Diabetes Texas Diabetes Prevention and Control Program

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Diabetes Texas Diabetes Prevention and Control Program

  1. 1. Diabetes <ul><li>Texas Diabetes Prevention and Control Program </li></ul><ul><li>Jan Marie Ozias, PhD, RN </li></ul>
  2. 2. Texas Diabetes Council Texas Department of Health Centers for Disease Control and Prevention Community-based organizations Health care systems
  3. 3. Objectives <ul><li>Define Insulin Resistance and risks for type 2 diabetes (T2D)/CVD </li></ul><ul><li>Discuss estimated lifetime risk T2D for children </li></ul><ul><li>Outline risk assessment </li></ul><ul><li>Discuss primary prevention strategies </li></ul><ul><li>List school staff activities </li></ul><ul><li>Discuss NDEP guide for schools </li></ul>
  4. 4. Natural Progression: Intervention Landmarks <ul><li>From Low Risk (Lean Body) </li></ul><ul><li>High Risk ( Obesity) </li></ul><ul><li>Insulin Resistance </li></ul><ul><li>Impaired Glucose Tolerance </li></ul><ul><ul><li>(“pre-diabetes”) </li></ul></ul><ul><li>Beta cell failure - reduced insulin secretion </li></ul><ul><li>Established Diabetes </li></ul><ul><li>Complications </li></ul>
  5. 5. Insulin Resistance <ul><li>Insulin regulates blood glucose and influences cell growth </li></ul><ul><li>Fat cells (abdominal) influence insulin sensitivity </li></ul><ul><li>Muscle cells become less sensitive </li></ul><ul><li>Incrs production insulin to keep blood glucose wnl </li></ul><ul><li>Measure: formula with fasting plasma insulin and glucose </li></ul>
  6. 6. So what? <ul><li>Risk progression to pancreatic dysfunction </li></ul><ul><li>Increasing IR increases odds of Metabolic Syndrome (MS) </li></ul><ul><li>MS: endothelial dysfunction (atherosclerotic lesions) and cardiovascular disease </li></ul><ul><li>Accompanied by high blood pressure and dyslipidemias (low HDL, high TG) </li></ul>
  7. 7. Metabolic Syndrome and Obese Youth <ul><li>Risk T2D and CVD (3+ criteria) </li></ul><ul><ul><li>BMI > 97%ile </li></ul></ul><ul><ul><li>TG >95%ile </li></ul></ul><ul><ul><li>HDL< 5%ile </li></ul></ul><ul><ul><li>BP (systolic or diastolic)>95%ile </li></ul></ul><ul><ul><li>Impaired glucose tolerance (OGTT, not fingerstick) </li></ul></ul><ul><ul><li>Source: Weiss et al. NEJM June 3 2004 </li></ul></ul>
  8. 8. Independent CVD Markers <ul><li>Underlying inflammation markers associated with obesity </li></ul><ul><ul><li>elev C-reactive protein </li></ul></ul><ul><ul><li>elev Interleukin-6 (regulates C-reactive protein) </li></ul></ul><ul><ul><li>lower Adiponectin (protective ) </li></ul></ul>
  9. 9. Insulin Resistance in Puberty <ul><li>Normally reduces insulin sensitivity </li></ul><ul><li>?? lower in Tanner stages II-IV </li></ul><ul><li>Likely related to other hormones - GH, not androgens </li></ul><ul><li>High insulin:glucose ratios </li></ul><ul><li>Can recover unless beta cells otherwise compromised (genetics, obesity) </li></ul>
  10. 10. IR and risks for T2D <ul><li>Unchangeable </li></ul><ul><ul><li>Genetic: immediate family </li></ul></ul><ul><ul><li>Abdominal fat distribution (“apple” v “pear”) </li></ul></ul><ul><ul><li>Puberty (transient) </li></ul></ul><ul><li>Changeable </li></ul><ul><ul><li>Obesity (High BMI, adult waist circumference) </li></ul></ul><ul><ul><li>Sedentary most days </li></ul></ul><ul><ul><li>Food choices and portion size </li></ul></ul>
  11. 11. Estimated 1,558,004 Adult Texans with Diabetes (Diagnosed + Undiagnosed) 15,356,640 Texas Adult Population (Age 18 Years and Older) 2001
  12. 12. Age-Adjusted Prevalence of Diabetes Texas vs. US, BRFSS, 1994-2002 Source: Centers for Disease Control, Division of Diabetes Translation
  13. 13. Co-morbid Conditions Source: Texas BRFSS, 1998-2000
  14. 14. Complications <ul><li>Heart disease </li></ul><ul><li>Stroke </li></ul><ul><li>Digestive disturbance </li></ul><ul><li>Blindness </li></ul><ul><li>Kidney disease </li></ul><ul><li>Neuropathy </li></ul><ul><li>Amputation </li></ul><ul><li>Dental disease </li></ul><ul><li>Pregnancy Complications </li></ul>
  15. 15. Trends <ul><li>Prevalence of diagnosed type 2 in younger adults rising </li></ul><ul><li>Highly correlated with obesity </li></ul><ul><li>Highest risk: non-Hispanic Blacks, Native Americans, Hispanic, Asian Americans </li></ul><ul><li>30-45% new onset pedi cases are type 2 </li></ul><ul><li>“ Pre-diabetes” increases population of concern </li></ul><ul><li>SEARCH (Incidence/ prevalence) study </li></ul>
  16. 16. Overweight in Texas School-Age Children
  17. 17. Kids at Risk for type 2 Diabetes <ul><li>Can grow into young adults at high risk </li></ul><ul><li>Very overweight youth*: </li></ul><ul><ul><li>over 20% have impaired glucose tolerance </li></ul></ul><ul><ul><li>4% had type 2 diabetes </li></ul></ul><ul><ul><li>co-morbidities (sleep apnea, cardiovascular) </li></ul></ul><ul><ul><li>*Source: N E J M Feb 2002 </li></ul></ul>
  18. 18. Estimated Number of Males and Females, Born in Texas, in the Year 2000, at Risk for Developing Diabetes in Their Lifetime Sources: Narayan, K.M., et al. (October 8, 2003) &quot;Lifetime Risk for Diabetes Mellitus in the United States, JAMA,290(14). Birth numbers based on 2000 population, Texas Department of Health, Bureau of Vital Statistics Number in Thousands 26.7% 31.2% 40.2% 49.0% 45.4% 52.5% 36.9% 43.3%
  19. 19. Evaluating Youth at Risk (ADA) <ul><li>Age 10 or (puberty if earlier) and every 2 yrs IF </li></ul><ul><li>Overweight (BMI >85%ile) </li></ul><ul><ul><li>AND at least 2 risk factors: </li></ul></ul><ul><li>Family hx: first and second degree relative </li></ul><ul><li>High risk ethnic group </li></ul><ul><li>Signs of insulin resistance: hypertension, polycystic ovary syndrome, dyslipidemia, acanthosis nigricans </li></ul><ul><li>FPG preferred in medical home </li></ul>
  20. 20. Ft Worth ISD Study <ul><li>Gd 5 (n=1076) </li></ul><ul><li>Findings: </li></ul><ul><ul><li>1/3 overweight (>85%ile) </li></ul></ul><ul><ul><li>1/4 at risk for T2D on ADA criteria </li></ul></ul><ul><li>Follow up Mx Am children at risk (n=61) and sibs (n=78) </li></ul><ul><ul><li>Source: Urrutia-Rojas X et al. J Adol Health 2004;34:290-99 </li></ul></ul>
  21. 21. Ft Worth ( cont’d ) <ul><li>ADA-criteria positive Mx Am group (139) </li></ul><ul><ul><li>76% BMI 85%ile; 54% BMI 95%ile </li></ul></ul><ul><ul><li>49% AN positive </li></ul></ul><ul><ul><li>60% elevated insulin (fasting glucose wnl) </li></ul></ul><ul><ul><li>41% high LDL-C (>100 mg/dl) </li></ul></ul><ul><ul><li>Conclusion: use overweight and ADA criteria to identify families at risk </li></ul></ul>
  22. 22. Primary Prevention <ul><li>Prevention and delay of type 2 diabetes algorithm (texasdiabetescouncil.org) </li></ul><ul><li>Diabetes Prevention Program ( http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/index.htm ) </li></ul><ul><li>NDEP Small Steps (ndep.nih.gov) </li></ul>
  23. 23. School Nurse “Menu” <ul><li>Be informed: health of community, coordinated school health program </li></ul><ul><li>Model healthful practices </li></ul><ul><li>Include BMI in assessment and reports to parents; open door to other risks </li></ul><ul><li>Assist teachers with interesting lessons </li></ul>
  24. 24. Evaluating for IR <ul><li>TDH resource information for primary care clinicians. </li></ul><ul><li>Overweight (BMI  95 th percentile-for-age) or “at risk of overweight” (85 th to <95 th percentile) sans co-morbidity is a finding </li></ul><ul><li>AN is a skin marker, finding or risk factor, not a disease. Evaluate for several possible conditions, including insulin resistance. </li></ul>
  25. 25. Environmental Factors <ul><li>School food service </li></ul><ul><ul><li>Healthy foods, food pricing, taste testing </li></ul></ul><ul><li>Physical Education </li></ul><ul><ul><li>Daily PE, High MVPA, Fun activities </li></ul></ul><ul><li>Vending machines and fundraising </li></ul><ul><li>Family/parent </li></ul><ul><ul><li>Modeling, norms, family practices </li></ul></ul><ul><li>After school programs </li></ul>
  26. 26. Coordinated Approach to Child Health (CATCH) <ul><li>Systems-oriented </li></ul><ul><li>Classroom, cafeteria and physical education </li></ul><ul><li>Coordination of : </li></ul><ul><ul><li>Health education </li></ul></ul><ul><ul><li>Physical education </li></ul></ul><ul><ul><li>Nutrition services </li></ul></ul><ul><ul><li>Parent involvement </li></ul></ul>
  27. 27. School Food Policy <ul><li>Texas Dept Agriculture - administering state agency for National School Lunch and School Breakfast Programs in Texas public schools </li></ul><ul><li>TDA enforces policy on Foods of Minimal Nutritional Value </li></ul>
  28. 28. All Schools <ul><li>Eliminate deep-fat frying </li></ul><ul><li>Portion size restrictions </li></ul><ul><li>Limit fats and sugar per serving </li></ul><ul><li>Fruits and vegetables offered </li></ul><ul><li>Low and no-fat milk </li></ul><ul><li>Request for trans fat information </li></ul><ul><li>100 percent real fruit and/or vegetable juices </li></ul>
  29. 30. Intervention <ul><li>Weight leveling, not reduction in growing kids </li></ul><ul><li>Consider age, residual linear growth potential, BMI and abdominal fat deposition, complications </li></ul><ul><li>Treat early </li></ul><ul><li>Family Involvement </li></ul><ul><li>Increase physical activity/ movement </li></ul><ul><li>Limit high fat/calorie foods </li></ul><ul><li>Support </li></ul>
  30. 31. Overweight Sensitivity <ul><ul><ul><li>Fatness/Excess Fat </li></ul></ul></ul><ul><ul><ul><li>Obese </li></ul></ul></ul><ul><ul><ul><li>Large Size </li></ul></ul></ul><ul><ul><ul><li>Unhealthy BMI </li></ul></ul></ul><ul><ul><ul><li>Unhealthy Weight </li></ul></ul></ul><ul><ul><ul><li>Weight Problem </li></ul></ul></ul><ul><ul><ul><li>“ Ideal” weight </li></ul></ul></ul><ul><ul><ul><li>Weight </li></ul></ul></ul><ul><ul><ul><li>Excess Weight </li></ul></ul></ul><ul><ul><ul><li>BMI </li></ul></ul></ul><ul><ul><ul><li>Overweight? </li></ul></ul></ul><ul><ul><ul><li>Lifestyle </li></ul></ul></ul><ul><ul><ul><li>Health </li></ul></ul></ul><ul><ul><ul><li>Reasonable weight loss </li></ul></ul></ul>
  31. 32. Legislative Issues <ul><li>Children with diabetes in school </li></ul><ul><li>Screening youth for obesity and/or AN </li></ul><ul><li>Children -physical activity, nutrition, and healthy body weight </li></ul><ul><li>Jt Comm Health and Nutrition in Schools </li></ul><ul><li>Pediatric Diabetes Research registry </li></ul>
  32. 33. Resources <ul><li>National Diabetes Educ Program: www.ndep.nih.gov </li></ul><ul><ul><li>Small Steps Big Rewards; Paso a Paso </li></ul></ul><ul><ul><li>Guide for Schools </li></ul></ul><ul><li>CDC: www.cdc.gov </li></ul><ul><ul><li>School Health Index </li></ul></ul><ul><ul><li>BMI values ages 2 to 20 yrs </li></ul></ul><ul><ul><li>Guidelines for increasing physical activity </li></ul></ul>
  33. 34. <ul><li>The physical health of Texas will determine its fiscal health… </li></ul><ul><li>Eduardo J. Sanchez, M.D., M.P.H. </li></ul><ul><li>Texas Commissioner of Health </li></ul>

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