Diabetes Mellitus, Type 2

1. Diabetes Mellitus, Type 2 Presentation By Heather Hawley

2. Epidemiology • “Diabetes mellitus currently afflicts approximately 21 million Americans, 90% to 95% of whom have type 2 diabetes.” (Ding, Eric L., Song, Yiqing, Malik, Vasanti S., and Liu, Simin. “Sex Differences of Endogenous Sex Hormones and Risk of Type 2 Diabetes: A Systematic Review and Meta-analysis.”JAMA, 295(11): March 15, 2006: 1288 - 1299. http://jama.ama-assn.org.ezproxy.ahsl.arizona.edu/content/vol295/issue11/index.dtl) • “Both the prevalence rate for diabetes and the number of people with diabetes have increased steadily since a national system for ascertaining diagnosed diabetes was established in 1958.”(Kenny, Susan J., Aubert, Ronald E., and Geiss, Linda S. “Prevalence and Incidence of Non-Insulin-Dependent Diabetes”, in Diabetes in America, 2nd Ed., 44. http://diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter4.pdf.)

3. Epidemiology, cont. • Incidence and prevalence of diabetes increases with age. • Prevalence: of Americans 60 and over “18.3 percent (8.6 million people) have diabetes.”(CDC, “Frequently Asked Questions”, http://www.cdc.gov/diabetes/faq/research.htm). • Incidence: Americans 65-79 years of age have rates of diabetes more than five times higher (14.9 per 1000 population) than adults less than 45 years of age (2.9 per 1000 population). • Children are increasing likely to be diagnosed.

4. Epidemiology, cont. • Diabetes is associated with risk factors such as obesity, sedentary lifestyle, ethnicity and gender.

5. Impact of the disease upon specific minority/ethnic groups • Minority populations disproportionately affected are: American Indians, Asians, Latinos, and African Americans. • “African Americans are 1.6 times more likely to have diabetes than Non-Hispanic Whites, while Native Americans are 2.2 times more likely and Latinos, 1.5.” (American Diabetes Association, “Minorities with Diabetes at Increased Risk for Heart Disease, Stroke”, http://www.diabetes.org/for-media/2005-press-releases/Heart-Month.jsp.)

6. Impact of the disease upon specific minority/ethnic groups, cont. • Prevalence: “10.8 percent of non-Hispanic blacks, 10.6 percent of Mexican Americans, and 9.0 percent of American Indians have diabetes, compared with 6.2 percent of whites. Certain minorities also have much higher rates of diabetes-related complications and death, in some instances by as much as 50 percent more than the total population.” (AHRQ, “FactSheet: Diabetes Disparities Among Racial and Ethnic Minorities”, http://www.ahrq.gov/research/diabdisp.htm)

7. Impact of the disease upon specific minority/ethnic groups, cont. • Growing risk among Asian Americans: “prevalence of type 2 diabetes is 2 to 3 times higher among Japanese Americans living in Seattle compared with non-Hispanic whites. The prevalence is 2.5 times higher among Native Hawaiians compared to white residents of Hawaii .” (National Diabetes Education Program. “Diabetes and Asian Americans and Pacific Islanders”, http://www.ndep.nih.gov/diabetes/pubs/FS_AsAm_Eng.pdf)

8. Impact of the disease upon specific minority/ethnic groups, cont. • Diabetes is one of the top 10 causes of death for all women. • “For African American women, the diabetes death rates are the highest in terms of both underlying cause (49.6 per 100,000) and multiple causes (156.5 per 100,000). American Indian/Alaska Native and Hispanic women have high rates as well. The lowest rates are reported for Asian/Pacific Islander women.” (U.S. Department of Health & Human Services, “Steps to Healthier Women: Diabetes”.).

9. Impact of the disease upon specific minority/ethnic groups, cont. • For African American women 20 years old and over, the diabetes rate is 11.8%, and with 1 in 4 African American women over the age of 55 having this disease; a rate which is twice the rate of white women. (U.S. Department of Health & Human Services, “Steps to Healthier Women: Diabetes.”) • Among Latino women, 25% have been diagnosed with this disease, “and about 33 percent of deaths among them list diabetes as the underlying cause,” and among American Indian/Alaska Native women there is “three times the risk of being diagnosed with diabetes as whites of similar age.” (U.S. Department of Health & Human Services, “Steps to Healthier Women: Diabetes.”)

10. Impact of the disease upon specific minority/ethnic groups, cont. • Among American Indian tribes, the Pima Indians have the highest overall risk, especially for complications such as eye disease. (U.S. Department of Health & Human Services, “Steps to Healthier Women: Diabetes.”)

11. Current clinical treatment • Hypoglycemic pills and/or insulin AND non-drug interventions for “diet modification, weight control and regular exercise.” (Florence and Yeager. “Treatment of Type 2 Diabetes Mellitus.” 2835-44, 2849-50.) • Foot and eye checks are extremely important • “Diabetes is a leading cause of blindness, renal failure, and foot and leg amputations in adults.”(Florence and Yeager. “Treatment of Type 2 Diabetes Mellitus.” 2835-44, 2849-50.) • Cochrane Systematic Reviews: “Group-based training for self-management strategies in people with type 2 diabetes is effective by improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.” (Deakin, McShane, Cade, and Williams. “Group based training for self-management strategies in people with type 2 diabetes mellitus.” The Cochrane Database of Systematic Reviews: http://gateway.ut.ovid.com.ezproxy.ahsl.arizona.edu/gw2/ovidweb.cgi.)

12. Nursing care • Extremely important in behavioral treatment strategy of encouraging healthy lifestyle changes and patient education. • Nurses are patient educators on: managing diabetes, medications, diet and exercise, glucose monitoring and dispelling myths.

13. Drug therapy • Drug therapy for type 2 diabetes involves pharmacologic agents such as pills and/or insulin to control blood glucose levels and is usually instituted if diet and exercise fails. • Drug therapy typically starts with monotherapy;if monotherapy fails then combined therapy, where a patient takes up to three oral medications, is usually prescribed. • Drug therapy=hypoglycemic agent from one of five classes: sulfonylureas, meglitinides, thiazolidinediones, biguanides, and [alpha]-glucosidase inhibitors.” (Nelson and Palumbo. “Addition of Insulin to Oral Therapy in Patients with Type 2 Diabetes: 257-263.)

14. Drug therapy, cont. • If the combined drug therapy fails, and the diabetes patient exceeds the ADA guidelines of blood sugar concentration “greater than 7.0%” on an A1C test (a test for average blood glucose control for the past 2 to 3 months) then insulin therapy is usually instituted. (American Diabetes Association, “A1C Test”, http://www.diabetes.org/type-2-diabetes/a1c-test.jsp)

15. Nutritional therapy • First resort in treating type 2 diabetes is diet modification and an exercise regimen. • No specific “diabetes diet” that is applicable to everyone; diet should be personalized. • Food eaten is closely connected to blood sugar levels. • Controlling carbohydrate consumption integral for managing blood sugar levels because “carbohydrate consumption has the fastest effect on increasing blood glucose.” (Joslin Diabetes Center, “There is no such thing as a ‘Diabetic Diet’”, http://www.joslin.org/managing_your_diabetes_665.asp) • “For most people with diabetes (and those without, too), a healthy diet consists of 40% to 60% of calories from carbohydrates, 20% from protein and 30% or less from fat.”(American Academy of Family Physicians, “Diabetes and Nutrition”, http://familydoctor.org/349.xml).

16. Nutritional therapy, cont. • Exercise is another very important element of controlling blood glucose levels, because it burns glucose rapidly. • “With a daily low-resistance, high-frequency exercise/activity program lasting 45 to 55 minutes, the control of blood glucose for those with diabetes improves and stabilizes even before weight loss is achieved.”(Cleveland Clinic Health Information Center, “Diet and Exercise: The Keys to Success with Diabetes.”) • Strong evidence that diet and exercise can also delay or prevent type 2 diabetes. (Burnet, Elliott, Quinn, Plaut, Schwartz, and Chin. “Preventing Diabetes in the Clinical Setting.”84.)

17. Psychological issues • Anger: “Diabetes is the perfect breeding ground for anger”, because people may feel their lives are threatened. People may become angry because they feel diagnosis is unfair (“Why me?”) (American Diabetes Association, “Anger”, http://www.diabetes.org/type-2-diabetes/anger.jsp) • Depression: “several studies suggest that diabetes doubles the risk of depression compared to those without the disorder.” (National Institute of Mental Health, “Depression and Diabetes”, http://www.nimh.nih.gov/publicat/depdiabetes.cfm) • Depression “negatively impacts psychosocial functioning and quality of life”, depressed diabetics “exhibit poor glycemic control, noncompliance with therapy” and in turn have more “diabetic complications” than non depressed diabetics. (Petersen, Timothy; Iosifescu, Dan V.; Papakostas, George I.; Shear, Deborah L.; Fava, Maurizio. “Clinical characteristics of depressed patients with comorbid diabetes mellitus”. International Clinical Psychopharmacology. 21(1): 2006 Jan: 43-7).

18. Economic issues: costs of the disease From the American Diabetes Association website, the cost of diabetes in America (90-95% of diabetes cases are type 2): • The total annual economic cost of diabetes in 2002 was estimated to be $132 billion. • Direct medical expenditures totaled $92 billion and comprised $23.2 billion for diabetes care, $24.6 billion for chronic diabetes-related complications, and $44.1 billion for excess prevalence of general medical conditions. Indirect costs resulting from lost workdays, restricted activity days, mortality, and permanent disability due to diabetes totaled $40.8 billion. • The per capita annual costs of health care for people with diabetes rose from $10,071 in 1997 to $13,243 in 2002, an increase of more than 30%. In contrast, health care costs for people without diabetes amounted to $2,560 in 2002. • One out of every 10 health care dollars spent in the United States is spent on diabetes and its complications.

19. Associations/Advocacy Groups From the MedlinePlus website, Diabetes Organizations: • American Diabetes Association: The American Diabetes Association is “The nation's leading nonprofit health organization providing diabetes research, information and advocacy”, whose mission “is to prevent and cure diabetes and to improve the lives of all people affected by diabetes.” • National Diabetes Education Program (National Institute of Diabetes and Digestive and Kidney Diseases) “is a federally funded program sponsored by the U.S. Department of Health and Human Services' National Institutes of Health and the Centers for Disease Control and Prevention and includes over 200 partners at the federal, state, and local levels, working together to reduce the morbidity and mortality associated with diabetes.” • National Diabetes Information Clearinghouse (National Institute of Diabetes and Digestive and Kidney Diseases) “The National Diabetes Information Clearinghouse (NDIC) is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health (NIH), one of eight health agencies of the Public Health Service, which is under the U.S. Department of Health and Human Services.” Their mission is “to increase knowledge and understanding about diabetes among patients, health care professionals, and the general public.” • National Institute of Diabetes and Digestive and Kidney Diseases “The National Institute of Diabetes and Digestive and Kidney Diseases conducts and supports research on many of the most serious diseases affecting public health….such as diabetes….”

20. Consumer/Patient Health Information • American Diabetes Association: Provides diabetes information to those with diabetes and their families, healthcare professionals, and the public. • Arizona Health Sciences Library, Diabetes Subject Guide: Provides diabetes patient resources in the following areas: African Americans, American Indians and Alaska Natives, Arizona Resources, Asians and Pacific Islanders, Children and Teens, Diabetes and Pregnancy, Diabetes Insipidus (Type 1), Diet, Eye Problems, Heart Problems, Kidney Problems, Nerve Problems, General Resources and Hispanic Americans. • Cleveland Clinic Health Information Center: Diabetes Mellitus: Provides Diabetes information on in the following areas: Written resources, Calendar of Events, Clinical Trials, Departmental Website, and Interactive resources. • Joslin Diabetes Center: Focuses on diabetes Research, clinical Care, and consumer Education; is affiliated with the Harvard Medical School. • Medline Plus: Diabetes: Provides diabetes information on: Latest News, From the National Institutes of Health, Overviews, Diagnosis/Symptoms, Treatment, Prevention/Screening, Pictures/Diagrams, Health Check Tools, Alternative Therapy, Nutrition, Coping, Disease Management, Specific Conditions, Related Issues, Financial Issues, Newsletters/Print Publications, Clinical Trials, Genetics, Research, Dictionaries/Glossaries, Directories, Organizations, Law and Policy, Statistics, Children, Men, Women, Seniors, Other Languages.