Recession Leaves Diabetics Without Care, at Risk

The economic crisis is pushing diabetics to literally risk life and limb, as many who have lost jobs and health insurance now are cutting back on _ even going without _ doctor visits, insulin, medicines and blood sugar testing.

Black Public Health Expert: Time for Us to Take Full Responsibility for Our Bodies, Wellness

By: Jackie Jones, BlackAmericaWeb.com

When it comes to black Americans and health, we are our own best and worst enemies.

While obesity, hypertension, diabetes, heart disease and tobacco-related illnesses affect Americans generally, black Americans are affected disproportionately in every category.

“We experience much more severely diseases related to cardiovascular health and blood vein systems,” said Reed V. Tuckson, M.D., executive vice president and chief of medical affairs at UnitedHealth Group.

Tuckson said black Americans cannot wait for legislation, government policy or employers to provide the resources to ensure a healthier life. The message, he said, is “that we as individuals have to be responsible for what we do with our bodies and our lives.”

Tuckson, a public health expert who also serves as chair of the advisory committee on genetics, health and society for the U.S. Department of Health and Human Services, said that cardiovascular disease is not only the No. 1 killer of Americans; it is also the most expensive disease to treat because of all the chronic, related diseases that need constant treatment and monitoring.

Tuckson said he also was concerned about the infant mortality rate in the black community.

“It’s a significant social, moral and ethical issue,” Tuckson told BlackAmericaWeb.com, pointing out that black infants are twice as likely to die as other American babies and at twice the death rate for a few other nations, including Japan.

Americans spend $2 trillion on health care annually, about half of what is spent in the rest of the world, but ranks 30th in life expectancy and 31st in infant mortality rates.

Asked how so much can be spent on health care with such poor outcomes, Tuckson said, “The answer really boils down to our money and how we spend it.”

“We’re very good at saving their lives. We’re very good at being able to treat the consequences of heart attacks,” Tuckson said. “We’re finding that we’re spending our money on the chronic care of these diseases.”

To live a better life, Tuckson said, black Americans must eat better, work out and quit smoking, the latter being the most obvious place to start. “(Smoking) is the stupidest decision any human being can make. … We have got to exercise. We have to get off our rusty dusties and do something.”

The argument that, for some, a lack of access to safe neighborhoods, affordable gyms, clean parks, schools that offer gym, art, music and after-school programs for children contributes to poor health outcomes doesn’t wash with Tuckson.

He said people can work out at home and take the stairs at work, for starters. It’s a matter of setting priorities, he said, even down to creating a lifestyle that is conducive to working out.

They can also demand better from their schools and civic leaders.

“It is a rare community that has a hundred African-American parents descend on the school system or school board and demand adequate recreation facilities and programs. How is it possible that with all the money and resources in the African-American community that parents would feel there isn’t a place they can take their kids for safe recreation and exercise?” Tuckson said.

Health insurance is a particular concern for black Americans as well. Statistics show 47 million Americans are without health insurance, and a recent report by the Joint Center for Political and Economic Studies revealed African-Americans are especially concerned about cost and availability.

“In each community, there is a department of insurance. Every state has one that provides ready access to insurance companies in your community and provide ways for shopping for the most affordable and personally appropriate” care, Tuckson said.

Human resources departments can help employees with health insurance through their jobs navigate the options.

He said seniors can get care through Medicaid and for younger, eligible people -- including the unemployed -- Medicaid offers significant benefits. SCHIP, the State Children’s Health Insurance Program, is an underutilized program that provides coverage for children. Additionally, he said, community-based health centers provide excellent resources.

Asked what black voters should listen for as the presidential candidates, as well as local and state officials, discuss their health care plans, Tuckson cautioned against putting too much faith in any one candidate.

“When you are really realistic, it’s going to be very difficult for the next president, whoever he or she may be, to have any significant resources to mount any major effort,” he said.

Tuckson said self-reliance is the key to healthier living.

The most important thing anyone can do, he says, is, to “love yourself and love your children enough to choose life, as opposed to disease and death.”

DIABETES EPIDEMIC GROWS

The Impact is Being Felt Globally; UN Takes Action.

The Global Partnership for Effective Diabetes Management called for an overhaul in the world's attitude and approach toward diabetes treatment and prevention in order to reverse the rising diabetes epidemic recently recognized by the first United Nations (UN) World Diabetes Day.

"The UN Resolution is a major milestone as it recognizes diabetes as a serious, growing and costly threat to individual and world health." said Martin Silink, International Diabetes Federation President and campaign lead for the UN Resolution on Diabetes. "The staggering statistics of this disease show that there is absolutely no room for complacency."

"If we don't take action now, by 2025 almost 400 million people will be living with diabetes globally," said Professor Stefano Del Prato, chair of the Global Partnership and professor of endocrinology at the University of Pisa, Italy. "No single patient, physician, government or region is equipped to confront diabetes alone.

Worldwide, diabetes currently affects 246 million people. By 2025, it is expected to affect almost 400 million and the World Health Organization (WHO) estimates increases in diabetes rates will occur in developing countries because of population growth, ageing, unhealthy diets, obesity and sedentary lifestyles.

DIABETES STRIKES YOUNGER AND YOUNGER

By Anita Manning, USA TODAY

Lilly Branka, 5, a kindergartner in Medfield, Mass., and Richard Zarate, 12, a seventh-grader in San Antonio, live in different worlds, but they have something in common: diabetes.
Until recently, almost all children had the type of diabetes Lilly has: type 1, the form of the disease caused by the immune system's destruction of cells in the pancreas that produce insulin. People with type 1, who account for 5%-10% of those with diabetes, require daily injections of insulin to survive.

Richard and a growing number of children and teens have the more common form of diabetes, type 2, which used to be called adult-onset diabetes because it did not occur in children.

But the nationwide trend toward more high-fat food and less high-activity play has run smack into a genetic predisposition for diabetes in some communities, especially those with large Latino populations, sparking what pediatrician Jane Lynch of the Texas Diabetes Institute calls a "very scary, very alarming" epidemic of type 2 diabetes in children.

"We have close to 300 children we follow with type 2 diabetes," some as young as 7, Lynch says. "When I trained in the early '90s, it was essentially unheard of."

The increasing incidence of diabetes in children threatens to offset the benefits of improved diabetes treatment that have led to reductions in many of the disease's deadly or disabling complications.

Richard is being treated at the diabetes institute as part of a national study, Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY), and his mother, Christine Zarate, who also has diabetes, is grateful.

She had long suspected her only child, who she says always has been overweight, might also have the disease, because he had an area of darkened skin on the back of his neck, a marking doctors call acanthosis nigricans. It is often caused by high levels of insulin, which can occur when people are overweight and their bodies don't use insulin efficiently. The body tries to compensate for that by churning out extra insulin.

Zarate, who works as a private nurse, says she recognized the discoloration and knew what it meant. "I've tried to get him diagnosed since he was about 6 or 7, but the pediatrician he had at that time — I didn't have insurance — she never did a blood test on him."

Two years ago, at age 10, Richard began having symptoms, such as unusual thirst and frequent urination, and his mother checked his blood with her own glucose meter. The reading indicated Richard's blood sugar level was about five times higher than normal. She took him to the emergency room, where he was diagnosed and given insulin. They were told to see a diabetes specialist, but local doctors had months-long waiting lists.

The diabetes institute "was a godsend," Zarate says. As a participant in a clinical trial, Richard gets free diet and exercise counseling, medications and regular checkups. He is "doing wonderful," his mom says. He's taking two medications but is off insulin. "He's real careful, watches his carbs," she says. But "he's still a kid who wants to eat a hamburger."

Bleak future for type 2 kids

For doctors, type 1 diabetes is familiar in children, but treating kids with type 2 is uncharted ground. Only insulin and the drug metformin are approved for use in children, but insulin as a first-line treatment can cause weight gain in kids who already are overweight, Lynch says, and metformin alone is often not enough.

In one arm of the TODAY study, children, including Richard, are given metformin and Avandia, a drug that improves the body's ability to respond to insulin and appears also to preserve the functioning of cells in the pancreas that produce the hormone. But Avandia has been linked to an increased risk of heart attack in adults. That hasn't been seen so far in children, she says, but they're being closely monitored.

"It's alarming to be in the midst of this," she says. "We are seeing here 7-year-olds, 8-year-olds with pure type 2 diabetes. They're very obese, and within five years, we're seeing kidney complications, we're treating 10-year-olds for hypertension, high lipids and having to see how (the drugs to treat those conditions) interact with diabetes."

Lynch predicts that by the late teens, many children with type 2 diabetes will be facing health problems that a generation ago didn't occur until midlife.

"We have children with declining (kidney) function who are 17," she says. "We've had kids on multiple drugs for high blood pressure who are 18. We find ourselves using a lot of adult medications," and studies have not been done to assure their safe use in children. "This has been a huge, scary learning curve for us in this study. We keep venturing further and further out on that limb."

Diet and exercise counseling have proven successful in the trial, but insurance companies may not cover the cost of a nutritionist or diabetes educator, "and it takes intensive education and reinforcement" to cause behavior changes, Lynch says.

"We definitely underestimate the degree of psychological and nutritional nursing support it takes to keep these kids on track."

A new wrinkle is that some children appear to have symptoms of both type 1 and type 2 diabetes, a hybrid known as double diabetes.

Dorothy Becker, chief of pediatric endocrinology and diabetes at Children's Hospital in Pittsburgh, who coined the term, says it's a combination of the failure of insulin-producing cells that is a hallmark of type 1, and insulin resistance, which is associated with obesity in type 2. If a child with type 1 diabetes is also overweight, whatever remaining insulin-producing cells are still functioning can't keep up with the greater need for insulin.

Schools get involved

Becker says her team has found up to 30% of type 1 children are overweight at the time of diagnosis and have characteristics of type 2 diabetes, including high blood pressure and high cholesterol. "This has increased over the last two decades," she says, the same time period when the national waistline has been expanding.

The Centers for Disease Control and Prevention, which is tracking diabetes in children, last year reported about 154,000 children have been diagnosed, the majority with type 1. How many remain undiagnosed is not clear, but doctors say both forms are increasing, and schools have noticed, too.

Many have taken steps to ensure that kids with diabetes get the support they need. The American Diabetes Association's Safe at Schools program trains teachers and school nurses to help young children monitor their blood sugar levels and administer insulin.

At Memorial School in Medfield, outside Boston, nurse Mary Ellen Zappulla went through the program earlier this month at the Joslin Diabetes Center to brush up the skills needed to help Lilly, one of two children with type 1 diabetes in the kindergarten class.

Each day, Lilly reports to Zappulla's office to get her blood sugar level tested and to adjust her insulin pump as needed.

"This is the first little girl I've had with an insulin pump," says Zappulla, who hasn't had any problems with the procedure. "These little ones are very knowledgeable" about their disease, she says. "She's very aware of her body" and knows when her sugar levels are off track.

But just in case, Lilly's teacher carries a radio device to call the nurse if needed.

In the Bronx section of New York, Montefiore Medical Center operates clinics in 15 schools where students are screened and treated for diabetes. The largest school health program in the country, it provides medical care to 15,000 students, and as part of a community health effort, it offers weekend and after-school nutrition, cooking and walking programs for students and their families.

"A big focus is prevention of obesity and exercise," says pediatrician John Leo. "We've opened a food co-op in the South Bronx, making available healthy food choices to the community," but it's "not a quick fix."

"We can diagnose overweight, screen for diabetes, strategize a plan to maintain or lose weight, but what's really important is educating the students and family about risk factors for diabetes and metabolic syndrome," a cluster of symptoms that puts someone at risk for heart disease, Leo says. "A lot of parents are not even aware their child is overweight."

The perils of processed food

There are plenty of overweight kids in San Antonio, too, Richard's mom says. "They're obese because of the way people eat here. Too much fast food, and the Mexican foods we have here are made with too many processed things."

Zarate encourages Richard to take care of himself, but "trying to get him to eat vegetables takes an act of God and Congress."

Nor is he much for sports. "He's a video-game nut. I say, 'You want to sign up for basketball?' He'll say no." Her sister tries to get him to walk around the apartment building, "and he complains the whole time."

But doctors at the clinic have been impressed that Richard is "so cooperative. He takes care of himself," Zarate says. "It's because when he's not taking care of himself, he doesn't feel good. I said, 'It's up to you.' "