Type 2 Diabetes

AACE recently created a statement called “Policy for the Elimination of Healthcare Disparities in the USA.” This statement asserts:

AACE actively opposes the continued existence of endocrine healthcare disparities in the USA, and will devote its resources to diminish these disparities. AACE members, staff, partners and others with whom AACE interacts will continue to advocate for understanding, prevention and elimination of endocrine healthcare disparities.

(To read the full position statement, visit www.aace.com/publications/position-statements.)

But why does AACE have a statement on healthcare disparities? Why make this a focus for members of AACE? The answer is because AACE believes that to best treat people with endocrine diseases all medical professionals must be aware of the many differences that make one person different from the next. This includes:

• The different risks and impact certain diseases may have on them
• What the best choice of therapy is
• Access to care
• The ability to afford medical care.

So what does this really mean?

Let’s take a look at diabetes.

In the US, there is a higher incidence of type 2 diabetes [dye-uh-BEE-teez] (the most common form of diabetes) in Latino, Asian, and African American people compared with white people. The reasons for this are not known. Some people might be more likely to get diabetes, partly, because of how well the insulin made in their body works.

In 2009 more than 14% of American Indians and Alaska natives over 19 years old who received care from the Indian Health Service had diabetes. Rates varied a great deal depending on the region of the country that they came from. For example, about 5% of Alaska native adults had diabetes. Yet more than 33% of American Indian adults living in southern Arizona had diabetes. See below for the big difference in diabetes between ethnic groups and subgroups.

Risk of Developing Diabetes Compared to Non-Latino Whites

• Asian Americans: 18% higher
• Latinos: 66% higher
• African Americans: 77% higher

Risk of Developing Diabetes Among Latino Compared With Non-Latino Whites:

• Mexican Americans: 87% higher
• Puerto Ricans: 94% higher
• Cubans: Equal
• Central Americans: Equal
• South Americans: Equal

Clearly, there are different rates of diabetes in different populations.

What about prediabetes progressing to diabetes?

About 60 million Americans have prediabetes [PREEdye-uh-BEE-teez]. People with prediabetes have blood sugar levels that are higher than normal but not high enough to be diagnosed as diabetes. People with prediabetes are more likely to end up with diabetes than those with normal blood sugars. It is not known if ethnicity is a risk factor for going from prediabetes to diabetes. The Diabetes Prevention Program looked at whether people at very high risk of diabetes that
exercised and made changes to their diet and lost weight could avoid getting diabetes. People with a high fasting blood sugar level, whether of white, African American, Latino, American Indian or Asian ethnicity, all got diabetes at an equal rate. But this finding was very different from earlier studies done in San Antonio and Colorado. The earlier studies found that Latino people in a prediabetes state had a higher risk of developing diabetes than non-Latino whites. More studies are needed for us to know whether one group is more likely than another to develop diabetes.

We also do not know if diabetes drugs might lower the risk of developing diabetes. In the Diabetes Prevention Program taking metformin [met-FOR-min] (a common diabetes treatment) lowered the risk of developing diabetes. But there was no difference in risk reduction due to ethnicity. Yet other studies have shown very different results. In a study called the DREAM study (in which people took rosiglitazone [ROE-zi-GLI-ta-zone]), progression to diabetes in those with prediabetes went down by more than 40% in all ethnic groups. But the reduction was smaller in South Asians and greater in Latinos. Differences in age, sex, body mass index (a measure of weight, taking into account also height or a measurement of waist–hip ratio) did not explain the difference seen by ethnicity.

So prevention of diabetes in different ethnic populations remains confusing as to what might or might not work. More research is clearly needed!

What about diabetes complications?

African Americans and Latinos in the US have a higher risk of end-stage kidney disease and diabetes eye disease. Although eye exams find effects of diabetes on the eye, African Americans have fewer eye exams than others for diabetes eye disease. On the other hand, Asians with diabetes have a lower risk of heart attack and foot amputation compared with whites.

Should treatment of diabetes and/or diabetes complications be different in different ethnicities?

People with diabetes are at greater risk for heart disease and heart attacks than the general population. African Americans with diabetes are more likely than whites to have a bad lipid profile, which puts them at high risk for heart disease. African Americans generally need to focus on improving LDL and HDL levels, and whites generally need to pay more attention to triglycerides [try-GLIS-er-ides].

In perspective

We just reviewed differences in only one disease. There are differences seen in race, sex, economic status, and country of origin that relate to many conditions, such as bone disease, obesity, high blood pressure, and other conditions that have not even been studied as much as diabetes. Education and research needs to be supported so that we can prevent or at least better manage these conditions among different groups. To do this we need to address the issues of access to care as well as its cost, which contributes to healthcare disparities in the US.

Dr. Trence is Director of the Diabetes Care Center and Associate Professor of Medicine at the University of Washington Medical Center in Seattle. She is also the University of Washington Endocrine Fellowship Program Director and Director of Endocrine Days, a medical education program for endocrinologists practicing in the Pacific Northwest. She is on the Board of Trustees for the American College of Endocrinology, chairs the AACE CME committee and is co-editor of EmPower Magazine.

Rates of new cases of diabetes (mainly type 2) have soared in the United States over the last 20 years. One of the ethnic groups with the greatest rise is the African American population. Over 12% of African Americans have diabetes. Women and the elderly have the highest rates. One in four African-American women over age 55 has diabetes and 25% of African Americans between the ages of 65 and 74 are affected. African Americans are almost two times more likely to have diabetes than non-Latino whites.

Why are some people more prone to diabetes than others?

We don’t know exactly why. Some scientists believe that African Americans inherited a “thrifty gene” from their African ancestors. This gene helped Africans “store up” food in their bodies during abundant times and use food energy efficiently during periods of famine. But now that food is abundant for many Americans, this thrifty gene is making many African Americans get diabetes because they are becoming obese. Some studies show that there is a problem in how insulin is put into the blood stream (secreted) and how well it works (sensitivity or resistance) in African Americans compared with non-Latino white people. This may explain why they are more likely to develop diabetes. The number of African Americans that are overweight and/or obese has risen significantly in the last 50 years. This is partly because people tend to have jobs that aren’t as physical as they used to be. Also, the diet has changed to eating more high-calorie cheap foods that are rich in carbohydrates and saturated fats but low in fiber.

What other factors affect diabetes care for African Americans?

In the US, African Americans with diabetes are less likely to get routine diabetes care and services to prevent complications. They also have higher blood sugar levels than non-Latino whites. Major health care barriers include less access to health services and low income and education. Compared with non-Latino whites, African Americans have more joblessness, lower income, and are more likely to be uninsured or on programs like Medicaid. Many African Americans receive medical care from community health centers in their neighborhood. However, these facilities are usually subsidized by the government and have much less resources than private health clinics. More and more doctors no longer see patients with Medicaid because they don’t get proper reimbursement. This further limits access to quality health services.

Many African American patients with insurance cannot afford out-of-pocket health expenses for their drugs, diabetes testing supplies, and healthier foods that they should be eating. Thus, these patients are not able to stick to their treatment plan. Many live in areas that are unsafe for outdoor exercise and have very few sources for fresh fruits and vegetables. It is important to note that differences in social status and access to care do not fully explain why African Americans have poorer control of diabetes. African American patients with diabetes tend to receive lower quality of diabetes care even when they have the same health insurance and receive care in the same setting as non-Latino whites. The cause of health care differences among insured populations is an active area of research. Studies suggest that diabetes care is better when health care providers understand African American culture and design therapy taking this into account.

Other factors are associated with poor diabetes outcomes in African Americans. African Americans are less likely to take their medications or monitor their blood sugar every day. They are more likely to miss medical appointments. They may not have the money to take their medications as directed. African American patients often report that they don’t understand instructions about their medical treatment and don’t know their target blood glucose. Many African Americans with diabetes often feel that there is nothing they can do to change things about their disease, so they stop trying. Men especially distrust the medical system because of past racial injustice. African Americans also have a more relaxed attitude towards overweight body image. This may also result in a tendency toward diabetes. Overweight has been seen as a sign of good health while being thin is associated with stigma of disease or drug use.

How can diabetes complications be prevented ?

Despite the higher prevalence and complications from diabetes, African Americans can prevent many complications by improving their diabetes control. Diabetes can also be prevented in this ethnic group by adopting a healthier lifestyle. In the Diabetes Prevention program study, which was a multi-ethnic study, healthy diet and exercise reduced the incidence of diabetes by 58%, and was better than taking medication. The lifestyle group achieved this significant reduction in risk of diabetes by losing just 5%– 7% of their body weight. A recent 10-year study of more than 200,000 men and women over age 50 found that the risk of diabetes was lowest among those with five healthy behaviors:

• Maintaining a normal body weight (BMI below 25)
• Never smoking or smoke-free for over 10 years
• Doing at least 20 minutes of intense activity more than three days a week
• Consuming a healthy diet
• Drinking very little alcohol.

A person’s risk of diabetes was lower the more healthy behaviors they had. These five healthy behaviors lowered diabetes risk even in those with a family history of diabetes.

If you are at risk for diabetes you must adopt healthy lifestyle habits and make sure that you are routinely screened for diabetes. One way to do this would be to make sure it is part of your annual physical exam with your health care provider.

If you are currently living with diabetes, there are many things you can do to improve your care and help your medical team provide better care to you. In most instances, this team will consist of a variety of health care providers like doctors, nurses, dietitians and diabetes educators. The more active part you play in managing your diabetes, the better your blood sugar control will be.

Healthy habits that positively impact your diabetes control include:

• Taking your medications as directed
• Checking blood sugar levels on a regular basis
• Taking good care of your feet
• Keeping your medical appointments
• Doing regular physical activity
• Eating a healthy diet rich in complex carbohydrates and low in simple sugars and saturated fat
• Medical visits:
  • Routine visits with your medical team
  • Yearly eye exam to screen for changes related to diabetes
  • Foot check-ups with the podiatrist.

What to do to prepare for your medical appointments

• Bring a list of your medications, blood glucose log and meter.
• Ask questions about things you do not understand.
• Learn about how the medications you take for your diabetes work to keep your blood sugar levels normal.
• Make a list of questions and bring them with you.
• Speak to your team about any concerns you have about side effects of medications you are taking. We now have a variety of medications for diabetes so your doctor may be able to switch you to something else.
• Let your team know if you cannot afford your medications or testing supplies so that they can design a more affordable diabetes treatment plan.
• Know what an A1C level is and know your target A1C (estimate your average blood sugar level in the last three months). The goal A1C according to the American Association of Clinical Endocrinologists (AACE) is 6.5%, which equals an average blood sugar level of 126 mg/dL, but may be higher for some people with diabetes who have other medical conditions.

Other Related Conditions

Heart disease remains the number one cause of death for people with diabetes in this country. So, in addition to controlling your blood sugar levels, you have to take care of the other risk factors for heart disease like high cholesterol, hypertension, and smoking. Your blood pressure should be less than 130/80 mm Hg and target for LDL (bad cholesterol) is under 100mg/dL, or under 70mg/dL if you already have heart disease. Create a chart to keep track of your A1C, LDL,
and blood pressure levels. If your blood pressure, A1C, or LDL levels are higher than desired, find out from your doctor how your treatment plan will be changed to achieve this.

In managing a chronic condition like diabetes, a positive outlook is essential. There will be times when you feel tired of testing the blood sugar or exercising or paying very close attention to your diet. Some people feel very guilty about this and stop coming to medical appointments. This is the wrong approach to take. This is the time to lean on your diabetes team. Let them know where you are struggling so they can help you get back on track.

Dr. Okeke is an endocrinologist at Joslin Diabetes Center. She is interested in multicultural diabetes care, specifically the disparities in diabetes care that exist for patients from minority ethnic groups, and ways to develop culturally competent diabetes programs for minority patients. Dr. Okeke is also a staff endocrinologist at Harvard Vanguard Medical Associates.

*We would like to thank Tarin Jackson for her role in developing this article.

Type 2 Diabetes in Kids and Adolescents
By A. Jay Cohen, MD, FACE

We need two basic substances to get into every cell in our body, oxygen and fuel (mostly in the form of glucose). While oxygen can easily zip into our cells from the blood stream without any extra work, getting glucose (fuel) into the cell is more complex. Cells require a key (insulin) to open the doors (receptors) and allow glucose into the cell. These doors have hinges, door handles and key holes. In our everyday life, if you have a small amount of insulin (keys), it’s easy to open the doors and our cells easily obtain food (mostly glucose or sugar) from the bloodstream.

Type 1 diabetes is a disease in which the body does not make enough insulin because, usually, there is an (autoimmune) attack on the beta cells of the pancreas, which gradually destroy the ability to make insulin; therefore, with no “keys,” the doors of the cells cannot open, resulting in the cells starving within a sea (bloodstream) of extra food (glucose, etc.).

In type 2 diabetes, many problems develop as the person usually becomes more overweight (with less exercise and eating more calories). Initially, the door hinges, door handles and keyholes get progressively stuck or “gunky” or “rusty” resulting in resistance to the usual number of keys (insulin resistance). In order to open the doors (receptors) to get food into the cells, our cells call out for additional insulin (hyperinsulinemia) and food. At first, this can work, but gradually the pancreas wears out; it cannot continue to make massive amounts of insulin and it starts to decrease the insulin secretion. Our usual storage sites for food in the body (liver and fat cells) may actually produce extra glucose and fat to attempt to supply the rest of the body with food,because the peripheral cells (mostly muscle cells) do not know there already is enough food in the blood stream. This results in elevated glucose levels in the blood stream. Whew!!!

Type 2 diabetes has become much more common in kids and teens in the United States over the last 10 years, especially in those who are overweight. Between 10 and 50 percent of children with a new diagnosis of diabetes may have the form known as type 2 diabetes. This disease was almost unheard of 20 years ago. It is especially common in Hispanic youth, African Americans, Asian/Pacific Islanders and American Indian youth, but can occur in anybody. The rapid rise in obesity, not being physically active and consumption of excessive calories seems to have led to the epidemic of children with type 2 diabetes. About 50 to 90 percent of kids and adolescents with type 2 diabetes have a parent or close relative that also has type 2 diabetes.

Associated problems can include obesity, high blood pressure (hypertension), elevated cholesterol and fat levels in the blood stream (hyperlipidemia), irregular menses and potential risks of infertility (polycystic ovarian syndrome), and a darkened, rough skin condition in the creases of the skin (acanthosis nigricans). When these problems cluster together, they may be called metabolic syndrome. Children with type 2 diabetes are at an accelerated risk for the long-term complications of diabetes, including heart disease, stroke, kidney disease and nerve damage.

How do you treat type 2 diabetes?

First, we want to prevent the disease. Daily exercise for 60 minutes, decreasing obesity, eating healthy foods with the right portion size is a good first step. Treatment of type 2 diabetes takes multiple steps working together:

• Develop a total treatment plan with your endocrinologist.
• Educate the child/adolescent and the entire family.
• Involve your school, faith-based organizations, neighbors and community.
• Learn healthy food choices, proper portion sizes and develop an eating plan.
• Exercise every day; we breathe and eat every day, so it’s time to exercise every day.
• Check blood glucose levels, write them down and discuss with your doctor.
• Set a good example as a parent. You have to also perform all of these tasks daily.
• Take medication as prescribed, if needed. Compliance is important.
• Aggressive management of possible associated problems is a key, including elevated blood pressure, cholesterol and fat levels.
• Continue daily working on overall health goals.

Thanks and good luck!

Work as a team with your endocrinologist.

A. Jay Cohen, MD, FACE, is the Medical Director at The Endocrine Clinic, P.C. He is also Clinical Assistant Professor in the Department of Family Medicine at the University of Tennessee and Clinical Associate Professor in the Department of Pharmacology at the University of Tennessee; Director of the Diabetes Advisory Panel at St. Francis Hospital; and a consultant in endocrinology at St. Jude Children’s Research Hospital. He is actively engaged in numerous phase 2 and 3 endocrine clinical research studies in areas such as inhaled insulins, new type 1 and 2 diabetes agents, novel osteoporosis agents, new androgen therapies, and long acting growth hormones. He is a primary investigator into humanized anti-CD3 monoclonal antibodies to potentially cure type 1 diabetes.

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Through the Lens of a Diabetes Patient
By Sarah Senn

David Mendosa is a celebrity in the online diabetes community. He is one of the Internet’s most prolific writers on the topic. Like many others, David did not know what to expect when he was diagnosed with type 2 diabetes. His insightful and research-packed blog entries on topics such as diabetes testing are read by thousands.

In 1994, David went to see his physician because of pain he was having. The doctor ordered blood tests and one showed that his A1c level was dangerously high, at 14.4 percent. David recalls the doctor asking, “Has anyone ever told you that you have diabetes?” The answer was no.

“That diagnosis changed my life,” David explains, “I was enjoying my independence. Life had been so easy that I had put on more than a few pounds.”

Before being diagnosed with diabetes, David served as a Foreign Service Officer in the US government for 15 years. In 1980, he became a freelance writer for a small business magazine. Shortly after his diagnosis in 1994, David decided to put his knack for writing to use discussing something he knew about first-hand— living with diabetes. As a journalist, he already knew how to captivate an audience, and hoped to inspire others by writing about his experiences and success.

To control his diabetes, David started a low-carbohydrate diet, and took anti-diabetic medication for several years. Today, David manages his diabetes with a healthy diet, an exercise program, and with regular visits to his doctor. As a result of his new lifestyle modifications, David brought his weight down from 313 lbs to his current 152 lbs. He has been able to keep the weight off for several years. David has also maintained a lower A1c level, his most recent test result at 4.8 percent.

“I’ve never been healthier or happier,” he exclaims.

David is too busy to let diabetes take control of his life, so he’s taken control of his diabetes. Now at age 73, David is an active voice in the online diabetes community. He is a contributing author to a variety of diabetes publications, and is a diabetes consultant for HealthCentral.com, a leading health information Web site for patients.

David notes that staying active is essential in maintaining his condition. As an avid hiker, photographer, freelance writer and diabetes patient, he encourages other people who have diabetes to find ways to have fun with their exercise. David hopes to motivate others with his blog, “Fitness and Photography for Fun,” which integrates his need to exercise with his loves for hiking and photography. Since being diagnosed with type 2 diabetes, David has hiked through parks along the Pacific Coast and over mountain trails across Colorado. He has even crossed the Continental Divide on foot. You can visit David’s fitness blog at

http://www.mendosa.com/fitnessblog/.

Looking back on his experiences, David says, “What people with diabetes have to do to control their disease is exactly what everyone has to do to prevent it.”

For more information about David Mendosa, visit www.mendosa.com.

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HOW DOES OBESITY RELATE TO TYPE 2 DIABETES MELLITUS?

Obesity is a biological and treatable disease. This condition has physical, metabolic and psychological complications that take away from our health. The metabolic complications of obesity develop gradually. It increases the risk of heart attacks and stroke. Obesity is not a character flaw, and it is not just about the pant size or the looks. Obesity is not something we wish on ourselves, and it is not our fault if we have it. Some say that people with obesity lack character or will, and their opinion is naive. In reality, there are a myriad of biological processes that together cause the accumulation of fat mass.

Our body is like a car: it needs to be refueled, and waste needs to be removed. Fuels come from what we eat. Each meal gets digested to protein, carbohydrate and fat. In turn, the intestines absorb the building blocks of each of these nutrients. In the blood we get circulating fats (cholesterol and triglycerides), circulating sugar (glucose), and the building blocks of proteins (amino acids).

Energy balance is the relationship between the calories that we ingest and the calories we burn every day. Energy balance is negative if we burn more calories than we ingest. In this situation we may need to borrow calories from energy stores. Over time a negative energy balance leads to fat weight loss. Energy balance is positive if we ingest more calories than we burn. We are very good at storing these excess ingested calories in fat cells, also called adipocytes. Over time a positive energy balance leads to fat weight gain. Individual adipocytes get bigger and bigger (hypertrophy). Fat deposits get redistributed with weight gain. Some fat pools, especially the fat inside of the abdominal cavity, may then cause disease.

Hormones are substances that are made in a part of the body, enter the circulation, and have biological effects in other parts of the body. They help regulate our internal environment and, therefore, play a crucial role in regulating our weight. When hormones do not work properly, illness develops. Insulin is a hormone made in the beta cells of the pancreas. Insulin works like the hose and nozzle at the gas station, it moves fuel. At the gas station the hose and nozzle move gasoline from the gas pump into a car’s gas tank. Similarly, insulin moves fuels from the circulation into cells. The major fuels that insulin helps move are glucose and triglycerides. When insulin does not work, glucose and triglycerides do not go into cells, they stay in the circulation. This makes the blood sugar and blood triglycerides rise. If the blood sugar goes up enough, an individual can develop type 2 diabetes mellitus.

Type 2 diabetes mellitus is caused by the accumulation of fat in most people. Fat inside the abdominal cavity, also known as visceral fat, causes insulin resistance. Visceral fat becomes a treatment target for patients with diabetes. The best measure of visceral fat is the waist circumference. The more overweight a person is, the bigger the waist circumference, and the bigger the waist circumference, the higher the risk of getting diabetes.

Weight loss makes blood sugar control easier, and can prevent diabetes in the first place. Even modest weight loss has tremendous benefits!

HOW DO I LOSE OR CONTROL WEIGHT AND PREVENT OR TREAT DIABETES?

Your current behavior needs to be modified. To lose weight you have to achieve a negative energy balance. Your caloric expenditure needs to be more than your caloric intake. The National Diabetes Education Program, a joint venture of the NIH and CDE, which AACE and ACE support, has a program that you can embrace, “Small Steps: Big Rewards.”

■ Increase your caloric expenditure.

• Get regular physical activity.
• Try to be physically active at least 30 minutes every day.
• If you are able, go for a brisk walk, participate in sports, start dancing classes, or engage in active games (Frisbee, sledding, making snowmen or snow angels, etc.)
• If you are very overweight remember this: a two minute walk every hour on the hour becomes a 30-minute walk at the end of the day. Every hour stand up, walk away for a minute, and then walk back. Two little minutes add up!
• Decrease your caloric intake.

The most important thing to do is limit portion sizes. Always go small!

• Eat healthy meals rich in vegetables, fruits, and whole grains. try to eat 10 servings of fresh fruits or vegetables every day.
• Eat less refined carbohydrates, such as sweets and white bread.
• Limit the amount of high-sugar beverages you drink, such as soft drinks and fruit punches.
• Limit the intake of high-fat foods like ice cream, butter, peanut butter and high-fat meats.
• Limit alcohol to no more than 1 drink per day for women, 2 per day for men. Avoid drinking alcoholic beverages if you have any difficulty controlling them.
• Always eat a balanced breakfast, and try to place most of your daily calories with this morning meal.
• Have a small dinner and don’t eat after 7 p.m.

■ Aim to lose 5 to 10 percent of your current body weight over the next 6-12 months.

• For a 240-pound person, this is 1-4 lbs. per month.
• Losing weight too fast can be unhealthy and often leads to rebound weight gain.
• The three keys to success with weight management are patience, persistence, and realism. Set goals that you can realistically achieve, and give yourself the time to meet these weight loss goals.

■ Get your family and friends involved!

• When your support people work with you, success is easier!
• Encourage your family and friends to eat healthy meals and be active with you.
• Put peer pressure on everyone around you to be healthier.

Good nutrition and increased physical activity are lifestyle changes that must be continued long-term to keep weight off and have better diabetes control.

The bottom line is this:

Focus on being the healthiest person you can be every day. Think of every day as an opportunity to have better nutrition and more physical activity. Medications are simply tools that your endocrinologist puts in your hands to help you. Have a healthy day every day. Then the weight will go down and the diabetes will improve!

Ayesha Ebrahim, MD, FACE, is board-certified in Internal Medicine and Endocrinology. Dr. Ebrahim earned her medical degree from King Edward Medical College in Lahore, Pakistan, in 1995, and completed a two-year Endocrinology and Metabolism Fellowship at New York Medical College. She provides endocrinology care for adolescents and adults.

J. Michael González-Campoy, MD, PhD, FACE, is Medical Director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME). He earned his MD and PhD from Mayo Medical School and Mayo Graduate School of Medicine in 1991. He is board certified in Endocrinology, Diabetes and Metabolism. Dr. González-Campoy is a recognized national expert on diabetes and obesity and a proponent of adiposopathy as a treatment target. Dr. González-Campoy is Clinical Assistant Professor of Medicine at the University of Minnesota.

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