|
|
 |
May 2004 Article: Phoenix Area Diabetes Program |
Diabetes control is a collaborative effort.
Preventing and controlling diabetes in the Phoenix Area is a joint project of:
- Phoenix Area IHS Diabetes Program
- 40 tribes
- 3 Urban Indian Health Programs UIHPs)
- 42 grantees in the Special Diabetes Programs for Indians (SDPI)
- 11 service units
- 30 patient care facilities (hospitals, clinics and Health Stations)
We also collaborate with outside organizations, including
- American Diabetes Association (ADA)
- Arizona Department of Health Services (ADHS)
- Nevada State Diabetes Program (State of Nevada, Health Division, Bureau of Community Health, Chronic Disease Program)
among others
.
Recent years have seen two major shifts:
- tribes have assumed an increasing role in this battle, and
- efforts are being targeted at earlier discovery, intervention and prevention
.
|
|
What is diabetes?
Type 2 diabetes starts as insulin resistance, caused by a combination of:
- inherited (genetic) factors,
- While American Indians and Alaska Natives appear to be especially vulnerable to diabetes, this problem was rare before 1950,
so genetics is clearly not the whole story.
- environmental factors,
- Stressful living conditions and lack of traditional foods and herbs may contribute to the diabetes problem.
- and behavioral (life style) factors.
- Lack of exercise is clearly important, and foods with high sugar and calorie content help bring on diabetes.
When the body’s tissues become resistant to insulin (no longer respond normally to insulin), the pancreas compensates making
more insulin. This leads to “hyperinsulinemia” (more than normal amount of insulin in the blood). Hyperinsulinemia causes
many of the body’s tissues to function abnormally, and thus causes multiple problems. This group of problems is now called
the Insulin Resistance Syndrome (IRS), or “Metabolic Syndrome.”
IRS can include
- skin darkening (Acanthosis Nigricans, or “AN”),
- abnormal menstruation (polycystic ovary syndrome, or PCOS),
- cholesterol abnormalities (dyslipidemia),
- high blood pressure,
- some cancers and
- other problems
IRS brings on disability and death mainly by
- cardiovascular disease (CVD)
- (blood vessel damage which causes stroke, heart attack and amputations),
and by
- type 2 diabetes.
- In a sense, type 2 diabetes is “the terminal phase” of IRS. Studies had shown that when a person does develop diabetes,
aggressive treatment can greatly improve the quality of life. Just as it is better to treat diabetes before complications
develop, it is better yet to stop IRS before diabetes develops. The Diabetes Prevention Program (DPP, a research study)
proved that diabetes can be delayed or prevented if we do something about it before the patient develops full-blown
diabetes. American Indians of the Phoenix Area participated in the DPP, and now are helping tell others about their
success.
What are we accomplishing?
Primary Prevention (Stopping diabetes before it starts)
This is mostly an effort to persuade people to live a healthier life style. When we get children to exercise more, eat
healthier foods, etc., it will take many years to see that fewer are developing diabetes. Some programs have been able to
show reductions in obesity, and one program has showed lower A1c levels in children five years after their participation in
the program ended. Some tribes are seeing fewer new cases of diabetes, but it is too soon to be sure this is not just
year-to-year variation. Finding ways to prove we are actually making progress is one of the major challenges of primary
prevention programs.
Secondary and Tertiary Prevention (Preventing complications and disability)
The annual IHS Diabetes Care and Outcomes Audit allows us to see improvement in these areas. The attached charts show
improvement from 1999 to 2003 in
Glucose control:
• More patients with A1c under 7
• Fewer patients with A1c of 10 or more
Blood pressure control
• More patients with blood pressure under 130/80
• Fewer patients with blood pressure of 140/90 or higher
Lipid control
• More patients with total cholesterol under 200
• More patients with LDL (bad) cholesterol under 100
• More patients with HDL (good) cholesterol above 45
• More patients with triglycerides under 150
Special examinations to prevent complications
• More patients who have had foot exams
• More patients who have had eye exams
• More patients who have had dental exams
• More patients who have had electrocardiograms (ECGs)
Immunizations and user of preventive medications
• More patients who have received influenza vaccine and pneumococcal vaccine
(Fewer patients current on tetanus-diphtheria, due to a nationwide shortage of the material)
More patients taking aspirin, which reduces stroke and heart attack risk
More patients taking ACE inhibitors, which reduce the risk of kidney failure
Unfortunately,
Overweight and Obesity do not show such favorable trends.
Obesity continues to increase among our patients with diabetes, but
we are getting better at monitoring it.
Fewer charts had inadequate data for calculating BMI.
Increasing obesity is a major problem and a difficult challenge, both in Indian country and throughout the United States.
Who is the team?
- Phoenix Area Diabetes Program – Phoenix Area Office
- Charles E. Rhodes, M.D., Diabetes Consultant
(Rosemary Lane retired October 31, 2004, and we certainly miss her.)
- Phoenix Area Data Improvement Project
- The Phoenix Area Office’s Office of Planning, Evaluation and Information Resources (OPE&IR) operates a program to
improve the quality of diabetes data throughout the Phoenix Area, using SDPI grant funds set aside by the tribal leaders for
this purpose. Currently, this is coordinated by S.M. Satpathi of the Computer Branch of OPE&IR.
- IHS Service Units
- Each service unit has someone designated as diabetes coordinator, diabetes team leader, or diabetes program director.
These people coordinate diabetes care and supervise the annual diabetes audit. The number of diabetes educators, nurses,
doctors and other professionals on the diabetes team varies from one service unit to another. Because diabetes is such a
major problem, all health care workers are members of the diabetes team.
- Health care facilities
- Clinics and health centers, both tribal and federally operated, have diabetes coordinators with functions similar to the
service unit coordinators. Again, all health care workers are members of the diabetes team.
- Tribes and Urban Indian Health Programs
- The three Phoenix Area UIHPs and 35 of the 40 tribes are SDPI grantees. Each grantee has a program director for the
diabetes prevention project. Their activities vary widely, depending on tribal decisions on how to get the most from
limited funding. Some focus on primary prevention (dealing with people who do not have diabetes) and others on those with
diabetes and complications. These program directors include nurses, dietitians, CHRs, and others. Programs vary widely in
size, and most have several full time and part time workers.
- Surrogate grantees
- For those tribes unable to receive SDPI grants, another tribe or the local IHS service unit receives the allocated funds and
administers the grant-funded diabetes prevention project.
- Phoenix Indian Medical Center (PIMC)
- The Diabetes Center of Excellence (DCOE) at PIMC is funded by an SDPI grant to prevent diabetes and its complications in
patients of the Phoenix Service Unit who do not live on one of the service unit’s six tribal reservations.
PIMC-DCOE also provides consultation and support, including a 24/7 breast feeding support phone service, to workers
throughout the Phoenix Area and beyond.
- Dr. Charlton Wilson, director of the PIMC DCOE, is currently the main worker on the OPE&IR Data Improvement Project.
For several years, he has served as a National Diabetes Program consultant on diabetes data issues. Now he is making sure
the benefit of all that work is available at each service unit, facility, UIHP and tribe.
- ITCA and ITCN
- These tribal organizations have been especially helpful in the data improvement effort.
What does the future hold?
The American Indians of the Phoenix Area, and the Phoenix Area IHS, have shown their determination to prevent diabetes and
its complications.
- The Diabetes Control and Complications Trial (DCCT) proved that good control of diabetes reduces complications in
type 1 diabetes, and
- The United Kingdom Prospective Diabetes Study (UKPDS) showed the same for type 2 diabetes.
- The Diabetes Prevention Program (DPP) showed that the progression of the Insulin Resistance Syndrome from pre-diabetes
to diabetes can be delayed or prevented.
Through FY 2008, in addition to increased budgets for the current diabetes prevention projects, Congress has
provided funds for new grants (to be competitive) for primary prevention of diabetes and for prevention of
cardiovascular disease in patients with diabetes. These new projects should serve as models for the rest of Indian
Country. We look forward to better living circumstances and better life styles for all AI/AN peoples, and to
reductions in overweight and obesity, in insulin resistance, in cardiovascular disease and in diabetes with all its
other complications. The American Indians of the Phoenix Area have the opportunity to be the role models for the
entire country and the world in eliminating this huge health problem.
For more information, contact Dr. Charles Rhodes, Phoenix Area IHS Diabetes Program,
at (602) 364-5195.
|
Phoenix Area Indian Health Service
Two Renaissance Square • 40 North Central Avenue • Phoenix, AZ 85004-4424
|
|
