NurseWeek: Quiet epidemic

Quiet epidemic
With Type 2 diabetes on the rise, nurses encourage patients to adopt – and maintain – healthy habits

By Cathryn Domrose
November 27, 2000
Photo: Corbis

Once a disease of the old and overweight, Type 2 diabetes now accounts for 20 percent of cases of children with diabetes. The majority of affected children have one trait in common: obesity.


	You've read the article. Now tell us what you think. Additional Coverage Diabetes prevention falls short Cut fat, lift weights to stop diabetes It's not how much weight you lose...it's how you keep it off Related Sites Type 2 Diabetes in Children Website American Diabetes Association Continuing Education Take a 1-unit course on diabetes Take a multi-unit course on diabetes Now, a children’s disease The American good life – abundant food, 360 channels, cars outside the doorstep – has not been good for America’s children. It has made them fat, and with that fat has come an explosion of Type 2 diabetes. Once a disease of the old and overweight, Type 2 diabetes now accounts for 20 percent of cases of children with diabetes. The rise has been most pronounced among American Indian youngsters, although children of Hispanic, African-American, Asian and Pacific Island descent are increasingly at risk. The majority of affected children have one trait in common: obesity. None of this surprises Robert Unger, MD, director of Touchstone Diabetes Center at the University of Texas Southwestern Medical Center in Dallas. Childhood obesity, lack of exercise and early-onset diabetes go hand-in-hand. "Our children are programmed from a very early age" toward obesity by a variety of causes that include advertisers hawking junk food and conveniences that have turned exercise into an option rather than a necessity, he said. These young diabetics face a lifetime of management, a situation that is just starting to hit home with pediatric nurses. "The biggest impact so far has been on the school nurse," said Gayle Lorenzi, RN, a certified diabetes educator and chair of the Diabetes Coalition of California. "Suddenly, they have all these children with what used to be a disease of adulthood. They are having to completely rethink treatment programs." So far, however, treatment programs for Type 2 diabetes, which rely heavily on increasing exercise and decreasing calories, have been a hard enough sell with adults who don’t have decades ahead of them before complications arise. As a first step, Lorenzi would like to see the schools bring back physical education, and lots of it "We need to get that back for all kids," she said. "Exercise is so much a part of good health." To that, Unger would add parents who aren’t afraid to turn off the TV or limit junk food. "I think at the public health level, the only real hope is to educate the next generation, to try to block this childhood obesity, because that invariably becomes adult obesity," he said. ~ Diane Sussman

Alma Bell, RN, comes from a family with a history of diabetes. Her grandmother and eight of her grandmother’s siblings had the disease. That puts her in the at-risk category. She has no doubts about what she must do to improve her odds. "I watch what I eat and I exercise," said Bell, nurse consultant for the Texas Department of Health’s diabetes program in Austin. "Those are things that we nurses can certainly be talking about with our patients."

According to recent studies, Type 2 diabetes – the kind that usually strikes adults – is increasing at an alarming rate, especially in people younger than 45. A recent report by the CDC predicts it will continue to increase as obesity – one of the primary indicators for diabetes – takes its toll on many Americans.

But fortunately, most research indicates that diabetes can be managed – and even prevented – through proper diet, exercise and careful monitoring. As traditional health educators and patient advocates, nurses have an important role in helping control what CDC researchers are calling an epidemic.

Right up our alley
"Nurses are trained to educate, support and advise," said Gayle Lorenzi, RN, a certified diabetes educator and chair of the Diabetes Coalition of California and a community health program manager at the University of California, San Diego. "This is right up our alley."

Diabetes mellitus is a group of diseases characterized by abnormally high levels of blood glucose. For various reasons, the body does not properly secrete or respond to insulin, the hormone that helps convert blood sugar to energy. Eventually, high blood glucose levels can lead to complications including blindness, amputations, kidney failure and an increased risk of cardiovascular disease.

"Diabetes is a very complex disease," said Michael Engelgau, MD, MS, a medical epidemiologist in the CDC’s Division of Diabetes Translation. "Every organ in the body can be involved to some degree."

Type 1 diabetes often is detected in childhood and is not related to obesity. Type 2 diabetes, which accounts for 90 percent of 18 million diabetes cases in America, usually strikes adults, especially those who are overweight or who have a family history of the disease.

Certain cultural and ethnic groups, including Hispanics, African Americans and American Indians are considered at risk for the disease, as are women who have had gestational diabetes or who have given birth to babies weighing more than 9 pounds.

According to a CDC study released in September, the prevalence of diagnosed diabetes in the nation has risen 33 percent between 1990 and 1998.

In Texas, an estimated 1.5 million people – about 10 percent of the state’s population – have diabetes. In California, an estimated 2 million people have the disease. In both states, the disease strikes a higher percentage of Hispanics and African Americans. In many cases – about half in Texas, one-third in California – those who have diabetes don’t know it.

"I think it’s the No.1 challenge to the health profession in the country," said Roger Unger, MD, director of the Touchstone Diabetes Center at the University of Texas Southwestern Medical Center in Dallas. "It’s a huge problem and it’s an American problem."

Populations in other countries are not showing the increases in diabetes that Americans are, he said.

Unger and others blame the increase, especially in younger people, on obesity. Cars, television and computers have more people sitting and fewer performing physical labor. While they sit, Unger said, they often eat calorie-laden fast food, chips and candy.

The increase in diabetes also may be due in part to an aging population, researchers say. The risk of getting diabetes increases with age. But according to the CDC report, the prevalence of diabetes jumped almost 70 percent in people 30 to 39 years old, a larger percentage increase than for any other age group.

Fortunately, Engelgau said, research shows that people with diabetes can improve their chances of delaying or avoiding complications by monitoring their blood glucose levels and blood pressure, and through diet and exercise.

Although the research is not complete, some reports also show that people in high-risk categories may be able to prevent getting diabetes by keeping their weight under control and exercising, he said.

Nurses’ health
Data from the Nurses’ Health Study, which follows 70,000 women, shows that one hour of brisk walking each day can cut the risk of developing Type 2 diabetes in half.

"That’s an important message," said Frank Hu, MD, Ph.D., associate professor of nutrition at the Harvard School of Public Health and lead author of the report on diabetes. "The most practical way to prevent diabetes is increasing physical activity and [proper] diet."

Which often is easier said than done, according to nurses who work with people who have diabetes. As a nurse consultant, Bell has known people diagnosed with diabetes who do everything they can to get their weight down and establish exercise routines until they get their blood sugar under control. Then they fall back into their old habits, she said, and the blood sugar goes back up.

"They don’t realize that once you’ve been diagnosed with this disease, you have it," she said, no matter what your blood glucose meter reads.

Jane Hannah, PHN, RN, a certified diabetes educator, works as a public health nurse for the Preventive Health Care for the Aging Program in Orange County, Calif., and is the coordinator of the Senior Diabetes Coalition. She also contracts with hospitals and other health agencies to teach classes for people with diabetes.

Many people first diagnosed with diabetes have a hard time understanding they have a serious chronic illness, she said. They say they don’t feel bad, they don’t understand what’s wrong.

"Diabetes is a progressive illness," she said. "It doesn’t happen overnight."

People with diabetes need to understand that they must monitor their blood sugar and take action before they start to feel bad, she said. As a diabetes educator, Hannah’s job is to teach people how to be good self-managers – to have good glycemic control, stop smoking, get into exercise programs, change their eating habits and reduce their stress levels.

"In my classes, I tell people, ‘You live with yourself 365 days a year,’ " she said. "You see your doctor maybe three or four times."

Because doctors don’t have much time to spend with patients, nurses often are in the best position to work with patients with diabetes. Engelgau said programs where patients checked in regularly with nurse case managers, who checked their blood glucose, weight and blood pressure and gave them information and feedback, have shown great success in controlling glucose levels.

Not a white-coat disease
But managing diabetes doesn’t mean telling someone what to do, Lorenzi said. "Diabetes is not a white-coat disease. It’s a disease that requires interaction between the patient and the health care provider."

For instance, for patients who have never eaten breakfast, orders to eat fruit and cereal every morning could just overwhelm them, she said. Instead, she suggests negotiation, saying something like, "Maybe you could have a glass of milk."

She recommends nurses become familiar with resources for diabetes patients so they can refer them to management training programs, diabetes educators, nutrition counselors and support groups. Nurses also should be good role models by paying attention to their risk factors for diabetes, getting screened regularly, exercising and watching their weight, Bell said.

Above all, Lorenzi said, nurses should not become discouraged by the difficult job of getting people to change their lifestyles, bit by bit. Right now, she said, that’s the best defense the country has against the diabetes epidemic.

"We can’t give up. We can’t assume that because someone’s not willing to do something now doesn’t mean they won’t ever be able to do it. You have to work with people where they are," she said.