Diabetes Educators Face Growing Epidemic in Arkansas - ...

Diabetes Educators Face Growing Epidemic in Arkansas

Diabetes Educators Face Growing Epidemic in Arkansas
By: JENNIFER BOULDEN

In the fight against the spread of diabetes in Arkansas, a creative ground war is being fought by educators in small programs across the state helping people of all ages.

"It's been reported that probably 235,000 people in Arkansas have diabetes and don't know it," said Sandra Brown, director of community health for Baptist Health. "We rank fifth in the nation in incidence of diabetes. Diabetes is the sixth-leading cause of death in Arkansas and the fourth leading cause of death among African-Americans. It's a big problem in our state."

In June the Centers for Disease Control released the latest national diabetes statistics. According to that report, close to 8 percent of the U.S. population had diabetes in 2007, including 17.9 million people with diagnosed cases and an estimated 5.7 million people as yet undiagnosed. Almost a quarter of people over 60 have the disease. Moreover, another 57 million people nationwide have pre-diabetes.

Studies show that 9.2 percent of Arkansas adults had physician-diagnosed diabetes in 2007 and that the state spends an estimated $1.5 billion a year on diabetes. Arkansas has 40 certified diabetes self-management education programs in 29 counties, but a whopping 46 counties have no such program available.

Diabetes is a cause particularly close to Brown's heart, since it runs rampant in her father's side of the family. Her grandparents had seven children, six of whom became diabetic.

"They grew up with a Southern diet," Brown said. "Yes, they had vegetables, but it was all cooked with the Southern fat meats, eating plenty until you're stuffed. They all have died from heart disease, and both of my grandparents died of a stroke. In my generation of the family, we exercise not because we want to get up that early in the morning, but because we saw what happened to our family members who didn't. I guess that's why I'm so passionate about it."

In Paragould, Certified Diabetes Educator Pat Malone is equally passionate about diabetes education and prevention, but for a different reason. Malone has worked for Arkansas Methodist Medical Center's Diabetes Self-Management Education (DSME) program for two and a half years, but before that she was a critical care nurse for the hospital.

"I saw diabetics after they had their heart attacks, or amputations or when we were hooking them up to dialysis, or the ones who were having laser surgery done from losing their eyesight. I saw what happens when they don't know how to manage their disease or don't get help in time," she said. "But now I'm on the offensive, not the defensive. I'm out front teaching them how to avoid going there. Diabetes, though, is now a pandemic, and we're going to need more offense."

Malone said that for the 24 million diabetics in the U.S., there are currently 15,000 Certified Diabetes Educators and another 10,000 who are uncertified. "You do the math, it's clear to see how many more educators are needed just in the U.S.," she said. "Overseas, that shortage is even worse."

Brown said that historically, diabetes care at Baptist Health has been divided into the hospital-based DSME program, which primarily serves the insured population, and treating the uninsured and underinsured at the system's many church-based Community Wellness Centers in Central Arkansas, which provide what care they can, including blood sugar screenings. That model will change, though, in the next few months as Baptist plans to adapt much of the self-management program to its Community Wellness Centers, bringing diabetes-specific education about healthy eating, exercising, monitoring and medication to the most needy members of the communities.

"In 2009, we're going to be more aggressive about helping patients who are without healthcare coverage," Brown said. "We are going to be adding another component in early 2009 at some of the centers, expanding it to all if it proves successful. It will be pretty much what they do at the hospital's Self-Management Program, but making it culturally appropriate and educating the clients on self-management of their diabetes.

"Diabetes is very costly—I think it's been documented in the literature that one out of every four Medicaid dollars is spent on diabetes," Brown continued. "It brings in all the complications, increases their chances for heart attack, stroke, blindness, loss of limbs, kidney failure, so it makes sense to invest in prevention and management."

In 2006, Medical News of Arkansas reported on a new multi-pronged diabetes initiative serving the hard-hit Mississippi Delta region in Arkansas and neighboring states, spearheaded by the Delta Regional Authority. Two years into the project, Alternate Regional Co-Chair Rex Nelson reports that the group in August voted to suspend the initiative.

"Our board decided to appoint an advisory group to look at the results of the first two years. The advisory group is then to advise the full board as to whether any changes are needed before going forward with the third year of the program," Nelson said, adding that funding is not at issue. "We have $1.5 million already sitting in the bank for year three. The board just wants to make sure it is spent in the wisest way possible. I felt the first two years were very successful."

In at least West Memphis, though, Delta citizens are receiving record amounts of diabetes education thanks to Crittenden Regional Hospital's partnership with the University of Arkansas for Medical Sciences.

Ramona Taylor, director of the Crittenden Regional Hospital Delta Center On Aging, said the hospital entered into a partnership with UAMS six years ago, when it became clear that diabetes was a "burgeoning epidemic" in the area. She said that with help from the state health department and UAMS, the hospital became an American Diabetes Association (ADA) certified Diabetes Education Center.

UAMS' Delta Area Health Education Center last year began providing a dietician to do outpatient education. "For the last 16 months, we've been trying to work with industry and the general public in learning more about nutrition, looking at weight loss, portion sizes, increasing exercise to address diabetes. We want to help people follow their physician's plan, what they can do on their own to manage it, and then what can we as a community, as a hospital, a medical school, what can the combined citizen community do to stop the increase in diabetes," Taylor said.

Much of the hospital's prevention efforts have focused on dietary education, not only for adults, but also in the schools and PTA groups. "Honestly, for some of us, we're too old to change our habits. We're going to keep eating our fried foods and such, but the real potential for change is in the younger generation. If we can change how they eat and how they view nutrition and exercise, we can do a lot to reverse the trends," she said.

That includes free classes on nutrition and how to make healthy recipes, placemats from the Arkansas Foundation for Medical Care with the recommended portion sizes (a deck of cards sized portion of meat, for example), talks and information provided to local Parent Teacher Associations, working directly in the classrooms with students, and having a dietician available for consults with children and their parents, by physician referral.

"We printed up special referral forms in all the doctors' offices, so if they see a patient that needs dietetic counseling for diabetes, weight loss or weight gain, they fax it to us," Taylor said.

Malone agreed that the most alarming trend in recent years is the growing number of juvenile type 2 diabetics. "We anticipate type 2 with adults, but when we start seeing kids at (ages) 8, 9, or 10 becoming type 2, it's definitely a wake-up call," Malone said. "That's one of our focuses, to work with schools and with parents. We have to teach them how to prepare meals that are healthy, to take TV and video games away and get them involved in sports or riding their bikes, whatever we can get them involved in the evenings to reduce the chances of diabetes in these kids."

Citing one innovation for such children at the West Memphis program, Taylor said a certified parent educator provided by UAMS also sits in on the nutritional counseling sessions. Although she said parent educators primarily work with new parents or intervene in cases of suspected or potential child abuse, in West Memphis, the parent educator's armory of skills and curricula are also being co-opted for changing the way families are fed.

"One of the things we've looked at is using her to work with families about eating, nutrition and obesity. The parent educator sits in on the dietician sessions with a nurse and finds ways to combine the family dynamics change model with the nutritional advice from the dietician," Taylor said. "Having the parent educator, nurse, and dietician all meet with the pediatric patient and mother, they can together look at all the different dynamics and evaluate the best approach."

Taylor said the hospital has also participated in several research efforts, such as a current study by Eli Lilly, Inc. to evaluate the efficacy of providing diabetes self-management education to diabetic schizophrenics. "We were a little wary at first, but so far the schizophrenic patients have been even more interested in the education than non-schizophrenics," she remarked.

Like other programs around the state, Malone said the diabetes education efforts at AMMC have all the work they can handle.

"Our hospital is actively involved in the community. We're involved in many health fairs in the community each month. Every day I'm out there asking people, 'Are you a diabetic? Have you worked with a diabetes educator? What can I tell you about it?'" Malone said. "Now we're trying to get into the schools and I have two support groups going right now for diabetics. There's just always a lot of activity going on."

Brown and Malone each said that physicians' biggest limitation in treating diabetes is simply time, but both agreed that there is within those limitations still room for improvement.

Brown said she wishes physicians could create mechanisms in their offices for blue-collar workers and for those parts of the population that have the least access to information to help them find a diabetes education program for ongoing education to reinforce their initial diabetes education.

"Giving people medications is one part of treatment, but the other part is education and learning how to take care of yourself. A lot of diabetics just don't have the tools or the knowledge, even after a doctor diagnosis," Brown said. "So many times we think things are fixed with a pill, but we have to get that client with someone who has the time to teach and be patient with their learning curve."

She is especially emphatic about the need for physicians' offices to take a bigger role in connecting uninsured or underinsured patients with free or sliding-scale resources for their continued diabetes care.

"While we may have a shortage of clinics and providers that uninsured people can afford, we still have to be able to do a better job of managing and coordinating their care with the resources that are available. We could all create ideal programs if we had the money. The key is that when they do have contact with a healthcare provider, that healthcare provider knows about and maximizes whatever diabetes resources are available."

Malone said that in the end, improving diabetes care comes down to money. "I've heard at least one expert say that diabetes could be the disease that bankrupts healthcare," she said. "When we look across the world and the expense of caring for people with complications of diabetes, it's astronomical."

Still, she said, despite the odds, she finds hope and rejuvenation for the work ahead every day.

"I get hope when I'm sitting there talking to my patients, and you see the light come on and they get it. They understand diabetes doesn't have to control their lives, doesn't have to be the end. I tell them, 'You understand, now go share that. Talk to your family, talk to your friends, talk to your church, your children,'" she said. "It gives me hope when I have someone come in and say, 'I've been a diabetic for eight or nine years but I don't know how to take care of myself; will you show me how to take care of myself?' or when a parent says, 'You're right. I'm going to change how I feed my children and make sure they're doing something active every day.' That's hope. Based on the little things I see every day, I am very hopeful we can turn this problem around."

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