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June 24, 2010

On Health — Diabetes:

Pitt experts examine the issues

applesIncreasingly, studies have shown, people are seeking health-related information. A recent Pew Internet study found that 80 percent of Americans with Internet access turn to the web for answers to their medical and health questions.

But three-quarters of consumers fail to check how reliable and how current that information is, the study revealed.

In an effort to detangle some of the overload of health information that is out there, this occasional University Times series, On Health, is turning to Pitt experts for current — and reliable — information on some of today’s major health-related topics.

The statistics are downright staggering. According to the American Diabetes Association, more than 23 million people, or 10.7 percent of all adults in the United States — a number that’s increasing rapidly — are estimated to have diabetes, the group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.

It is believed that 5.7 million of these do not know they have the disease. The number of people diagnosed with diabetes rose from 1.5 million in 1958 to 17.9 million in 2007, an increase of epidemic proportions.

Other facts about diabetes:

• Type 2 (previously called non-insulin-dependent or adult-onset) diabetes accounts for 90-95 percent of all diagnosed cases.

• Minorities are disproportionately affected: 14.7 percent of all non-Hispanic blacks age 20 and older are estimated to have diabetes.

• Diabetes is the seventh leading cause of death in the United States — responsible for 17 percent of all deaths after age 25. The overall risk of death among people with diabetes is double that of people without the disease.

• Diabetes is the leading cause of new blindness, end-stage renal disease and amputation. It increases the risk of heart attack and stroke at least three-fold.

• Medical expenditures for a person with diabetes average $11,744 annually, more than twice the cost for someone without diabetes.

• Total health care and related costs for diabetes run about $174 billion annually. Direct medical costs (e.g., hospitalizations, medical care, treatment supplies) account for about $116 billion of that total.

• If trends continue, it’s estimated that one in three people born in 2000, and one in two minorities, will develop diabetes.

Moreover, it is estimated that an additional 57 million adults have pre-diabetes, a condition where blood glucose levels are higher than normal but not high enough to be called diabetes.

About the only good news is that studies, including those conducted by University researchers, have shown that by losing weight and increasing physical activity people can prevent or delay pre-diabetes from becoming full-blown diabetes.

Six Pitt diabetes specialists recently discussed their work with University Times staff writer Peter Hart and projected trends for diabetes care, prevention, education and research.


Linda Siminerio

Linda Siminerio, executive director of the University of Pittsburgh Diabetes Institute, is cautiously optimistic about progress in meeting the challenges of the diabetes epidemic. The institute serves as the umbrella organization under which diabetes prevention, education, treatment and research are coordinated at Pitt and UPMC.

“I’m encouraged. We’re looking more and more at preventing diabetes, at lifestyle interventions, and Pitt is at the forefront of this,” said Siminerio, who also is U.S. spokesperson for the International Diabetes Federation and a legislative advocate for diabetes prevention programs.

“But it’s going to take a lot of things to get the epidemic in check. The big thing is behavior change,” Siminerio said.

Several planks in the national health care reform legislation are diabetes-specific, including:

• Providing grants for community organizations to establish lifestyle intervention programs and to improve screening efforts in the senior population;

• Funding the development of training outreach programs, and

• Creating a national diabetes report card by collecting vital statistics.

There are two main types of diabetes, accounting for more than 95 percent of cases, Siminerio explained. (A third, least common type, is gestational diabetes, a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy.)

Both Type 1 and Type 2 diabetes involve how the body responds to blood sugar. When food is digested, it’s broken down into sugar and sent into the bloodstream. As blood sugar rises, the brain tells the pancreas to make insulin, which causes the glucose to be sent into fat, liver and muscle cells for storage or to be used as energy.

Siminerio said that Type 1 diabetes (commonly known as juvenile diabetes) is an autoimmune disease in which the body attacks and destroys its own insulin-producing islet cells in the pancreas. Those with Type 1 diabetes need insulin injections to survive.

Type 2, the most common form of diabetes, is insulin resistance, she explained. The pancreas makes insulin, but the body’s cells push the sugar back into the bloodstream. The pancreas works harder and eventually gets worn out. Medications can treat insulin resistance.

Research findings have changed the way people think about diabetes and its treatment. One Pitt study of  more than 1,400 diabetics verified the value of intensified care: multiple daily insulin shots; regular glucose testing; close monitoring of diet, and individualized support to keep blood sugar at or near normal.

The 10-year study was ended early when it showed how dramatically such care reduced the risk of diabetes complications: Blindness was reduced by 76 percent; kidney disease declined by 56 percent, and nerve disease complications dropped by 60 percent.

But, Siminerio said, the current health care system does not support this kind of care. “Under our reward system, you only get paid to treat the disease, not to get patients to lose weight, for example. The whole thing is out of whack,” she maintained.

She is trying to change that system. Her work at Pitt’s Diabetes Institute has led to the chronic care model for improved health care delivery. The institute has developed 26 diabetes self-management education programs, one of the largest networks in the country. The aim of the programs, which have been recognized by the American Diabetes Association, is to expand diabetes research; provide educational programs for physicians and other caregivers to bring state-of-the-art diagnostic efforts to individuals; create community intervention and education programs, and expand the use of telemedicine tools, including an electronic diabetes medical record and a portal for patients.

“We’re coming at this from all sides,” Siminerio said. “The goal of the model is to have an activated, informed patient who is able to self-manage the condition.”

She advocates team preventive medicine, which requires changing the health care delivery system. “I do not need to see an endocrinologist on every visit. I might need to see the pharmacist, or the nurse, so we need to expand the education and training to more groups of health care professionals,” she said.

“What the chronic care model has is all those elements that overlap: community resources and policies; health care organizations, which have as subsets delivery system design, decision support, clinical information systems,” Siminerio said.

“The most important element, though, is self-management: How do we help you manage your condition? That concept is new. We’ve never done that before, but our research has shown it greatly improves outcomes,” she said.

“We do know that good diabetes control helps prevent complications, but if a diabetic already has complications, the condition becomes hard to manage every day. The treatments, the medications, are complicated. So self-management education is to me the most important step.”

Integrating technology into health care will be a key to combating the diabetes epidemic, Siminerio said.

Pitt has developed a telemedicine project that enables patients to be seen remotely, which is  one way of handling the national shortage of endocrinologists.

One result of all the renewed attention on diabetes and a shift to the team-care model will be the economic boost of creating different kinds of health care jobs.

“That’s one aspect with a positive economic benefit: to look at roles and training differently,” Siminerio said.

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