1. Diabetes 1
Diabetes: A Chronic Condition
By Joe Beavers, BSHM

2. Diabetes 2
Diabetes: A Chronic Condition
The diabetes epidemic in the United States has reached critical proportions. Not only is
diabetes a problem in the U.S., worldwide diabetes (high glucose levels) accounts for half of the
deaths in adults below the age of 70 (WHO, 2016). This paper will address the impacts diabetes
is having world-wide and on the U.S. healthcare system.
Diabetes: Worldwide
According to the World Health Organization (WHO), the diabetes epidemic is growing
faster than just about any chronic illness. Between the years of 1980 to 2014, the cases of
diabetes have increased a dramatic 300 percent. In 1980 approximately 108 million people had
diabetes. In 2014 an astounding 422 million have the chronic disease (WHO, 2016). China has
had the largest increase in diagnosed cases of diabetes of any developed country. The increase in
China is attributed to the westernization of China, and a slow government response to the
problem (Suliman, 2015). According to Suliman (2015), “China has the highest number of
diabetics in the world, totaling 109 million people in 2015—roughly 11 percent of the
population” (para 2). The 109 million people with diabetes in China accounts for one-third of the
World’s diabetic population.
Why the Increase in Diabetic Cases?
There are several hypotheses being considered as to the rise in diabetes. One theory is
called “the cow’s milk theory.” When infants are fed cow’s milk, their bodies do not receive
important nutrients found in breast milk (Kolb & Wasumth, 2000). However, there are many
other studies that show no correlation with cow’s milk and diabetes. A theory that seems to be
logical and completely correctable is the consumption of processed foods and sugars. As
mentioned earlier, China’s diabetes epidemic is related to the westernization of China. The

3. Diabetes 3
increased use of high-fructose corn sugar (HFCS) in food does have negative effects on the
human body (Zeratsky, 2015).There is a direct correlation with the increased usage of high
fructose corn syrup and the increase in obesity. Obesity is directly related to pre-diabetes and
Type 2 diabetes. Tappy, (2010) states,
“ …there is no doubt that fructose consumption has increased over the past four decades
in the United States, that teenagers and young adults are the highest consumers, and that
the sweetened beverages are the main dietary source of fructose” (para 14).
Teenagers and young adults are experiencing higher than average pre-diabetes diagnoses;
however, the jury is still out on making the certain conclusion that HFCS is a cause of diabetes.
Blanck, et al, (2013), illustrates the prevalence of increased obesity rates in the U.S. between the
years of 1999 to 2010. This also corresponds with the increases in diabetes diagnoses. The
highest jump in obesity rates were among children and young adults—those who consume the
most HFCS in their diets.
Diabetes in the United States
The leading cause of heart disease, blindness, kidney disease and stroke in the U.S. and
world-wide is diabetes (HHS, n.d.; WHO, 2016). In the United States, an estimated 25.7 million
people have diabetes (Creighton, 2013). One in 12 people that have diabetes go undiagnosed
(CDC, 2014). Type 2 diabetes is the most common form of diabetes. The American Diabetes
Association estimates that 87% of diabetes cases in the U.S. are Type 2 cases (“Diabetes”, n.d.).
Chronic illnesses such as diabetes are the most costly illnesses to treat in the United States
(CDC, 2014).

4. Diabetes 4
The Cost of Diabetes
According to the American Diabetes Association, “…the total costs of diagnosed diabetes
have risen to $245 billion in 2012 from $174 billion in 2007, when the cost was last examined.
This figure represents a 41 percent increase over a five year period” (“Cost of diabetes [1]”, 2013
para 1). As of 2015, the cost of diabetes on the U.S. healthcare system has grown to $322 billion.
Based on the figures presented, the cost of diabetes (if left unchecked) will be over a half-trillion
dollars within the next decade. The American Diabetes Association estimates that every day,
3,835 people will be diagnosed with diabetes, 200 will suffer amputations, 136 will enter end-
stage kidney disease and 1,795 people will develop severe retinopathy that leads to vision loss
and blindness (“Cost of diabetes [2]”, 2015).
Efforts and Challenges to Combat Diabetes
With the passage of the Affordable Care Act (ACA), a strong emphasis has been placed
on preventative care, patient education and quality measures to combat all chronic illnesses
(HHS, n.d.). Incentives for reimbursements focus on management of chronic illness. These
incentives are designed to prompt providers to focus on management of chronic illnesses such as
diabetes. For instance, Medicare and Medicaid allows for wellness checks, three month lab
testing at no cost to patients (CMS, n.d.). Other insurers in Managed Care are also following suit.
While these strategies are proven quality measures, none of them will work without patient
cooperation. Lifestyle choices are directly related to chronic illness (CDC, 2014). Patient
education is the biggest challenge for providers. Another challenge for the management of
diabetes is the high cost of prescription drugs such as, new insulins. While Medicaid will cover
some prescriptions, recently developed insulins that have been proven effective are not generally
covered.

5. Diabetes 5
Federal and State Involvement
Federal law provides that schools must not discriminate against students that have
diabetes. Students must be able to participate in all school sports and activities. Schools must
also have trained staff to assist in monitoring glucose levels of students and allow students to
self-monitor and manage their diabetes (“Policies”, n.d.). In the state of Arkansas (where this
author resides), the American Diabetes Association states, “Arkansas allows school staff to
administer insulin, as long as a health plan is in place, a doctor authorizes it, parents have signed
a release, and volunteers are trained by health care professional in insulin administration”
(“Arkansas policy”, n.d., para 2). Additionally, the state of Arkansas allows students to carry
medical devices such as, needles, monitors, and to carry prescription medication for diabetes.
Arkansas also allows students to self-manage their diabetes. In a 2013article from the Centers for
Disease Control (CDC), Stellefson, Dipnarine and Stopka states,
“The 16 studies included various study designs, including 9 randomized controlled trials,
and settings, including academic-affiliated primary care practices and private practices.
We found evidence that Chronic Care Model (CCM) approaches have been effective in
managing diabetes in US primary care settings. Organizational leaders in health care
systems initiated system-level reorganizations that improved the coordination of diabetes
care. Disease registries and electronic medical records (EHRs) were used to establish
patient-centered goals, monitor patient progress, and identify lapses in care” (para 3).
The statement above lends credence to the fact that public health and primary care’s integration
is imperative for the proper management of diabetes. Additionally, the use of EHRs is vital in the
patient-centered approach to managing chronic illnesses.

6. Diabetes 6
Public Health’s Role
Public Health and primary care must coordinate efforts in the management of diabetes
and other chronic conditions. Public health agencies can provide strong community awareness of
diabetes management and promote healthy lifestyle choices. Establishing diabetes support
groups in communities (especially rural communities) will help educate people on how to
manage their illnesses. Not all diabetics respond the same to treatments. Support groups can
provide various scenarios that may help. Rural communities have higher than average chronic
illness rates. Public health agencies in these affected communities can concentrate efforts for
these populations (Institute of Medicine, 2012).
Conclusion
Not all of the news is bad concerning diabetes. Diabetes is controllable. Public health
agencies and primary care providers will have to work in concert to manage this disease. Patient
education is the key to success. The question is, how can public health, primary care and
managed care organizations change people’s attitudes toward better lifestyle choices? The use of
CDC Chronic Care Models (CCMs) in concert with EHRs is a step in the right direction. The
U.S. healthcare system is facing a half-trillion dollar price-tag associated with diabetes over the
next decade. “Diabetes taught me discipline.”—Sonia Sotomayor

7. Diabetes 7
References
Arkansas Policy, (n.d.). American Diabetes Association. State Laws, Regulations and Policies
for School Diabetes Care – Arkansas. Retrieved December 14, 2016 from
http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-
school/legal-protections/school-laws-and-policies/state-laws-and-policies-
display.html?state=AR
Blanck, H. et al, (2013). Obesity in the United States 1999 to 2010. Retrieved January 21, 2016
from website http://www.cdc.gov/mmwr/preview/mmwrhtml/su6203a20.htm
CDC, (2014). 2014 National diabetes statistics report. Retrieved December 8, 2016 from
http://www.cdc.gov/diabetes/data/statistics/2014StatisticsReport.html
CMS, (n.d.). Innovations. Retrieved November 12, 2016 from https://innovation.cms.gov/
Cost of Diabetes [1], (2013). American Diabetes Association. Retrieved December 12, 2016
from http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
Cost of Diabetes [2], (2015). American Diabetes Association. Retrieved December 12, 2016
from http://www.diabetes.org/diabetes-basics/statistics/infographics/adv-staggering-cost-
of-diabetes.html
Creighton, (2013). Top public health issues facing health officials. Retrieved December 8, 2016
from ,http://online.creighton.edu/mph/masters-in-public-health/resources/top-public-
health-issues-facing-health-officials
Diabetes, (n.d.). American Diabetes Association. Type 1 Diabetes. Retrieved December 8, 2016
from http://www.diabetes.org/diabetes-basics/type-1/
Kolb, H., Wasumth, H., (2000). Cow’s milk and immune-mediated diabetes. Retrieved
December, 14, 2016 from https://www.ncbi.nlm.nih.gov/pubmed/11115792

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References cont’d
HHS, (n.d.). Overview of the healthcare law. Retrieved November 28, 2016 from
http://www.hhs.gov/healthcare/facts-and-features/key-features-of-aca-by-
year/index.html#
Institute of Medicine, (2012). Primary Care and Public Health. Exploring integration to improve
population health. Retrieved November 28, 2016 from
http://www.nationalahec.org/pdfs/PrimaryCareandPublicHealth_ReportBrief.pdf
Policies, (n.d.). American Diabetes Association. State Laws, Regulations and Policies for School
Diabetes Care. Retrieved December 14, 2016 from http://www.diabetes.org/living-with-
diabetes/parents-and-kids/diabetes-care-at-school/legal-protections/state-laws-and-
policies.html
Stellefson M, Dipnarine K, Stopka C., (2013). The Chronic Care Model and Diabetes
Management in US Primary Care Settings: A Systematic Review. Retrieved December
14, 2016 from https://www.cdc.gov/pcd/issues/2013/12_0180.htm
Suliman, A., (2016). The looming public health crises threatening to take down China’s health
care system. Retrieved December 10, 2016 from http://qz.com/756585/diabetes-is-chinas-
next-public-health-crises/
Tappy, L., (2010). Metabolic effects of fructose and the worldwide increase in obesity.
Physiological Reviews Published 1 January 2010 Vol. 90 no. 1, 23-46 DOI:
10.1152/physrev.00019.2009
WHO, (2014). Non-communicable Diseases (NCD) Country Profiles, 2014. Retrieved January
21, 2016 from http://www.who.int/nmh/countries/cub_en.pdf?ua=1

9. Diabetes 9
References cont’d
Zeratsky, K., (2015). What is high-fructose corn syrup? What are the health concerns? Retrieved
December 8, 2016 from http://www.mayoclinic.org/healthy-lifestyle/nutrition-and-
healthy-eating/expert-answers/high-fructose-corn-syrup/faq-20058201