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Introduction
Introduction

In 2000, the Central Ohio Diabetes Association has released a study in cooperation with The Ohio State University and Dr. Franklin Banks, Associate Professor with the OSU School of Public Health. The purpose of the study was to determine the needs of persons with Type 2 diabetes who reside in Central Ohio, and to identify barriers that inhibit them from receiving appropriate health care. Diabetes In Central Ohio: A Problem We Can't Afford To Ignore was the first study to present detailed data on the prevalence of diabetes and barriers to treatment in Central Ohio.

The full report consolidates and summarizes the information from the study to provide strategic direction to Central Ohio Diabetes Association and others concerned about the impact of diabetes in our community. Our goal is to provide a succinct picture of the impact of diabetes in Central Ohio, (highlighting the prevalence of diabetes and its complications in the United States, Ohio, Franklin County and Columbus), the needs of Central Ohioans with diabetes, and the barriers they face in accessing health care and practicing successful diabetes self-management. The following is a summary of findings of the study.

Although there is an abundance of data related to diabetes in the United States, there is less on diabetes in Ohio and very little information specific to the needs of the Central Ohio diabetes community. The agency, having experienced increasing demand from the community for diabetes education/counseling, emergency medical assistance and screening services, decided it was imperative to gather local information to help develop and target services in the most client-focused and cost-effective way possible. Thus, a top priority from the 1995 Central Ohio Diabetes Association board retreat was to commission a detailed study of the Central Ohio diabetes population to help guide Central Ohio Diabetes Association's strategic planning and program expansion.

Central Ohio Diabetes Association recognizes diabetes as a serious community problem that needs a community solution. Conducting a study to better understand the impact of diabetes in the Central Ohio area, the needs of persons with diabetes and the barriers they face in living well with diabetes is the first step to planning a community response.

Diabetes Definition
Diabetes Definition

Diabetes mellitus is a group of diseases characterized by high levels of blood glucose (blood sugar) resulting from defects in insulin secretion, insulin action, or both. Insulin is a hormone produced by the pancreas which allows glucose (sugar) to enter body cells and be converted into energy. Insulin is also needed to synthesize protein and store fats. In uncontrolled diabetes, glucose and lipids (fats) remain in the bloodstream and, with time, damage the body's vital organs and contribute to heart disease. Diabetes can be associated with serious complications and premature death, but persons with diabetes can take measures to reduce the likelihood of such occurrences.

Diabetes is classified into two main types: Type 1 (previously known as insulin-dependent diabetes mellitus or "juvenile onset" diabetes), and Type 2 (previously known as noninsulin-dependent diabetes mellitus or "adult onset" diabetes). Type 1 diabetes accounts for 5 to10 percent of diabetes cases. Although this type of diabetes can occur at any age, it most often appears in the childhood or teen years. In Type 1 diabetes, the pancreas produces little or no insulin so that persons with Type 1 diabetes require daily injections of insulin to live.

The most common type of diabetes is Type 2 diabetes which affects 90 to 95 percent of those with diabetes. In Type 2 diabetes, the pancreas usually produces insulin, but for some reason, the body cannot use the insulin effectively. In both Type 1 and Type 2 diabetes, if uncontrolled the end result is an unhealthy buildup of glucose in the blood and an inability of the body to make efficient use of its main source of fuel. Over time, high levels of blood glucose damage microvascular and macrovascular systems and lead to complications such as blindness, amputations, heart disease and kidney disease.

Central Ohio Diabetes Association recognizes diabetes as a serious community problem that needs a community solution.

Type 1 and Type 2 Diabetes--The Difference

Type 1

Type 2

Previously known as insulin-dependent diabetes mellitus (IDDM) or "juvenile-onset" diabetes.

Previously known as noninsulin-dependent diabetes mellitus (NIDDM) or "adult-onset" diabetes.

Less common, accounts for 5 to 10 percent of diabetes cases.

The most common type of diabetes, accounts for 90 to 90 percent of diabetes cases.

Most commonly diagnosed in childhood or teen years.

Most commonly diagnosed in adults over the age of 40.

The pancreas produces little or no insulin so that person with Type 1 diabetes require daily injections of insulin to live.

The pancreas either produces an insufficient amount of insulin or the body cannot use the insulin effectively.

If untreated, the end result is death.

If untreated, the end result is serious complications which can lead to death.

For both Type 1 and Type 2 diabetes, if uncontrolled, the end result is an unhealthy buildup of glucose in the blood and an inability of the body to make efficient use of its main source of fuel. Over time, high levels of blood glucose damage microvascular and macrovascular systems and lead to complications such as blindness, amputations, heart disease and kidney disease.

Why Worry?
Why Worry?

Diabetes is a chronic disease that affects virtually every system of the body. Type 2 diabetes is an insidious disease with symptoms that may be missed (fatigue, weight gain, itching, slow healing of wounds), and is often undiagnosed for five to seven years after onset. Estimates vary, but it is generally recognized that nationally one-third to one-half of those with diabetes are unaware of their condition (in Ohio, one-half of those with diabetes are undiagnosed). This means 5.2 to 7.8 million people in the United States have undiagnosed diabetes. (CDC, DM Fact Sheet, p. 1)

Diabetes is a chronic disease that affects virtually every system of the body. Type 2 diabetes is an insidious disease with symptoms that may be missed (fatigue, weight gain, itching, slow healing of wounds), and is often undiagnosed for five to seven years after onset. Estimates vary, but it is generally recognized that nationally one-third to one-half of those with diabetes are unaware of their condition (in Ohio, one-half of those with diabetes are undiagnosed). This means 5.2 to 7.8 million people in the United States have undiagnosed diabetes. (CDC, DM Fact Sheet, p. 1)

Diabetes requires a rigorous regime of daily self-management. Each day patients with diabetes must monitor their blood sugars and make decisions as to medications, diet and exercise.
 
Diabetes requires a rigorous regime of daily self-management. Each day patients with diabetes must monitor their blood sugars and make decisions as to medications, diet and exercise. Undiagnosed or uncontrolled diabetes leads to devastating complications; diabetes is the leading cause of blindness, kidney disease and lower extremity amputations and a major contributor to heart disease.

Nationwide, diabetes is a serious health problem that affects 15.7 million people. (5.9 percent of the total U.S. population). 798,000 new cases will be diagnosed annually, compared to 625,000 annually in 1992. (Diabetes in America, p.47) Ninety percent (90 percent) of people with diabetes are adults over the age of 40 with Type 2 diabetes. According to the World Health Organization, the number of diabetes cases is projected to more than double by the year 2020.

 

Diabetes in Ohio and Franklin County
Diabetes in Ohio and Franklin County

Ohio's prevalence of diabetes is higher than the national average--7.2 percent of the Ohio population has diabetes compared to 5.9 percent of the total U.S. population; Ohioans are 5 percent of the total number of diabetes cases in the U. S. In Ohio, one-half of those with diabetes are undiagnosed.

Ohio has the third highest death rate due to diabetes in the nation.* (CDC, Multiple Causes) Nearly one in 10 deaths in Ohio are diabetes-related. (*Updated in 2001 from the second highest as stated in original report.)

As a result of diabetes-related complications, each year 2,391 Ohioans experience amputations, and up to 1,725 new cases of blindness and 550 new cases of end-stage kidney disease are diagnosed.

In 1992, the combined cost of diabetes in Ohio (direct medical cost and indirect costs due to lost productivity) was $4,031,000,000. (Burden of Diabetes in Ohio)

In Central Ohio (within a 50-mile radius of Columbus), 112,500 people will be diagnosed with diabetes by 2002 and will need diabetes education and services, as compared to 104,000 in 1999 (an increase of 8 percent); 59,000 will have undiagnosed diabetes in 2002 as compared to 54,500 in 1999 (an increase of 8.25 percent). (Central Ohio Diabetes Association, Entrepreneurial Report)

Nationally, the mortality rate is 11.9 per 100,000 people. Franklin County's mortality rate is 19.9 per 100,000 people and Columbus' diabetes mortality rate is 22.1 per 100,000 people. (CHD, Mortality)

Of particular concern is Columbus' African-American population which continues to increase slowly but steadily and which is at higher risk of developing diabetes. The African-American population in Columbus has grown from 22.1 percent in 1980 to 22.8 percent in 1997 and is projected to increase to 22.9 percent (160,616) in 2000 (CHD, Population). At the rate of 10.8 percent of African Americans developing diabetes, (CDC, DM Fact Sheet p. ) 14,872 African Americans in Columbus will have diabetes in 2000 -- this includes 500 new cases in this one year alone.

Study Description

The study had two major goals. The first goal was to examine selected health practices of persons with Type 2 diabetes. The second was to determine if those persons in the study perceived that they had barriers that inhibited them from receiving appropriate health care for their diabetes, and, if so, to identify those barriers.

Following a review of the local, state, national and international research literature, the study was conducted in two parts. First, three focus groups were conducted. Second, mail questionnaires were sent to a systematic, random sample of 246 persons with Type 2 diabetes who had received services from the Central Ohio Diabetes Association , and to a systematic, random sample of 598 persons with Type 2 diabetes seen at five of the Columbus Neighborhood Health Centers' seven clinics in Columbus and Franklin County. Completed questionnaires were received from 45.5 percent of the Central Ohio Diabetes Association sample and 43.8 percent of the clinic sample.

Major Findings

A. Columbus' African-American population has alarmingly higher rates of mortality due to diabetes.

In Columbus, African Americans have significantly higher rates of mortality due to diabetes: the age-adjusted death rate for black males is more more than four times the national mortality rate.
 
Although diabetes strikes people in all segments of the population, African Americans are particularly at risk for developing diabetes and are disproportionately affected by its complications. In the general population, 5.9 percent have diabetes; however in the African-American community rates of diabetes are as high as 25 percent. One in four African-American women over the age of 55 has diabetes and 25 percent of all blacks between the age of 65 and 74 have diabetes. (NIDDKD)

In Columbus, African Americans have significantly higher rates of mortality due to diabetes: the age-adjusted death rate for black males is more than twice that of white males (48.7 per 100,000 residents compared to 22.7 for white males) and more than four times the national mortality rate (11.9 per 100,000); the age-adjusted death rate for black females is 27.8 compared to 16 for white females. (CHD, Mortality)

B. Diabetes complications have already developed by the time that local people are diagnosed with and/or in treatment for diabetes.

Over half (54 percent) of clinic survey respondents had already developed complications from diabetes (vision problems, neuropathy and kidney disease), as had 44 percent of the Central Ohio Diabetes Association sample survey respondents. Both of these samples represent individuals who are already receiving treatment or education for their diabetes through Central Ohio Diabetes Association or the clinics. It is significant that 34 percent of the Central Ohio Diabetes Association sample and 25 percent of the clinic sample were diagnosed only because they had developed the symptoms of diabetes complications.

Complications/Co-Morbidity Rates

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Seven Underlying Reasons for Higher Rates of Death and Complications due to Diabetes in the Columbus Community

1. The inability to afford diabetes medications is a problem for a small, though significant, portion of the Central Ohio community.

Thirteen percent (13 percent) of both the Central Ohio Diabetes Association and the clinic samples reported that they have problems getting their medications. The most frequently cited reason was the inability to afford them. Although these are relatively small numbers, this inability to afford medication has a significant impact on the care of those individuals affected. Diabetes is a chronic disease requiring daily management. Research proves that tight control, achieved through strict adherence to a daily self-care plan which includes medications, diet, exercise and the monitoring of blood-glucose levels four to six times each day, prevents complications. Without tight control, complications are likely to develop within 10 to 15 years after onset.

2. A lack of insurance coverage for supplies prevents people from testing their blood sugar levels.

The second leading reason in the clinic sample and the leading reason in the Central Ohio Diabetes Association sample for not monitoring blood sugar levels was an inability to afford testing supplies. Among those who do not test because they cannot obtain supplies, a very high percentage of both samples (68 percent of the Central Ohio Diabetes Association sample and 52 percent of the clinic sample) cited cost as the reason. Among these respondents, 63 percent of the Central Ohio Diabetes Association sample and 37 percent of the clinic sample do not have insurance coverage for the supplies.

Although 46 states have passed legislation which would require private insurers to pay for diabetes education and supplies, Ohio is one of 6 states that have not.

Click Here For More Information
 
Forty-six states have passed legislation which would require private insurers to pay for diabetes education and supplies. Despite an ongoing grassroots effort to pass the legislation, there has been little support in the Ohio legislature. Since research demonstrates the important impact of self-management education and blood glucose testing on diabetes control and prevention of complications, such legislation should be examined as an approach for reducing Ohio's high rates of death due to diabetes. This legislation is needed to ensure that Ohioans have access to the supplies and education which will enable them to prevent complications.

3. Despite a strong economy, up to two-thirds of local people with diabetes are not always able to afford the necessary foods to meet their diet guidelines.

Up to 67 percent of survey respondents reported that they are not always able to get the necessary foods for their diet.
 
Up to 67 percent of survey respondents reported that they are not always able to get the necessary foods for their diet. Of those respondents, 70 percent of the Central Ohio Diabetes Association sample and 82 percent of the clinic sample attributed this to an inability to afford the foods they need. Because Central Ohio is not an economically challenged region, this is a startling statistic. Per-capita income in Central Ohio is slightly higher than the U.S. per-capita income (Census).

Proper diet is crucial to the prevention of diabetes complications, and in fact, to prevent diabetes itself. The primary risk for Type 2 diabetes is obesity. (Atlas of U.S. Mortality, p. 25). Access to adequate food is necessary for persons with diabetes to meet their meal plan requirements and more effectively control their diabetes. It is also necessary for persons seeking to reduce their risk of diabetes.

4. Individuals with diabetes do not receive sufficient instruction on diet.

The most frequently cited reason for not having seen a dietitian, in both samples, was the fact that the patient had received instruction regarding his/her diet from their physician. With today?s managed care system, physicians are able to spend less and less time with their patients. The physician lacks the time and specialized training to provide individualized nutrition therapy, yet many people with diabetes depend on the physician for diet education and apparently perceive a limited amount of diet education as sufficient.

5. The majority of diabetes patients do not get the recommended amount of exercise, often due to other health conditions which prevent exercise.

Our health-care community should focus on educating people about the relative benefits of the amount of time spent on exercise, emphasizing that relatively small amounts of time and effort can have an impact on diabetes care and control.
 
Approximately 75 percent of respondents are unable to get the recommended amounts of exercise. Up to 57 percent of these respondents cited other health conditions as the reason. As noted above, data shows that approximately one-third are dealing with heart or breathing problems and more than one-half with high blood pressure.

Other reasons for not exercising included being too busy and not liking to exercise. These findings suggest that because people may not perceive exercise programs as a priority, our health care community should focus on educating people about the relative benefits of the amount of time spent on exercise, emphasizing that relatively small amounts of time and effort can have an impact on diabetes care and control.

6. There is a general lack of awareness of Central Ohio Diabetes Association and other community resources that are available to persons with diabetes.

Both the survey and the focus groups indicate that the vast majority of patients have had some form of diabetes education and that they would be interested in further education if it was offered to them. However, the findings of this study also reveal that up to 54 percent of people who are in treatment for diabetes are already experiencing diabetes complications.

Clearly, the diabetes education that patients are receiving is not sufficient to effectively prevent complications. This study uncovered several key barriers to the more extended education that would help individuals prevent complications. The barriers include: a lack of awareness of Central Ohio Diabetes Association and other community resources for diabetes care; a lack of understanding by the individual with diabetes as to the extent of diabetes education that is needed, the current standard of care and the urgency of daily diabetes control. (CMAF, p.9)

These findings are reinforced by several national and local studies which discuss how our current health-care system contributes to these difficulties: the uninsured individuals lack routine preventive care which can help an individual utilize system resources; (van Putten, p.19) for insured individuals, the healthcare system remains focused more on acute vs. chronic care and on treatment vs. prevention; the results of the Diabetes Control and Complications Trial, a key study in the treatment of diabetes, has not been effectively disseminated to physicians; and, where offered, HMO's and PPO's are not promoting the use of benefits for diabetes education. (p.5)

7. Low-income and minority populations which are most at risk for diabetes and its complications have transportation/access problems and need community-based services.

Fifty-five percent (55 percent) of respondents in the clinic population stated they do not drive their own car, and at the same time, they indicated no clear alternative to meet their transportation needs. Some rely on the bus system or taxis and some indicated they walk. Seventy percent (70 percent) of respondents in the Central Ohio Diabetes Association sample drive their own car. The Columbus Medical Association Foundation (CMAF) study Access to Health Care; A Comprehensive Study into a Community Problem found that 24 percent of the uninsured have difficultly in arranging transportation for health-care needs; this is particularly true for mothers with young children and for older adults (p. 6)

Columbus needs more neighborhood-based services, including exercise facilities, and expansion of evening and weekend health care.
 
Focus groups also pointed to the barriers that transportation creates for individuals managing their diabetes. Clearly, to serve low-income populations Columbus needs more neighborhood-based services, including exercise facilities, and expansion of evening and weekend health care.

Conclusions

Although there are many epidemiological studies and a vast body of diabetes research literature, Diabetes In Central Ohio: A Problem We Can't Afford To Ignore is the first to present detailed data on the prevalence of diabetes and barriers to treatment in Central Ohio. The findings are alarming. Mortality rates in Columbus are almost double those of the United States (22.1 vs. 11.9 per 100,000) and the mortality rate for African-American males in Columbus are more than four times higher than the national rate for the general population (48.7 vs. 11.9 per 100,000).

The study clearly highlights the need in Central Ohio for increased emphasis on early diagnosis and prevention of diabetes complications. Central Ohioans are suffering far too often from costly complications of diabetes that are preventable. These complications are leading to high rates of mortality, particularly in Central Ohio and especially among African Americans.

Central Ohio needs a partnership between nonprofit, government and private organizations to address diabetes as a complex and urgent public health issue.
 
Central Ohio needs a partnership between nonprofit, government and private organizations to address diabetes as a complex and urgent public health issue that encompasses social and economic issues such as hunger, transportation and health-care coverage. The issues can only be resolved through a cooperative effort. Our community needs involvement from all sectors to change the future for those with diabetes and for those at risk of developing it.

We must not forget that the World Health Organization projects that the number of people with diabetes will more than double over the next 20 years. Considering these projections and the findings of Diabetes In Central Ohio: A Problem We Can't Afford To Ignore, diabetes is a serious threat to our community and one that needs a community response.

Recommendations

In response to the findings of this study, Central Ohio Diabetes Association is committed to increasing availability and accessibility of diabetes prevention, detection and self-management education and to reducing barriers such as hunger, transportation and cost in the Central Ohio community. The Central Ohio Diabetes Association Board of Trustees has approved a strategic plan for the agency that responds to the findings of Diabetes In Central Ohio: A Problem We Can't Afford To Ignore. Central Ohio Diabetes Association will expand resources for diabetes prevention, outreach and early detection programming for Type 2 diabetes and develop community partnerships to address the issue of mortality rates in minorities.

Central Ohio Diabetes Association is also working with an alliance of diabetes-serving organizations in Central Ohio on a campaign to raise awareness as to the urgency of diabetes control and the resources that are available.

In addition to its efforts, Central Ohio Diabetes Association supports a community solution and recommends the development of a task force to decrease Central Ohio diabetes mortality rates to at least the state level of 16 per 100,000. This will require a more intensive focus on mortality rates in African Americans.

The task force should include representatives from local and state government, transportation organizations, hunger organizations, physicians and physician organizations, other health-care professionals, managed care organizations, community funders and legislators.

The task force should focus on developing and supporting partnerships to address:

affordability of diabetes medications;
insurance coverage for diabetes supplies and education;
food insecurity issues;
diet education;
exercise and co-morbidities;
diabetes awareness and promotion of local resources;
transportation issues and the need for community-based services; and,
adherence among health-care professionals and consumers with diabetes to the higher standards for diabetes care and self-management as outlined in the DCCT and UKPDS studies and the ADA standards of care.
A coordinated, community-wide effort can improve the quality of life of Central Ohioans with diabetes and those at risk of developing diabetes.
 
In order to succeed, the diabetes task force must be sponsored by local government and community leaders providing high profile leadership and financial support. The task force must evaluate its effectiveness and impact on the community by monitoring its activities and assessing the need for future studies related to Central Ohioans with diabetes.

Through a coordinated, community-wide effort, the task force can reduce the rate of diabetes complications and mortality in Central Ohio and improve the quality of life of Central Ohioans with diabetes and those at risk of developing diabetes.

Copyright, 2000. All Rights Reserved. Central Ohio Diabetes Association . Columbus, Ohio.

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