Diabetes

1
Diabetes

• NPEP WORKSHOP
• Dwight Pargee, Fitness Coordinator
• United Indian Health Services

2
Type 2 diabetes

• Expanding horizons on diagnosis, treatment, and
  prevention

3
Understanding Diabetes

• What is diabetes? (Normal and abnormal sugar
  processing in the body)
• Type 1 2 diabetes
• Type 2 diabetes in American Indians

4
What is Diabetes?

• A problem with the way your body uses food to
  store and make energy.
• (and lots of other stuff)

5
What is Diabetes?

• A chronic disease characterized by high blood
  sugar which can effect many organs and systems of
  the body
• A disease which can damage tissues before an
  individual is diagnosed or has symptoms
• An illness which may affect individuals
  differently
• Some aspects of diabetes are still poorly
  understood

6
Understanding Diabetes

• Glucose (a kind of sugar) is an important fuel
  for your body
• Insulin (a hormone or messenger protein that is
  made in the pancreas) helps glucose get into many
  kinds of cells in the body
• With diabetes, there is a problem with the
  glucose getting into the cell where it can be
  used for fuel

7
Understanding Diabetes

• When the glucose cant get into the cell
  properly, it stays in the bloodstream
• When the glucose level in the bloodstream rises,
  the glucose may attach to proteins or cause other
  imbalances leading to build-up of toxins in the
  body (and you dont feel a thing)

8
Understanding Diabetes

• Over time, this can result in damage to the
  tissues (and you dont feel a thing)
• Insulin resistance may also lead to tissue
  damage independent from that of high blood sugar
  (and you dont feel a thing)

9
A Key Player - Insulin

• Insulin a hormone made by special cells in the
  pancreas gives signals to many tissues,
  including the signal to move glucose from the
  blood into the cells. Insulin mainly tells the
  body to store energy for the future.
• Insulin Resistance - the decrease in the tissues
  ability to respond to insulins signal.

10
A Key Player - Insulin

• Insulin a hormone made by the Beta cells in
  the pancreas gives signals to many tissues,
  including the signal to move glucose from the
  blood into the cells. Insulin mainly tells the
  body to store energy for the future.
• Insulin Sensitivity - the ability of different
  tissues to respond to insulin.
• Insulin Resistance - the decrease in the tissues
  ability to respond to insulins signal.

11
What Kind of Diabetes?

• Type 1
• Complete shutdown of cells that make insulin
• Cannot live without insulin
• Type 2
• The body still makes some Insulin
• The insulin signal is not as powerful
  resistance
• Gestational Diabetes or Diabetes of Pregnancy
  (like type 2 diabetes)

12
Feature Type 1 Type 2
13
(No Transcript)
14
Normal Glucose Metabolism
Nutrition Carbohydrates (starches sugars)
Tissues (Muscle and Fat)
Liver
Glucose
glucose storage (glycogen) and production
Pancreas
Insulin
15
What Goes Wrong in Diabetes?
Nutrition (carbohydrates)
Tissues (Muscle and Fat)
Liver
Type 2 insulin resistance
Glucose
excess glucose production
Pancreas
Insufficient or no insulin
16
What is Insulin Resistance?
17
Insulin Resistance

• Insulin is like a messenger-key to a lock on
  the cell, it opens the lock to let in glucose
• Many cells, especially muscle and fat cells, need
  insulin to help get the glucose in the cell.
• Folks with insulin resistance need more
  messenger-keys (insulin) to let the
  glucose into the cell

18
Insulin Resistance

• Insulin resistance can also result in damage to
  blood vessels in the body that leads to heart
  attacks and strokes.
• This damage usually starts before the
  blood sugar starts going up
• (and you dont feel a thing
• until your first heart attack.)

19
More Key Players

• Pancreas - monitors levels of glucose in blood
  continuously and provides enough insulin to keep
  blood glucose level lt120mg/dL
• Muscle - the tissue that is best able to burn
  glucose in its cells.
• Fat stores excess energy, communicates with the
  liver, responds to signals given by insulin
• Liver - stores and releases sugar, providing
  enough to keep blood glucose level gt60mg/dL.

20
The Epidemiology of Diabetes in the USA

• Incidence
• Type 1 30,000/year
• Type 2 850,000/year
• GDM 3-8 of pregnancies

Prevalence
150,000
750,000
10,000,000
10,000,000 (6,000,000 undetected)
Estimates based on U.S. population of 250 million
21
Global Epidemic Of Diabetes

• More than 135 million people worldwide had
  diabetes in 1995 (4.0)
• 300 million people are expected to have the
  disease by 2025 (5.4)
• 42 increase in developed countries
• 170 increase in developing countries
• Urban dwellers more likely to have the disease
  than rural inhabitants

King, et. al., Diabetes Care, 1998
22
Age-adjusted prevalence of diagnosed diabetes
among American Indians/Alaska Natives aged 20
years or older, by IHS area, 2001
Age-adjusted based on the 2000 U.S.
population. Source FY01 IHS APC file. Excludes
data from 39 service units (7 of the IHS user
population).
23
Increase in diabetes prevalence among persons
aged 2059 years, by age U.S. general
population and American Indians/Alaska Natives,
1990 and 1998
Source Mokdad et al. Diabetes Care
200023127883, and Indian Health Service
outpatient data. 1829 years in U.S. general
population.
24
Prevalence of diagnosed diabetes among children
and young people by age group, 1990-2001
Per 1000
79 increase
68 increase
106 increase
25 increase
Year
Source IHS Diabetes Program Statistics
25
Mortality Rates in American Indians Alaska
Natives
Trends in Indian Health, 1997 Age adjusted rate
per 100,000
26
Burden of Diabetes in the U.S.

• Increases the risk of heart attack and stroke by
  24 fold
• The leading cause of new blindness, end stage
  renal disease, and amputations
• 193,140 deaths from diabetes a year (7th)
• Costs 98 billion or more per year

CDC National Diabetes Fact Sheet 1998
27

• About 80 percent of people with type 2 diabetes
  are overweight.
• Type 2 diabetes is often part of a metabolic
  syndrome that includes obesity, elevated blood
  pressure and high levels of blood lipids.
• Unfortunately, as more children and adolescents
  become overweight, type 2 diabetes is becoming
  more common in young people.

28
Diabetes Why Me?

• Its in your genes right?
• NO.
• Getting more calories than needed, over a
  healthy weight
• Physical activity Sedan and screen lifestyle
• Aging

29
Diabetes Why Me?

• Psychosocial and Cultural trauma?
• What evidence?
• Other Diseases and conditions
  (e.g. smoking, medications)

• We dont know everything! (not yet
  anyway)

30
Why is this happening in Children Adolescents?

• Born to a mother who had gestational diabetes
• High birth weight qualified
• Low birth weight qualified
• Less physical activity
• More food, calories that we dont use, calories
  from things like saturated fats
• Stress and depression?
• We dont know all the answers

31
Diabetes in the American Indian community

• The actual reasons for the increase in type 2
  diabetes remain both elusive and complex our
  work toward a complete understanding of this will
  no doubt continue for some time to come.
  However, several observations belie a simple
  genetic causation. Fifty to sixty years ago,
  type 2 diabetes was nearly nonexistent in
  American Indian populations. Lest we think this
  was merely a problem of poor diagnostic abilities
  or case finding, consider that type 2 diabetes
  prevalence increased 106 in the 15-19 year old
  American Indian/Alaskan Native populations alone
  from 1990-2001

32
Risk Factors in Children Adolescents

• Family history of type 2 diabetes in first or
  second degree relative
• Born to a mother who had gestational diabetes
• High or low birth weight qualified
• American Indian, Hispanics, Blacks
• Hypertension, blood pressure
• Dyslipidemia, cholesterol and fats in the blood
• Acanthosis Nigricans
• Polycystic Ovarian Syndrome

Insulin resistance
33
Diabetes Research

• Diabetes Control Complication Trial (DCCT)
• Type 1 Diabetes, 10 year study
• Blood glucose control decreases complications

34
Diabetes Related Complications

• Cardiovascular Disease
  (Heart attacks and Stroke)
• Blood Vessel (Peripheral Vascular) Disease
• Kidney Disease (Nephropathy)
• Nerve Disease (Neuropathy)
• Eye Disease (Retinopathy)
• Dental/Peridontal Disease

35
Summary of (even more) Recent Research Findings

• It is even more important to lower cholesterol
  and fats in the blood for patients with diabetes
  in order to prevent heart attacks and stroke
• Good blood sugar control in pregnancy may reduce
  the risk of complications by 50.
• Smoking increases your chance of getting diabetes

36
Type 2 Diabetes and Complications
High Blood Sugar
High Cholesterol
Smoking
Excess calories and Insulin Resistance
High Blood Pressure
High Blood Levels of Insulin
Reaven GM, Am Heart J 19911211283-1288.
37
Natural History of Type 2 Diabetes
Environmental factors e.g. nutrition, more
calories than needed, physical inactivity
Onset of diabetes
Complications
Disability
susceptible physiology
IFG IGT
Death
High Sugar High Cholesterol High Blood Pressure
Kidney Eyes Nerves
Blindness Renal failure CHD Amputation
Insulin resistance Hyperinsulinemia Low HDL
FPG gt126 mg/dL CPG gt200 mg/dL
IFG 110-125 mg/dL IGT 140-199 mg/dL
Heart Attacks and Strokes
38
Foundations of Therapy

• Education, Education, Education
• Self management, individual learning styles
• Simplicity (i.e. avoid complexity!)
• Nutrition
• Identify barriers to change
• Family community support
• Physical Activity

39
At least Two Approaches To Fitness

• Traditional
• Frequency 3-4 days/wk
• Intensity 65-85 of maximum heart rate
• Time Minimum of 20 minutes/session

• Alternative
• Physical activity every day.
• Moderate intensity (brisk walking)
• Accumulate 30 minutes or more every day

40
the all-American diet
Oh yeahNow That place was really a greasy
spoon!
41
Type 2 Diabetes

• The most important factor in caring for Type 2
  Diabetes that we can control
• is our lifestyle.
• We need to try to live in a way that matches how
  our bodies were made to live.

42
The Diabetes Prevention Program (DPP)

• 3,234 participants with impaired glucose
  tolerance (IGT)
• Average age 51 yrs (range 25-85 yrs)
• 45 from ethnic/minority groups (171 American
  Indian participants, 5 of the study)

43
DPP Goals Primary

• To prevent or slow the development of type 2
  diabetes in persons with impaired glucose
  tolerance (IGT) and other high risk
  characteristics

44
Lifestyle Intervention

• Intensive Lifestyle Modification
• A comprehensive program using a Case Management
  approach with the following specific aims

• Reduction of fat and calorie intake
• Physical activity at least 150 minutes per
  week
• gt 7 loss of body weight

45
DPP Study Results

• Participants from the lifestyle group reduced
  their risk of getting type 2 diabetes by 58

46
DPP Study Results

• Lifestyle intervention worked very well in
  elderly (gt60 yrs), reducing development of
  diabetes by 71

47
What do the results of the DPP mean to our
communities?

• Screening for diabetes AND for IGT in AI/AN
  communities
• Create lifestyle programs for diabetes
  prevention case management approach
• Purchase metformin for diabetes prevention

48
Type 2 Diabetes Prevention

• The most important factor in caring for and
  preventing Type 2 Diabetes that we can control is
  our lifestyle.
• We need to try to live in a way that matches how
  our bodies were made to live.

49
...youve got to be careful if you dont know
where youre going, because you wont get there.

• ...when you come to a fork in the road, take it.

Yogi Berra
50
Questions?

• Anybody seen my magic wand?

51
Sandy Lake School Diabetes Prevention Program

• The Sandy Lake First Nation School Diabetes
  Prevention Program was created during the 1998
  school year to help students in grades 3 and 4
  learn about and practice healthy eating and
  physical activity behaviours the only known ways
  to prevent diabetes. Developing healthy behaviors
  at a young age should give students the skills
  and motivation to continue these behaviors into
  adulthood.
• The program was designed to address the
  individual, social, and structural levels of
  influence on children's behaviors associated with
  making healthy food choices and physical
  activity.
• The 4 components of the Sandy Lake School
  Diabetes Prevention Program include a classroom
  curriculum, family outreach, peer activities, and
  changes in the immediate school and store
  environment

52
Sandy Lake program description

• COMPONENTDESCRIPTIONClassroom Curriculum
• 17 lessons on healthy eating and physical
  activity. Focus on the identification of healthy
  foods, skills building, behavior modeling, and
  food preparation.
• Family
• Information booths during school parent night
  events
• Letters sent home on healthy eating and physical
  activity
• Weekly radio show topics
• Articles in the local newsletter
• Peer
• Angel Cooking Video Club (kids cooking club)
• Diabetes Kids interviews on the Sandy Lake Youth
  Radio show
• Youth Radio Show, which focuses on healthy
  lifestyles, is now offered in collaboration with
  Sandy Lake's Brighter Futures Project
• Environment
• Board of Education Policy of no pop or chips on
  school grounds
• School breakfast snack program
• Healthy food promotion in local stores
• Community-wide SLHDP diabetes prevention
  activities

53
Curriculum description

• CLASSROOM CURRICULUM
• The Sandy Lake First Nation School Diabetes
  Prevention curriculum is a culturally appropriate
  healthy lifestyle curriculum for students in
  grades 3 and 4. The lessons draw upon social
  learning theory and traditional learning styles
  and includes role modeling, taste tests, skills
  building, goal setting, and games.
• This is a 2 year curriculum which begins in grade
  3 and continues in grade 4. Each of the 17 units
  contains 2 lessons which are taught once a week
  for approximately 30 minutes each. The units of
  the Sandy Lake curriculum address three main
  components
• making healthy food choices (what are healthy
  food choices, encouragement for students to make
  healthy food choices, and providing students with
  the skills and opportunities to make healthy food
  choices in their daily lives)
• daily physical activity (what are different kinds
  of physical activities, the health benefits of
  physical activity, and providing students with
  opportunities for doing more daily physical
  activities) and
• learning about diabetes (basic information on
  diabetes and prevention)
• Each unit begins with an introductory story from
  an imaginary community called Winding Lake and
  includes two lessons with activities that
  reinforce the concepts of the unit. The stories
  and lessons are sequenced and build upon one
  another. Each unit begins with an introductory
  story from an imaginary community called Winding
  Lake and includes two lessons with activities
  that reinforce the concepts of the unit.
• www.sandylakediabetes.com

54
Pathways

• Pathways, a research study funded by the National
  Heart, Lung, and Blood Institute, is a
  school-based health promotion program that
  includes physical activity, nutrition, classroom
  curriculum, and family involvement. The primary
  purpose of the Pathways study is to prevent
  obesity among American Indian children by
  promoting increased physical activity and
  healthful eating behaviors.

55
Pathways

• Pathways includes four components. This
  intervention was designed so that all four
  components are to be implemented together. We
  highly recommend that you implement Pathways in
  this way. The four components of Pathways are
• Curriculum
• Family
• Food Service
• Physical Activity
• Each of these components and accompanying
  materials has been included for the use of
  interested teachers, school personnel, and health
  promotion practitioners. These materials can be
  viewed and printed.
• http//hsc.unm.edu/pathways

56
www.thecommunityguide.org

• Regular physical activity is associated with a
  healthier, longer life and with a lower risk of
  heart disease, high blood pressure, diabetes,
  obesity, and some cancers. Despite all the
  benefits of physical activity, most school-aged
  children in this country are sedentaryonly one
  in four gets the recommended amount of physical
  activity each day (30 minutes of moderate
  activity or 20 minutes of vigorous activity).
  Lack of physical activity has also contributed to
  a sharp rise in childhood obesity over the last
  20 years. Given that regular physical activity
  will help young people stay healthier, it is
  important to know what strategies work best to
  increase physical activity.
• A systematic review of published studies,
  conducted on behalf of the Task Force on
  Community Preventive Services by a team of
  experts, found that physical education (PE)
  classes taught in schools that included which
  enhance the length or activity levels, are
  effective in improving both physical activity
  levels and physical fitness among school-aged
  children. Based on this review, the Task Force
  issued a recommendation to implement programs
  that increase the length of, or activity levels
  in, school-based PE classes based on strong
  evidence of effectiveness.

57
Physical education in schools

• Background on the Interventions
• To increase the amount of time students spend
  doing moderate or vigorous activity in PE class,
  these programs seek to change PE curricula by
  making classes longer or having students be more
  active during class.
• Interventions reviewed included changing the
  activities taught (e.g., substituting soccer for
  softball) or modifying the rules of the game so
  that students are more active (e.g., in softball,
  have the entire team run the bases together when
  the batter makes a base hit). Many interventions
  also included health education.
• Findings from the Systematic Review
• In all 14 studies reviewed, students physical
  fitness improved.
• In 5 studies measuring activity levels during PE
  class, all recorded increases in the 1) number of
  minutes spent in moderate or vigorous physical
  activity, 2) percentage of class time spent in
  moderate or vigorous physical activity, and/or 3)
  intensity level of physical activity during
  class.
• The median estimates from the reviewed studies
  suggest that modifying school PE curricula as
  recommended will result in an 8 increase in
  aerobic fitness among school-aged children.
• Modifying school PE curricula was effective
  across diverse racial, ethnic, and socioeconomic
  groups, among boys and girls, elementary- and
  high-school students, and in urban and rural
  settings.
• In a separate literature review, having students
  attend school PE classes was not found to harm
  academic performance.

58
Social support

• A systematic review of published studies,
  conducted on behalf of the Task Force on
  Community Preventive Services by a team of
  experts, found that efforts made in community
  settings to provide social support for increasing
  physically activity are effective. Based on this
  review, the Task Force issued a strong
  recommendation to implement these efforts.
• Background on the Interventions
• These interventions focus on changing physical
  activity behavior through building,
  strengthening, and maintaining social networks
  that provide supportive relationships for
  behavior change (e.g., setting up a buddy system,
  making contracts with others to complete
  specified levels of physical activity, or setting
  up walking groups or other groups to provide
  friendship and support).
• Interventions included in the review involved
  either creating new social networks or working
  within existing networks in a social setting
  outside the family, such as in the workplace.
• Findings from the Systematic Review
• In all 9 studies reviewed, social support
  interventions in community settings were
  effective in getting people to be more physically
  active, as measured by various indicators (e.g.,
  blocks walked or flights of stairs climbed daily,
  frequency of attending exercise sessions, or
  minutes spent in physical activity).
• The median estimates from the reviewed studies
  suggest that social support interventions in
  community settings can result in a 44 increase
  in time spent being physically active and a 20
  increase in the frequency of physical activity.
• These interventions also improved participants
  fitness levels, lowered their percentage of body
  fat, increased their knowledge about exercise,
  and improved their confidence in their ability to
  exercise.
• These interventions were effective in various
  settings including communities, worksites, and
  universities, among men and women, adults of
  different ages, and both sedentary people and
  those who were already active.