
• Community Lectures
• Support Groups
• Syringe Disposal Program
• Glucose and Foot Screenings
• vHealthHighway
• -- Monthly email of wellness articles

• Individual and Groups Sessions
• Nutrition Counseling
• Insulin Pump Classes and Support
• Student with Diabetes School Program
• Yoga for People with Diabetes
• Safe Syringe Disposal Program
• Stress Management Program
• Diabetes Fitness Program
• Group Home Instruction
• Speaker Services

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If both areas offer very similar programs, why is
there such a huge disparity in the prevalence of
diabetes in each area?
City of Camden in Camden County
City of Flemington in Hunterdon County
Est. Pop in 2003 80,089 Median Household Income
23,421 Ancestry Family History African
American - 53 Puerto Rican - 29 Other
Hispanic or Latino - 4 Sub-Saharan African -
2 African - 2 West Indian (excluding Hispanic
groups) Support for Libraries Local gov.
funding was below national average in
2001-2002 Education 5 of residents age 25 or
older have a bachelors or advanced college degree
Est. Pop. in 2003 4,234

Median
Household Income 39,886 Ancestry Family
History African American - 3 Puerto Rican 7
Other Hispanic or Latino West Indian (excluding
Hispanic groups) - 1 Support for Libraries
Local gov. funding was above the national average
in 2001-2002 Education 27 of residents age 25
and older have a bachelors or advanced college
degree
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Comparison between the city of Camden and
Flemington
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Treatment Focus for Type 1

• Pathophysiology
• -- The pancreas does not produce insulin
• -- This is an autoimmune disease
• -- develops because the body destroys the beta
  cells in the islet tissue of the pancreas that
  produces insulin.
• So the main treatment goal for Type 1 diabetes is
  giving supplemental insulin.

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Treatment Focus for Type 2

• Pathophysiology
• Insulin resistance, which is a condition in which
  body cells do not fully respond to the action of
  insulin
• Your pancreas does not make enough insulin
• So the treatment goal for Type 2 Diabetes is
  increase bodys sensitivity to insulin and reduce
  sugar intake.

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Pharmaceutical Agents for Type 1

• Insulin- a hormone produced in the pancreas that
  allows sugar to enter body cells, where it is
  used for energy. It also helps store extra body
  sugar in muscle, fat, and liver cells.
• Sources of Insulin
• -- Pigs
• -- Cow
• -- Recombinant DNA

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The Almighty Insulin

• Insulin has to enter the body's bloodstream to be
  effective. This is accomplished through
  injections into the fat layer usually in the arm,
  thigh, or abdomen.
• The timing of insulin injections is very
  important. Insulin usually needs to be
  administered before mealtimes.

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Alternative Ways of Administering Insulin

• Injection aids
• Insulin pens
• Insulin jet injectors
• An inhaled insulin delivery system
• Subcutaneous infusion
• External insulin pumps

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The Insulin Pump

• An insulin pump is a small mechanical battery
  operated device that is about the same size as a
  pager or cell phone.  The insulin pump is made of
  a durable plastic that will withstand the wear
  and tear that is required in daily activity. 

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Waiting to InhaleThe Insulin Inhaler

• The FDA approved Pfizer's Exubera, the first
  inhalable form of insulin for diabetics in Late
  January of this year.
• Exubera is a dry, powdered form of insulin that
  is inhaled into the lungs. This is the first new
  form of delivery since diabetics started
  injecting insulin in the 1920s.

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Pharmaceutical Agents for Type 2. Cont.

• Biguanides-They lower blood sugar by decreasing
  the amount of sugar produced by the liver.
• -- Metformin (Glucophage)
• Alpha Glucosidase Inhibitors- block the enzymes
  that digest the starches you eat. This action
  causes a slower and lower rise of blood glucose
  through the day, but mainly right after meals.
• -- Miglitol (Glyset)
• -- Acarbose (Precose)

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Pharmaceutical Agents for Type 2

• Thazolinediones- They improve the way cells in
  the body respond to insulin by lowering insulin
  resistance.
• -- Piglitazone (Actos )
• -- Rosiglitazone.
• Sulfonylureas- work by causing your pancreas to
  release more insulin into the bloodstream. this
  way it lowers blood sugar and helps the way you
  use food to make energy.
• -- glipizide,
• -- tolazamide,
• -- glyburide.

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TLC Please!!! Therapeutic Lifestyle Changes

• Diet
• Of all racial groups, African Americans have
  the most difficulty in eating diets that are low
  in fat and high in fruits, vegetables, and whole
  grains. Some explanations for this include
• -- The greater market availability of packaged
  and processed foods
• -- The high cost of fresh fruit, vegetables, and
  lean cuts of meat
• -- The common practice of frying food
• -- Using fats in cooking.
• Exercise
• -- According to Initiative Media blacks watch
  73.6 hours of TV a week, about 17 hours more than
  Latinos and 22 hours more than Whites and Asians.
• Stress
• -- Living while black Index

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Can we be compliant??

• African-Americans with type 2 diabetes appear to
  be less likely than whites to take prescribed
  medications, reported in the July issue of the
  Journal of the National Medical Association.
• Factors that may lead to noncompliance with
  therapy include
• -- Onerous life-style changes,
• -- Drug side effects
• -- Failure to perceive benefit in the short term
  or believe that benefit will accrue in the long
  term.
• -- Cost (money and time)
• EDUCATION is the key!!!
• -- Explain to patients the importance of
  compliance when taking medications for type 2
  diabetes.
• -- Explain that oral medications, combined with
  diet changes and exercise, may prevent or delay
  the need for insulin injections, and can reduce
  the risk for complications such as blindness,
  heart disease, kidney failure, and vascular and
  neurological problems leading to amputations.
• A key reason of non-compliance in African
  Americans is the cultural factor.

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• Definition
• Customary beliefs, social forms and material
  traits of a racial, religious or social group
• May also refer to characteristics of everyday
  existence shared by a people in a place or time
• Culture can include the language, music,
  food, and rituals.

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African American Culture

• Nutrition
• General Dietary Influences
• --African Americans have difficulty eating diets
  low in fat and high in vegetables, fruits and
  whole grain
• --Explanations may include
• Availability of packaged and processed foods
• High cost of healthy foods, including vegetables,
  fresh fruits and lean cuts of meat.
• Common culture of frying foods and using fat in
  soul food preparation.

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African American Culture

• Derived from slavery and rural impoverished
  conditions
• Traditionally cooked and seasoned with pork
  products and fried in lard or oil
• Foods include chitterlings (chitlins), pork
  chops, potlikker, turnips, grits, and hushpuppies

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African American Culture

• African American Belief in Healthcare
• -- Culture affects African Americans taking
  symptoms seriously.
• -- Health beliefs stem from religious beliefs
• -- Many often turn to home remedies
• Yellow root tea lowers blood sugar
• Fresh pork helps improve hypertension

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African American Culture

• African American Belief in Healthcare
• -- Beliefs about diabetes
• Common themes include
• Running in families
• Eating too much sugar
• Not taking care of yourself

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African Americans And Healthcare

• Disparities reflect a long history of economic
  deprivation and barriers to healthcare
• --African American adults are less likely to have
  job based insurance
• --African Americans are twice as likely as Whites
  to report treatment with disrespect during a
  healthcare visit.
• --African Americans were almost twice as likely
  as whites to believe their doctors looked down
  on them.

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• Questions to consider
• --How does the African American culture deal with
  illness?
• --How are medical decisions made in the African
  American community?
• --What is the African American cultures norms
  about healthcare and sickness?

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Cultural Sensitivity

• Incorporation of experiences, norms, values,
  behavioral patterns, and beliefs of a specific
  population.

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Role Of the Government
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Is Congress Helping?

• Gestational Act
• Health Insurance Options
• School Legislative Action

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Gestational Act

• Gestational Diabetes occurs is 4 to 8 percent of
  all pregnant women. With this being the case,
  135,000 women in the United States alone are
  affected by this type of diabetes.
• In response to this, Sens. Hillary Rodham Clinton
  and Susan Collins presented the Gestational
  Diabetes (GEDI) Act to the U.S. Senate.
• The bill aims to lower the incidence of
  gestational diabetes and prevent women afflicted
  with this condition and their children from
  developing type 2 diabetes.

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Health Insurance Options

• Diabetes is a disease that is for most people
  self- managed. In order to stay healthy, a person
  with diabetes needs access to supplies like test
  strips, meters and insulin.
• Usually, people are able to get these
  medications and supplies through their health
  insurance policies.
• Ironically those who have diabetes may find
  difficulty obtaining and or keeping health
  insurance and life insurance!
• But through American Diabetes Association (ADA)
  these is hope!
• This association is committed to improving the
  quality of life for seniors affected with
  diabetes. Under the Medicare and Modernization
  Act, millions of people with Medicare will be
  able to live longer and healthier lives through
  utilization of new preventative services that
  became effective January 1, 2005.

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School Legislative Action

• Students with diabetes should have the same
  access to educational opportunities as other
  students. In some schools this principle is not
  exercised. As a result federal laws such as the
  Individual with Diabetes in Education Act (IDEA)
  have been instituted.

The states that have passed school diabetes care
legislation are marked in red.
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Programs
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Diabetes Outreach and Education (DOES)

• The Diabetes Outreach and Education System
  program (DOES) works with individuals and
  organizations to increase public awareness and
  encourage actions that will help communities
  control diabetes and its complications. This
  initiative supports the National Diabetes
  Education Program effort to help communities
  across the country develop comprehensive outreach
  programs and education campaigns to control type
  2 diabetes.

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Diabetes Outreach and Education (DOES) cont.

• The DOES program targets five southern Jersey
  communities Atlantic , Camden , Cumberland ,
  Salem and Ocean Counties . It is the first
  program of its kind in New Jersey and is a
  statewide model.

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• Lightened Hunterdon is a Partnership for Health
  initiative to raise awareness about weight
  management and increasing physical activity to
  Hunterdon County residents and health
  professionals

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New Jersey Area Health Education Centers (AHEC)

• The New Jersey Area Health Education Centers
  (AHEC) were established in 1978, in partnership
  with the University of Medicine and Dentistry of
  New Jersey, as part of a national initiative to
  strengthen the health of communities through
  educational partnerships.
• Camden AHEC is committed to improving the health
  of the medically underserved - the ethnic and
  culturally diverse, the aged, the poor, the very
  young, the unemployed, the homeless and the
  uninsured. Particular emphasis is on providing
  services in the communities of Camden and Camden
  and Burlington Counties.

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The Positives of (DOES)

• Increases knowledge of diabetes through
  educational programs and an annual congress
• Engages with statutory organizations on behalf of
  the people with diabetes.
• Promotes research that is relevant to people with
  diabetes in underserved areas.

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The Diabetes Association of South Africa (DASA)
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• Diabetes South Africa is a non-profit
  organization, funded in 1969 to be a support and
  an advocate for all people with diabetes in South
  Africa
• The Goal of DASA
• Our mission is to assist all people affected by
  diabetes so that their lives may be as healthy
  and satisfying as possible

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The Positives of (DASA)

• Informing, encouraging and supporting all people
  who have diabetes and their families.
• Acting as an advocate for people with diabetes,
  lobbying for better facilities, cheaper
  medication and better services.
• Promoting public awareness of diabetes, its
  symptoms and risks.

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The Birds Eye View of the Two
D.A.S.A
Vs.

• Education
• Community Role
• Research

D.O.E.S

• Education
• The Birds Eye View of the Two
• Government Role
• Public Awareness

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By consolidating the pros of both programs we
created our own Model.
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Solution

• Government officials should establish a
  program thats more cultural sensitive.

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Four Point Strategy

• Educate the public, caregivers providers
• Simplify the patient-physician education
  monitor their progress
• Motivate patients and providers through financial
  incentives, such as discounts
• Regulate health care standards and quality

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HEAL (Helping Every African American Live)

• Motto Exceptional living begins with diabetes!
• Goals Be effective by providing cultural
  sensitive
• services through
• -- Ongoing Support Groups
• -- Free Screenings for Diabetes and
  other incentives, such as discounts
• -- Seminars to educate diabetics on
  insulin injections and other treatments
• Implemented in areas with low socioeconomic
  status, such as Camden

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Funding for HEAL

• State funding
• American Heart and Lung Association
• ADA (American Diabetes Association)
• CDC (Center for Disease Control and Prevention)
• One Touch (machine that test blood sugar)
• NAACP
• Pharmaceutical Companies

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• Interview with Dr. Aliya Brown
• From Hunterdon Cardiovascular Group

Hunterdon Medical Center 190 Hwy 31, Suite
300 Flemington, NJ 08822 (908) - 788 - 6136