Type 2 diabetes

1. Type 2 diabetes Expanding horizons on diagnosis, treatment, and prevention

2. Understanding Diabetes What is diabetes? (Normal and abnormal sugar processing in the body) Type 1 & 2 diabetes Type 2 diabetes in American Indians

3. What is Diabetes? A problem with the way your body uses food to store and make energy. (and lots of other stuff)

4. What is Diabetes? • A chronic disease characterized by high blood sugar which can effect many organs and systems of the body • A disease which can damage tissues before an individual is diagnosed or has symptoms • An illness which may affect individuals differently • Some aspects of diabetes are still poorly understood

5. Understanding Diabetes… • Glucose (a kind of sugar) is an important fuel for your body • Insulin (a hormone or “messenger protein” that is made in the pancreas) helps glucose get into many kinds of cells in the body • With diabetes, there is a problem with the glucose getting into the cell where it can be used for fuel

6. Understanding Diabetes… • When the glucose can’t get into the cell properly, it stays in the bloodstream • When the glucose level in the bloodstream rises, the glucose may attach to proteins or cause other imbalances leading to build-up of toxins in the body (and you don’t feel a thing…)

7. Understanding Diabetes… • Over time, this can result in damage to the tissues (and you don’t feel a thing…) • “Insulin resistance” may also lead to tissue damage independent from that of high blood sugar (and you don’t feel a thing…)

8. A Key Player - Insulin • Insulin – a hormone made by special cells in the pancreas; gives “signals” to many tissues, including the signal to move glucose from the blood into the cells. Insulin mainly tells the body to store energy for the future. • Insulin Resistance - the decrease in the tissue’s ability to respond to insulin’s signal.

9. What Kind of Diabetes? • Type 1: • Complete shutdown of cells that make insulin • Cannot live without insulin • Type 2 • The body still makes some Insulin • The insulin “signal” is not as powerful = resistance • Gestational Diabetes or Diabetes of Pregnancy (like type 2 diabetes)

10. Normal Glucose Metabolism Nutrition: Carbohydrates (starches & sugars) Tissues (Muscle and Fat) Liver Glucose glucose storage (glycogen) and production Pancreas Insulin

11. What Goes Wrong in Diabetes? Nutrition(carbohydrates) Tissues (Muscle and Fat) Liver Type 2 insulin resistance Glucose excess glucose production Pancreas Insufficient or no insulin

12. What is Insulin Resistance?

13. Insulin Resistance • Insulin is like a “messenger-key” to a lock on the cell, it opens the lock to let in glucose… • Many cells, especially muscle and fat cells, need insulin to help get the glucose in the cell. • Folks with insulin resistance need more “messenger-keys” (insulin) to let the glucose into the cell

14. Insulin Resistance • Insulin resistance can also result in damage to blood vessels in the body that leads to heart attacks and strokes. • This damage usually starts before the blood sugar starts going up (and you don’t feel a thing …until your first heart attack.)

15. Global Epidemic Of Diabetes • More than 135 million people worldwide had diabetes in 1995 (4.0%) • 300 million people are expected to have the disease by 2025 (5.4%) • 42% increase in developed countries • 170% increase in developing countries • Urban dwellers more likely to have the disease than rural inhabitants *King, et. al., Diabetes Care, 1998

16. Age-adjusted* prevalence of diagnosed diabetes among American Indians/Alaska Natives aged 20 years or older, by IHS area, 2001 *Age-adjusted based on the 2000 U.S. population. Source: FY01 IHS APC file. Excludes data from 39 service units (7% of the IHS user population).

17. Prevalence of diagnosed diabetes among children and young people by age group, 1990-2001 Per 1000 79% increase 68% increase 106% increase 25% increase Year Source: IHS Diabetes Program Statistics

18. Mortality Rates in American Indians & Alaska Natives Trends in Indian Health, 1997; Age adjusted rate per 100,000

19. About 80 percent of people with type 2 diabetes are overweight. • Type 2 diabetes is often part of a metabolic syndrome that includes obesity, elevated blood pressure and high levels of blood lipids. • Unfortunately, as more children and adolescents become overweight, type 2 diabetes is becoming more common in young people.

20. Diabetes: Why Me? • “It’s in your genes…” right? • NO…. • Getting more calories than needed, over a “healthy” weight • Physical activity: “Sedan and screen” lifestyle • Aging

21. Diabetes: Why Me? • Psychosocial and Cultural trauma? • What evidence? • Other Diseases and conditions (e.g. smoking, medications) • We don’t know everything! (not yet anyway)

22. Why is this happening in Children & Adolescents? • Born to a mother who had gestational diabetes • High birth weight: qualified • Low birth weight: qualified • Less physical activity • More food, calories that we don’t use, calories from things like saturated fats • Stress and depression? • We don’t know all the answers

23. Diabetes in the American Indian community • The actual reasons for the increase in type 2 diabetes remain both elusive and complex; our work toward a complete understanding of this will no doubt continue for some time to come. However, several observations belie a simple “genetic” causation. Fifty to sixty years ago, type 2 diabetes was nearly nonexistent in American Indian populations. Lest we think this was merely a problem of poor diagnostic abilities or case finding, consider that type 2 diabetes prevalence increased 106% in the 15-19 year old American Indian/Alaskan Native populations alone from 1990-2001

24. Risk Factors in Children & Adolescents • Family history of type 2 diabetes in first or second degree relative • Born to a mother who had gestational diabetes • High or low birth weight: qualified • American Indian,Hispanics, Blacks • Hypertension, blood pressure • Dyslipidemia, cholesterol and fats in the blood • Acanthosis Nigricans • Polycystic Ovarian Syndrome }Insulin resistance

25. Diabetes Research Diabetes Control Complication Trial (DCCT) • Type 1 Diabetes, 10 year study • Blood glucose control decreases complications

26. Diabetes Related Complications • Cardiovascular Disease (Heart attacks and Stroke) • Blood Vessel (Peripheral Vascular) Disease • Kidney Disease (Nephropathy) • Nerve Disease (Neuropathy) • Eye Disease (Retinopathy) • Dental/Peridontal Disease

27. Summary of (even more) Recent Research Findings • It is even more important to lower cholesterol and fats in the blood for patients with diabetes in order to prevent heart attacks and stroke • Good blood sugar control in pregnancy may reduce the risk of complications by 50%. • Smoking increases your chance of getting diabetes

28. Foundations of Therapy • Education, Education, Education • Self management, individual learning styles • Simplicity (i.e. avoid complexity!) • Nutrition • Identify barriers to change • Family & community support • Physical Activity

29. Traditional Frequency: 3-4 days/wk Intensity: 65-85% of maximum heart rate Time: Minimum of 20 minutes/session Alternative Physical activity every day. Moderate intensity (brisk walking) Accumulate 30 minutes or more every day At least Two Approaches To Fitness

30. the all-American diet “Oh yeah…Now That place was really a greasy spoon!”

31. Type 2 Diabetes The most important factor in caring for Type 2 Diabetes that we can control is our lifestyle. We need to try to live in a way that matches how our bodies were made to live.

32. The Diabetes Prevention Program (DPP) • 3,234 participants with impaired glucose tolerance (IGT) • Average age 51 yrs (range: 25-85 yrs) • 45% from ethnic/minority groups (171 American Indian participants, 5% of the study)

33. DPP Goals: Primary • To prevent or slow the development of type 2 diabetes in persons with impaired glucose tolerance (IGT) and other high risk characteristics

34. Lifestyle Intervention Intensive Lifestyle Modification A comprehensive program using a Case Management approach with the following specific aims: • Reduction of fat and calorie intake • Physical activity at least 150 minutes per week • > 7% loss of body weight

35. DPP Study Results • Participants from the lifestyle group reduced their risk of getting type 2 diabetes by 58%

36. DPP Study Results • Lifestyle intervention worked very well in elderly (>60 yrs), reducing development of diabetes by 71%

37. What do the results of the DPP mean to our communities? • Screening for diabetes AND for IGT in AI/AN communities • Create lifestyle programs for diabetes prevention; case management approach • Purchase metformin for diabetes prevention

38. Type 2 Diabetes: Prevention The most important factor in caring for and preventing Type 2 Diabetes that we can control is our lifestyle. We need to try to live in a way that matches how our bodies were made to live.

39. “...you’ve got to be careful if you don’t know where you’re going, because you won’t get there.” “...when you come to a fork in the road, take it.” …Yogi Berra

40. Questions? Anybody seen my magic wand?

41. Sandy Lake School Diabetes Prevention Program • The Sandy Lake First Nation School Diabetes Prevention Program was created during the 1998 school year to help students in grades 3 and 4 learn about and practice healthy eating and physical activity behaviours: the only known ways to prevent diabetes. Developing healthy behaviors at a young age should give students the skills and motivation to continue these behaviors into adulthood. • The program was designed to address the individual, social, and structural levels of influence on children's behaviors associated with making healthy food choices and physical activity. • The 4 components of the Sandy Lake School Diabetes Prevention Program include a classroom curriculum, family outreach, peer activities, and changes in the immediate school and store environment:

42. Sandy Lake program description • COMPONENTDESCRIPTIONClassroom Curriculum • 17 lessons on healthy eating and physical activity. Focus on the identification of healthy foods, skills building, behavior modeling, and food preparation. • Family • Information booths during school parent night events • Letters sent home on healthy eating and physical activity • Weekly radio show topics • Articles in the local newsletter • Peer • Angel Cooking Video Club (kids cooking club) • Diabetes Kids interviews on the Sandy Lake Youth Radio show • Youth Radio Show, which focuses on healthy lifestyles, is now offered in collaboration with Sandy Lake's Brighter Futures Project • Environment • Board of Education Policy of no pop or chips on school grounds • School breakfast snack program • Healthy food promotion in local stores • Community-wide SLHDP diabetes prevention activities

43. Curriculum description • CLASSROOM CURRICULUM • TheSandy Lake First Nation School Diabetes Prevention curriculum is a culturally appropriate healthy lifestyle curriculum for students in grades 3 and 4. The lessons draw upon social learning theory and traditional learning styles and includes role modeling, taste tests, skills building, goal setting, and games. • This is a 2 year curriculum which begins in grade 3 and continues in grade 4. Each of the 17 units contains 2 lessons which are taught once a week for approximately 30 minutes each. The units of the Sandy Lake curriculum address three main components: • making healthy food choices (what are healthy food choices, encouragement for students to make healthy food choices, and providing students with the skills and opportunities to make healthy food choices in their daily lives) • daily physical activity (what are different kinds of physical activities, the health benefits of physical activity, and providing students with opportunities for doing more daily physical activities); and • learning about diabetes (basic information on diabetes and prevention) • Each unit begins with an introductory story from an imaginary community called Winding Lake and includes two lessons with activities that reinforce the concepts of the unit. The stories and lessons are sequenced and build upon one another. Each unit begins with an introductory story from an imaginary community called Winding Lake and includes two lessons with activities that reinforce the concepts of the unit. • www.sandylakediabetes.com

44. Pathways • Pathways, a research study funded by the National Heart, Lung, and Blood Institute, is a school-based health promotion program that includes physical activity, nutrition, classroom curriculum, and family involvement. The primary purpose of the Pathways study is to prevent obesity among American Indian children by promoting increased physical activity and healthful eating behaviors.

45. Pathways • Pathways includes four components. This intervention was designed so that all four components are to be implemented together. We highly recommend that you implement Pathways in this way. The four components of Pathways are: • Curriculum • Family • Food Service • Physical Activity • Each of these components and accompanying materials has been included for the use of interested teachers, school personnel, and health promotion practitioners. These materials can be viewed and printed. • http://hsc.unm.edu/pathways

46. www.thecommunityguide.org • Regular physical activity is associated with a healthier, longer life and with a lower risk of heart disease, high blood pressure, diabetes, obesity, and some cancers. Despite all the benefits of physical activity, most school-aged children in this country are sedentary—only one in four gets the recommended amount of physical activity each day (30 minutes of moderate activity or 20 minutes of vigorous activity). Lack of physical activity has also contributed to a sharp rise in childhood obesity over the last 20 years. Given that regular physical activity will help young people stay healthier, it is important to know what strategies work best to increase physical activity. • A systematic review of published studies, conducted on behalf of the Task Force on Community Preventive Services by a team of experts, found that physical education (PE) classes taught in schools that included which enhance the length or activity levels, are effective in improving both physical activity levels and physical fitness among school-aged children. Based on this review, the Task Force issued a recommendation to implement programs that increase the length of, or activity levels in, school-based PE classes based on strong evidence of effectiveness.

47. Physical education in schools • Background on the Interventions • To increase the amount of time students spend doing moderate or vigorous activity in PE class, these programs seek to change PE curricula by making classes longer or having students be more active during class. • • • Interventions reviewed included changing the activities taught (e.g., substituting soccer for softball) or modifying the rules of the game so that students are more active (e.g., in softball, have the entire team run the bases together when the batter makes a base hit). Many interventions also included health education. • Findings from the Systematic Review • In all 14 studies reviewed, students’ physical fitness improved. • • • • • • In 5 studies measuring activity levels during PE class, all recorded increases in the 1) number of minutes spent in moderate or vigorous physical activity, 2) percentage of class time spent in moderate or vigorous physical activity, and/or 3) intensity level of physical activity during class. • The median estimates from the reviewed studies suggest that modifying school PE curricula as recommended will result in an 8% increase in aerobic fitness among school-aged children. • Modifying school PE curricula was effective across diverse racial, ethnic, and socioeconomic groups, among boys and girls, elementary- and high-school students, and in urban and rural settings. • In a separate literature review, having students attend school PE classes was not found to harm academic performance.

48. Social support • A systematic review of published studies, conducted on behalf of the Task Force on Community Preventive Services by a team of experts, found that efforts made in community settings to provide social support for increasing physically activity are effective. Based on this review, the Task Force issued a strong recommendation to implement these efforts. • Background on the Interventions • These interventions focus on changing physical activity behavior through building, strengthening, and maintaining social networks that provide supportive relationships for behavior change (e.g., setting up a buddy system, making contracts with others to complete specified levels of physical activity, or setting up walking groups or other groups to provide friendship and support). • • • Interventions included in the review involved either creating new social networks or working within existing networks in a social setting outside the family, such as in the workplace. • Findings from the Systematic Review • In all 9 studies reviewed, social support interventions in community settings were effective in getting people to be more physically active, as measured by various indicators (e.g., blocks walked or flights of stairs climbed daily, frequency of attending exercise sessions, or minutes spent in physical activity). • • • • • The median estimates from the reviewed studies suggest that social support interventions in community settings can result in a 44% increase in time spent being physically active and a 20% increase in the frequency of physical activity. • These interventions also improved participants’ fitness levels, lowered their percentage of body fat, increased their knowledge about exercise, and improved their confidence in their ability to exercise. • These interventions were effective in various settings including communities, worksites, and universities, among men and women, adults of different ages, and both sedentary people and those who were already active.