The War on Diabetes

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The War on Diabetes
05/01/2008
By: Margaret Farley Steele

May 2008

The runaway disease is costing Connecticut money and lives.



It might be a foot wound that won't heal or narrowed blood vessels detected during a vision exam. For many people with Type 2 diabetes, these are the earliest indicators, and by the time these telltale signs surface the damage can be irreversible.

Roughly 70,000 adults in Connecticut-one third of those with the condition-don't know they have diabetes. Another 163,000 adults-or 6.2 percent of the population-have the diagnosis, which puts them at risk of blindness, kidney failure, cardiovascular disease, loss of limbs, pregnancy complications and premature death. Diabetes is now the sixth leading cause of death in America, and yet it still doesn't seem to have a high profile among the general public.

It isn't enough of a "cause," some say. "Diabetes doesn't have the cachet of, say, breast cancer, heart disease or AIDS," says Dr. Daren Anderson, chief medical officer for Community Health Center Inc., which serves over 100 towns in the state through 12 primary-care clinics, most in medically underserved areas. Yet, "diabetes is one of the most common and significant illnesses we see for adults," he says.

With diabetes, the body fails to produce or properly use insulin, a hormone needed to convert food into energy. Without insulin, we die. Whereas Type 1 diabetics-usually diagnosed shortly after birth or as children-tend to experience acute symptoms (excessive thirst, frequent urination and extreme fatigue), the symptoms of Type 2 diabetes are more subtle. It's possible to have Type 2 diabetes-often referred to as "adult onset diabetes"-for 10 years and not know it, says Patricia O'Connell, a nutrition diabetes educator at the Joslin Diabetes Center affiliate at the Hospital of Central Connecticut in New Britain.

The incidence of Type 2 diabetes has increased steadily since the 1990s, and those trying to stem the epidemic say the issues involved in the growth explosion are complex, but foremost among them is a lack of understanding. "People don't realize that untreated it's a fatal condition, and that medication is just one piece of management," says Bob Smith, executive director of the American Diabetes Association in Connecticut.

Most of the increase in Type 2 diabetes is linked to obesity and inactivity. Weight loss and increased exercise can often prevent or delay the disease and its complications even among those with prediabetes-blood sugar that is above normal but not yet at diabetes level. In 2002, the New England Journal of Medicine reported on a study of individuals with prediabetes that found that by losing 5 to 7 percent of their body weight and exercising moderately-about 30 minutes a day-they could keep the disease at bay.

"That was wonderful news," says Cindy Kozak, health program associate for the Diabetes Prevention and Control Program of the state Department of Public Health (DPH). But identifying those people most at risk, motivating them to make lifesaving changes and funding those efforts, have proven to be monumental hurdles.

In Connecticut, the disease takes a staggering toll medically and economically. In 2003, diabetes cost Connecticut $1.7 billion in direct and indirect costs, the indirect having to do with time lost from work. In 2005, hospital bills due to diabetes totaled $77 million, while another $39 million was billed for lower extremity amputations caused by diabetes, according to the DPH.

Despite medical advances, one third of children born in 2000 will eventually develop the disease. The upward trend persists in the face of medical advances mainly because of changing lifestyles. "We used to plow fields and bicycle everywhere," says O'Connell. "Today we drive our cars and sit in front of computers." As a result, two-thirds of U.S. adults are overweight or obese.

The link between obesity and diabetes is so clear that the term "diabesity" is used by those on the front lines of the war against diabetes. Kozak calls it a "perfect storm."

But ethnicity also helps determine who develops diabetes. Most at risk are American Indians, African-Americans and Hispanic/Latino. Although one can't modify ancestry or other risk factors such as age, family history or gestational diabetes, individual risk can be reduced by controlling weight, cholesterol and high blood pressure levels through exercise and low-calorie, low-fat eating.

That's easier said than done, especially for the poor. "It's cheaper to buy two McDonald cheeseburgers than a salad, fruits, vegetables and proteins," says Smith. And the poor are also less likely to get sufficient exercise or have access to routine medical care, so cities such as Hartford and Bridgeport have a disproportionate number of cases.

The food issue is huge. "Places like Burger King get a bad rap, but really it's the whole food industry," says Donna Hansen, a diabetes nurse educator at Bridgeport Hospital. In particular, she singles out the high cost of healthy foods and the current trend toward gargantuan portion sizes. "People can have a lot of different foods; it's the amount they eat that's the problem," she says.

The state last October issued a comprehensive "Diabetes Prevention and Control Plan 2007-2012." Prepared in cooperation with 70 partners and funded by the CDC, it outlines strategies and goals for halting and eventually reversing the epidemic.

For the nation, the CDC wants to reduce the prevalence of diabetes by 2.5 percent by the year 2010. Connecticut, however, set its target at a modest .5 percent reduction, because Connecticut's prevalence among adults is lower than the national average, says Kozak, and because .5 percent is more realistic. Given the state's aging citizenry (21 percent of those 60 or over have diabetes) and growing Hispanic population, simply leveling the numbers will be a challenge.

"We are currently focusing on education initiatives," says Kozak, who helped draft the guidelines. Those initiatives include promoting better diabetes management practices among medical assistants and primary care practitioners, stressing, among other things, the importance of check-up reminders and the value of intensive diabetes education. The plan also calls for developing prediabetes screening programs, increasing doctors' use of evidence-based guidelines, promoting the benefits of teaching self-management skills and encouraging diabetes-friendly practices in schools and at work.

Seeking funding from foundations for these projects is part of Kozak's job. The prevention and control program currently receives $272,000 a year from the CDC plus state funding for one staff position-roughly $100,000. "That's our budget," she says. "More funding is needed."

Early screening will help identify those with prediabetes. Diabetes educators like Hansen and O'Connell believe early screening and education efforts are invaluable. "If we wait until people have it, it's too late," says O'Connell. But if pre-diabetics are counseled and even school children get the message, O'Connell believes the trend might be reversed.

For those already diagnosed with diabetes, learning self-management strategies can help them stay well. At the initial diagnosis, patients are overwhelmed and may not take in what is said, says Hansen. "We spend 8 to 10 hours with these people," she says. Also critical for managing the condition are annual educational updates. "Diabetes care is evolving all the time," she adds. "There are new medications and new treatment modalities based on current studies." Many of her patients never had diabetes education or were counseled years ago. "What they got 10 years ago might not be accurate now or their condition might have changed," she notes.

Improving diabetes care means changing the standard practices of primary care providers. The best care, says Anderson, is given through large systems such as the Community Health Center network or the Veterans Administration Hospitals, which have the resources to help diabetics manage the multiple demands of their condition. These include foot doctors, diabetes educators, nutritionists and mental health professionals to assist with depression, which is common among diabetics. The larger systems are more likely to have electronic records systems, which allow care providers to remind patients of recommended checkups or inoculations.

Anderson says the medical profession has been slow to adopt evidence-based guidelines. "There's a lot of blame to go around," he says. He and others also cite insurance practices. "We have a crazy health-care system that reimburses treatment instead of prevention," he says.

Still, there remains the issue of changing public perception, which frustrates people like Smith of the ADA. Some of the best research in the world is under way at the University of Connecticut Health Center and at Yale-New Haven Hospital, Smith says, but "one of our biggest struggles is getting the word out." For example, the ADA has pinpointed the Mashantucket Pequot Indian tribe in Connecticut as an at-risk population and tried to involve them in organizing a road race in Mystic, but only a handful of people participate, according to Smith.

Nevertheless, those on the front lines remain optimistic. "We have to be," says Kozak. "We have to work together to stem the tide."


©Connecticut Magazine 2009