Type Two Diabetes: Successful Interventions for Chronic Disease Prevention

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Abstract

In this paper, we will look at type 2 diabetes.  Type 2 diabetes is a chronic illness related to glucose levels which decrease the quality of life in patients and adds considerable risk for complications like cardiovascular, renal, and heart disease.  It is a serious chronic disease that affects large portions of the population, but it affects the African and Latino population most drastically, both in the occurrence of diabetes and also in diabetic complications.  There is some debate as to why this community suffers at much greater rates than other communities, but it seems due to primarily social factors.  We will look at a successful intervention which relied on both individual behavior modification theory and social cognitive theory as a way to educate this community on better self-management for diabetic care.

Problem Description

Type 2 diabetes is a particularly prevalent chronic disease that significantly affects a large portion of the population.  It is estimated that around thirty million people in the U.S. alone suffer from diabetes, with Type 2 being the most common (Nichols, 2017).  This amounts to nearly ten percent of the entire U.S. population.

It is sometimes distinguished from other types of diabetes by another name, “adult-onset” diabetes because it is usually acquired along the lifespan.  From a biological perspective, type 2 diabetes occurs when the adipose and muscle cells lose their sensitivity to the action of insulin, or when the pancreas produces less insulin than is needed by the body; in both cases, the result is an increase in glucose levels (Bonat & Arcangelo, 2006).  

The symptoms of diabetes are wide-ranging.  The body may experience increased feelings of hunger or thirst despite adequate intake, along with increased rates of urination.  Someone with diabetes may also suffer from weight loss due to the body burning through muscle and fat instead of glucose.  Fatigue, blurred vision, and infections are all possible symptoms as well (Mayo, 2018).  When glucose levels are too high, the nervous system can be affected as well, causing nerve damage (Leontis & Hess-Fischl, 2016).  As a result of hypoglycemia, there also be symptoms like anxiety, increased heart rate, and sweating (Leontis & Hess-Fischl, 2016).  As diabetes progresses it can cause a variety of very serious complications, many of which are life-threatening.  The overall and general strain placed on the body from high blood sugar levels often places undue stress on internal organs, and as a result, diabetics are at a higher risk for cardiovascular disease, kidney disease, and strokes—each of which can be deadly in their own respects.

Type 2 Diabetes is a chronic disease which usually requires life-long management.  Diabetic symptoms by themselves are very uncomfortable and can decrease the quality of life.  Common pharmacological strategies for managing diabetes include insulin and metformin, with insulin first being used to control glucose levels with metformin being added afterward; these types of pharmacological strategies can be frustrating and life-disrupting due to the intravenous administration of the drugs as well as the possibility of side effects such as weight gain and even hypoglycemia (Peterson et al., 2007; Lebowitz, 2011).  With regard to diabetic complications, the need to manage the disease becomes more urgent.  Diabetic complications like kidney disease, cardiovascular disease, stroke, etc. all have their own reactive treatments and strategies as well.

In sum, type 2 diabetes is a very serious illness.  By itself, it can significantly decrease the quality of life and it often leads to serious health complications down the road.  It is almost as common as it is serious, with nearly ten percent of the population suffering from it.

Population Description

As just noted, diabetes affects many people.  However, the American Diabetes Association (2018) identifies minority groups as being at special risk for type 2 diabetes.  These include African Americans, Mexican Americans, and American Indians.  The higher rate of obesity in these communities is believed to be related to the higher rate of type 2 diabetes.  For this paper, we will focus on the African American community, as they are disproportionately at risk of diabetes.

The rate at which diabetes is onset in the African American community is in stark disparity with other communities.  The United States Office of Minority Health, under the supervision of the US Department of Health and Human Services, provides some fairly startling statistics, which are accurate as of 2016.  For one, the total prevalence of diabetes in the African American Community compared to the white community is virtually double, with nearly ten percent of the community suffering from type 2 diabetes while less than six percent in the white community.  They are likewise twice as likely to suffer from a lower-extremity amputation, and at greater rates for associated renal diseases, deaths, and visual impairment.  Across the board, the African American community is usually at twice—or greater—the risk of diabetes or diabetic complications compared to the white community.

Source of the Problem

It is not known with absolute certainty why the African American population suffers so disproportionately from diabetes.  Several ideas exist, however, and we will survey them briefly here.  

Probably the most contested source of the problem is genetics.  As Signorello et al. (2007) point out since prevalence rates among Whites exceeded those among African Americans through at least the first half of the 20th century [it has been hypothesized] that modern lifestyle factors (especially those that promote obesity) may have a greater effect on African Americans than Whites. (Sec 1)

Yet “treating race as an etiological factor has been the subject of debate,” with many arguing that race is a complex mixture of not just genetic but also behavioral, environmental, and social exposures (Signorello, 2007, Sec 1).  Yet, in their own study which attempted to control for various socioeconomic factors, they were unable to completely explain the disparity between white and African American diabetes rates and concluded that diabetes is at least genetically influenced to some degree (Signorello, 2007, Sec 9).  

The degree to which it is influenced is debated, though.  It is commonly agreed that “in comparison with Whites, African Americans often are poorer, have less education, are more likely to live in distressed households and communities, are less able to access quality health care, and have a less favorable risk factor profile for many diseases” (Signorello, 2007, Sec 1).  The preponderance of these relevant socio-economic indicators suggests that to some degree, the African American community’s higher prevalence of diabetes is related to lower rates of advantages, education, health access, etc.  So, while research suggests some genetic factor in the disease, it also does not close off the possibility that socioeconomic factors play as large, if not even a larger role.  After all, lower rates of health literacy, education, health care, healthcare access, point of care testing, healthcare quality, etc. in the African American community might be compared to higher levels of each of these things in the white community, thus explaining a large part of the discrepancy away due to these environmental factors rather than genetic factors for either side.

Besides, the statistics do not just say that African Americans are at a greater risk for diabetes.  They are also at a greater risk for diabetic complications, like amputation, vision failure, renal disease, and so on.  If it were only the case that African Americans have diabetic onsets at a higher rate while they did not suffer any additional complications, then distilling the source of the problem to genetics might be a fair conclusion.  But the preponderance of diabetic complications is more a matter of treatment strategies (or lack thereof), which pertains far more to health administration than it does to genetics.  Given that, we will be treating the source of the problem as an environmental one, i.e., the plethora of different socioeconomic disadvantages and risk factors common to the African American community.

Successful Intervention

Earlier on in this paper, we noted that diabetes is often treated pharmacologically with a common combination of insulin and metformin.  However, most diabetic strategists place as much emphasis on lifestyle changes to help manage the disease.  In fact, diabetes is a good example of a chronic disease where prevention and treatment often look the same (Bonat & Arcangelo, 2006).  

The successful intervention we will explore called the Diabetes Prevention Program (DPP) and it is a part of the ongoing National Institute of Diabetes and Digestive and Kidney Diseases-sponsored (NIDDK) Diabetes Prevention Program Outcomes Study (DPPOS). We will briefly summarize the intervention and how the program relates to the larger ongoing DPPOS. This was a very comprehensive and integrated program with a variety of components. Researchers are hopeful about this intervention citing its low cost, majority patient-controlled nature, and positive long-term effects. Already it has shown great potential after successful implementation; through a partnership with the Center for Disease Control’s (CDC) National Diabetes Prevention Program, a version of the DDP is available in several YMCA locations around the US (“Diabetes Prevention Program”, 2018).

Most of the program components were self-supporting in nature, but they were not dry; instead, they focused on behavior modification, empowerment, and patient education. The most powerful tools used in the program are readily available to any individual and emphasizes the patients’ own health empowerment. After the study concluded, all participants were given the modified version of the Lifestyle Change Program. 

The DPP followed 3,234 individuals at high risk for type 2 diabetes; of these participants, 55% were of Caucasian ancestry while the remaining 45% consisted of minority groups who hereditarily are at high risk such as those of African, Pacific Islander, or Latino descent. Rounding out the trial were individuals at risk for other reasons such as the women who have experienced gestational diabetes, the elderly, and people with a family history of the disease.

The trial consisted of assigning participants to one of a series of specialized groups designed to aid in type 2 diabetes prevention. The first group, entitled the Lifestyle Change Group (LCG), saw the participants engage in rigorous diet and physical activity; individuals assigned to this group worked out for 150 minutes per week and gradually consumed fewer calories over the course of 3 years to reach the goal of 7 percent body weight loss. To monitor their progress, researchers met with the participants an average of once every 10 days for the first 3 months and afterward every other month with frequent phone calls in the interim. The second group of participants were titled the Metformin Group and given instructions to take 850 mg of metformin twice per day but were only provided with standard diet and exercise advice. The Placebo Group participants were given standard diet and exercise advice as well; however, instead of metformin were given placebo pills. 

The results of this program proved to be significant. After the three years, the entire LCG – including all demographics – enjoyed a lowered chance of developing type 2 diabetes by 58% when compared to the Placebo group. Interesting enough the elderly individuals participating in the LCG saw a much-lowered risk than the rest at 71%. During their tenure as participants of the LCG, about 5% of the group actually developed diabetes; these individuals remained for the duration of the study and some received additional care from their own physicians as needed to control good blood glucose. 

The Metformin Group ended up having a 31% lowered chance of developing type 2 diabetes which represents a lower risk than those provided with placebos but a much higher risk than those engaging in the lifestyle changes of diet and physical activity. This suggests a combination of metformin and a healthy diet paired with sufficient physical activity to be the best way to prevent the disease. Metformin proved most effective for participants of certain groups such as those from ages 25-44, women who have suffered from gestational diabetes, and obese patients with a Body Mass Index (BMI) above 35. 

As a part of the DPPOS after the DPP study ended, the NIDDK followed its participants for 10 years. This effort was an attempt to gauge the DPP’s effect on type 2 diabetes later in life as well as its effect on other diabetes complications such as kidney disease, nerve damage, cardiovascular diseases, and cancer as well as age-related problems like memory trouble or physical functionality. 

After a decade all participants of the Diabetes Prevention Program delayed the development of diabetes by more than 30% compared with the placebo group. The individuals who did develop diabetes did so an average of 4 years later than their placebo group counterparts. Metformin also had a significant positive long-term effect; its users developed diabetes 2 years later than the placebo group. The DPP participants who continued taking metformin or placebo also improved their risk for cardiovascular disease; however, the metformin users achieved this status with use of fewer pharmaceutical medications (“Diabetes Prevention Program”, 2018). 

All in all, this intervention program provides proof that in order to begin to prevent type 2 diabetes the individual needs to take control of their own health in the way of healthy food consumption and some form of physical activity. This approach is laudable because of its ease of use, patient-controlled nature, and its use of low cost and widely accessible tools.

References

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Bonat, J. & Arcangelo, V.P. (2006). Diabetes mellitus. Pharmacotherapeutics for Advanced Practice: A Practical Approach (536).

Diabetes Prevention Program (DPP). (n.d.). Retrieved from https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp

Lebovitz, H.E. (2011). Insulin: Potential negative consequences of early routine use in patients with type 2 diabetes. Diabetes Care (34)2. Retrieved from http://care.diabetesjournals.org/content/34/Supplement_2/S225 

Leontis, L.M. & Hess-Fischl, A. (2016). Type 2 diabetes complications. Endocrine Web. Retrieved from https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-complications 

Nichols, H. & Webberly, H. (2015). Diabetes: The difference between type 1 and type 2 diabetes. Medical News Today. Retrieved from http://www.medicalnewstoday.com/articles/7504.php 

Peek, M. E., Ferguson, M. J., Roberson, T. P., & Chin, M. H. (2014). Putting theory into practice: A case study of diabetes-related behavioral change interventions on Chicago’s south side. Health Promotion Practice, 15(2 0), 40S–50S. http://doi.org/10.1177/1524839914532292

Peterson, K., Silverstein, J., Kaufman, F., & Warren-Boulton, E. (2007). Management of type 2 diabetes in youth: An update. American Family Physician 76(5).  Retrieved from http://www.aafp.org/afp/2007/0901/p658.html 

Signorello, L. B., Schlundt, D. G., Cohen, S. S., Steinwandel, M. D., Buchowski, M. S., McLaughlin, J. K., … Blot, W. J. (2007). Comparing diabetes prevalence between African Americans and whites of similar socioeconomic status. American Journal of Public Health, 97(12), 2260–2267. http://doi.org/10.2105/AJPH.2006.094482

Type 2 Diabetes. (2018). Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/syc-20351193