North Carolina’s Guide To Diabetes Prevention And Management
North Carolina’s Guide toDiabetes Preventionand Management2015-2020Manage weight Live tobacco free Participate in lifestyle change programs Participate in diabetes education Adhere to treatment plan Get adequate sleep
North Carolina’s Guide toDiabetes Preventionand Management20152020IntroductionThe number of North Carolinians who have or who are at risk for diabetes is growing.The financial burden, human suffering and loss of productivity that are a part of this diseaseare real and will get worse if more people do not take action now. While diabetes can presentchallenges on a daily basis, it is now evident that steps can be taken to prevent or delaythe onset of diabetes or manage existing diabetes with or without complications. All NorthCarolinians have a role in these efforts. We can all have a positive impact on the lives of thoseat risk for or with diabetes.This guide includes basic information about diabetes, its effects on the North Carolinapopulation, and suggestions on how individuals can prevent and manage the disease.The guide also includes specific strategies for community groups, employers and healthcare providers to help people manage their risk for developing diabetes, gain and maintaincontrol of diabetes, and reduce risks for diabetes-related complications.
What is diabetes?Diabetes is a chronic condition in which the bodyeither fails to produce any or sufficient insulin orbecomes resistant to that insulin. This leads to excessglucose levels in the blood.1Sustained high blood glucose levels over time can cause damage to blood vessels,resulting in serious health complications such as high blood pressure, heart diseaseand stroke, blindness, kidney failure and amputations.2 Persons with diabetes alsohave an increased risk for other diabetes complications: hearing loss, sleep apnea,periodontal disease, certain forms of cancer including colorectal and breast, sexualdysfunction and cognitive impairments including dementia.3There are four primary types of diabetes: prediabetes; type 1 diabetes, which affectsless than 10 percent of the population with diabetes; gestational, which is only presentduring pregnancy; and type 2 diabetes, which accounts for at least 90 percent ofdiagnosed diabetes.1North Carolina’s Guide to Diabetes Prevention and Management 2015–2020
PrediabetesType 1 DiabetesGestational DiabetesType 2 DiabetesPrediabetes is a conditionwhere people have higherthan normal blood glucose(sugar) levels, but notyet high enough to bediagnosed as diabetes.Prediabetes is sometimesreferred to as impairedglucose tolerance (IGT) orimpaired fasting glucose(IFG), depending on thetest that was used when itwas detected.4Type 1 diabetes maybe caused by a geneticcondition or environmentalfactors which cause thedestruction of cells in thepancreas that produceinsulin. Type 1 diabetesrequires the person to takeinsulin, as his/her bodydoes not produce insulinor produces insufficientamounts. Currently thereis no cure for this typeof diabetes, nor can thedestruction of the cells inthe pancreas be reversed.Gestational diabetes occurswhen insulin resistance(the inability of the body touse insulin for the uptake ofglucose) intensifies duringpregnancy. Gestationaldiabetes occurs inapproximately nine percentof pregnancies. Withoutintervention, 35 to 60percent of these womenare expected to developdiabetes in 10–20 years.5Their children are also atincreased risk of developingdiabetes.People who have type 2diabetes are insulin resistantand may also have someinsulin deficiency. Type2 diabetes is the mostprevalent form of diabetes.It affects nearly one in ninepeople in the United States.Most, but not all, patientswith type 2 diabetesare obese. The risk ofdeveloping type 2 diabetesincreases with age, obesityand physical inactivity. Itoccurs more frequentlyin women with priorgestational diabetes, amongthose with hypertensionor high cholesterol(dyslipidemia) and in certainracial/ethnic groups (AfricanAmerican, American Indian,Hispanic/Latino and AsianAmerican). It is oftenassociated with a stronggenetic predisposition,more than type 1 diabetes;however the genetics oftype 2 diabetes is poorlyunderstood.6pre212
Diagnosing DiabetesThere are several ways to diagnose diabetes, and the tests usuallyinvolve drawing blood at a health care provider’s office or commercialfacility and sending the sample to a lab for analysis. One way to diagnosis diabetes is to use a test called a hemoglobinA1c (A1c) to measure the average amount of glucose in a person’sblood over a three-month period. When a person’s A1c test is over 6.5percent, he/she is considered to have diabetes. If the test shows anA1c between 5.7 percent and 6.4 percent, the person is consideredto have prediabetes. It is possible for a person with prediabetes tolower his/her blood glucose so he/she never develops diabetes or atleast delays the development of diabetes. The A1c test is also usedfor people already diagnosed with diabetes to assess hyperglycemia(high blood sugar). It is typical for a person with diabetes to try to keephis/her A1c level below seven percent to prevent complications. Another test used to diagnose diabetes is the fasting blood glucose(FBG) test which measures blood glucose in a person who has fastedfor at least eight hours. This test is most reliable when given in themorning. People with a fasting glucose level of 100 to 125 mg/dl haveprediabetes. A level of 126 mg/dl or above, confirmed by repeatingthe test on another day, indicates a diagnosis of diabetes. FBG is themost commonly used test for diagnosing diabetes. The oral glucose tolerance test (OGTT) is another method to diagnosediabetes, prediabetes, and gestational diabetes. This test is usuallyperformed after overnight fasting and measures blood glucose beforeand two hours after a person drinks a liquid containing 75 grams ofglucose dissolved in water. Prediabetes is diagnosed at a two-hourblood glucose level of 140 to 199 mg/dl, and diabetes is diagnosed attwo hour blood glucose of greater than or equal to 200 mg/dl.3North Carolina’s Guide to Diabetes Prevention and Management 2015–2020The North Carolina Diabetes Advisory Council supportsefforts to find a cure for type 1 diabetes. A major focus ofthis guide and the Diabetes Advisory Council is on type 2because it is more common and is preventable. For theremainder of this document, references to “diabetes” will bereferring to type 2 diabetes unless indicated otherwise.
Prediabetes PrevalenceIn 2013, approximately nine percent of NorthCarolinians (630,000 individuals) reportedhaving prediabetes. The actual prevalencemay be anywhere from 11.6 percent to 21.7percent, as many people do not know theyhave prediabetes.7Diabetes PrevalenceIn 2012, approximately 10.4 percent(age-adjusted) of North Carolinians (750,000individuals) were diagnosed with type 1 andor type 2 diabetes (Figure 1).8 This statelevel prevalence was slightly higher than thenational prevalence of 9.7 percent.FIGURE 1: North Carolina—Percentage of Adults(aged 18 years or older) with Diagnosed Diabetes,2011–20131210864202011North Carolina20122013United StatesSource: Centers for Disease Control and Prevention, BehavioralRisk Factor Surveillance System4What does diabeteslook like and costin North Carolina?Racial/Ethnic Inequalitiesin Diabetes Prevalence and MortalityAmong racial and ethnic groups in North Carolina, type 2 diabetes does not occurequally. In 2012, 14.5 percent of African-Americans and 19.0 percent of American Indiansreported a diabetes diagnosis, compared to 9.7 percent of non-Hispanic whites andsix percent of Hispanics, though the particularly low reported rate for Hispanics is likelydue to under-sampling and under-reporting.9 While diabetes prevalence increases withage for all racial groups, the disease disproportionately affects older African Americans,affecting 28.1 percent of African Americans aged 55 to 64 and more than a third (36.3percent) of African Americans between the ages of 65 and 74 in 2012.10 Statewide,diabetes was the third leading cause of death for American Indians, the fourth leadingcause of death for African Americans and the seventh leading cause of death for nonHispanic whites in 2012.11
Geographic DisparitiesA regional analysis of North Carolina diabetes rates shows geographic differencesacross the state. In the Piedmont, where most of the state’s largest cities are located(including Charlotte, Raleigh, Greensboro and Durham), the rate of diagnosed diabetesis 9.9 percent. In the eastern and western regions, the rate of diagnosis is higher at11.1 percent.12 Regional disparities also include racial disparities. For example,in the Piedmont, 13.7 percent of African Americans report a diabetes diagnosis, whilenine percent of non-Hispanic whites do so.13Economic BurdenPeople with diabetes have medical expenses approximately 2.3 times higher than thosewithout diabetes.14 A majority (62.4 percent) of the medical costs are paid by governmentprograms, including Medicare, Medicaid and military health programs.15 Seventy-twopercent of national diabetes costs are attributed to direct health care expenses while 28percent represent lost productivity from work-related absenteeism, unemployment andpremature mortality.16Like the rest of the nation, North Carolina continues to face increases in diabetes-relatedspending. In 2012, roughly 8.3 billion of excess medical costs and lost productivity wereattributable to diabetes within the state.17 Diabetes is associated with an elevated hospitaladmission rate (1.9 per 1,000 population), with an average stay of 4.73 days. Diabeteswas the primary cause for 18,751 hospitalizations at a cost of 454 million in hospitalcharges in North Carolina in 2013. That’s over 24,000 per hospitalized case of diabetesper year.18 If the state does not take steps to help bring the diabetes epidemic undercontrol, annual health care costs are projected to surpass 17 billion by 2025.195North Carolina’s Guide to Diabetes Prevention and Management 2015–2020
How can diabetes be prevented,delayed and managed?Given the enormity of the diabetes epidemic and the number of peopleat high risk, approaches aimed exclusively at individual behavior changeare inadequate. Improvements in policy and environmental factors thatenable and reinforce healthy eating and active lifestyles are needed forwidespread and sustained behavior change and overall impact.20It is important to understand how individuals can actively protect theirown health. In North Carolina, diabetes stakeholders (listed at the endof this document as Plan Contributers) have selected eight evidencebased behaviors for diabetes prevention and management. Figure 2shows the progression of diabetes and what individuals can do toprevent and manage diabetes at each stage.This guide is designed to help community members, employersand health care providers:Behaviors that are appropriate for everyone to prevent diabetes arealso appropriate for people who are at high risk for diabetes. Thesesame behaviors can help people with diabetes manage their conditionand prevent complications. These behaviors are also actions thatthe community, health care providers and employers can facilitateor reinforce with strategies presented later in this guide. The eightbehaviors are described below and are organized by the headersassociated with the diabetes prevention continuum shown in Figure 2. Support diabetes prevention and management through strategiesthat shape the environment so that people are less likely to developdiabetes. Provide access to evidence-based education that prevents ordelays diabetes for people who are at high risk of developing type 2diabetes. Assist people who have already developed diabetes to remainhealthy and reduce their risk for developing diabetes complications.Type 2 diabetes prevention and management can be consideredalong a continuum including the recommendations for thefollowing: What all people can do to avoid developing diabetes(primary prevention). What people with multiple risk factors can do to delay or prevent it. How to manage the condition if it develops. How to avoid progression once it has been diagnosed.61. Diabetes Primary Preventiona. Manage weightb. Follow healthy eating guidelinesc. Participate in regular physical activityd. Live tobacco freee. Get adequate sleep2. Diabetes Prevention for People at High Riska. Participate in diabetes prevention education programs3. Diabetes Management and Prevention of Complicationsa. Participate in individual and/or group self-management educationb. Adhere to personalized diabetes treatment plans
FIGURE 2:Lifetime Risk Management for Developing and Controlling Type 2 DiabetesThe risk of developingdiabetes increases with age.Diabetes preventionfor people at high riskDiabetes primarypreventionGeneticsSome peopleare born withincreased riskfor developingdiabetes.Non-modifiable risk factorsinclude: Race/ethnicity Parent or sibling withdiabetes Mother who had gestationaldiabetesTo manage these risks, shareyour personal and familyhistory of diabetes with yourhealth care team.7ModifiableRisk Factorsfor DiabetesEveryone canlower his/herrisk ofdevelopingdiabetes by: Maintaining a healthy weight Eating healthy Engaging in physical activity Living tobacco free Getting adequate sleepPrediabetes(A1c 5.7-6.4)Once bloodsugar increasesto the rangeshown above,diabetes can stillbe prevented or delayed by: Maintaining a healthy weight Eating healthy Engaging in physical activity Living tobacco free Getting adequate sleep Participating in groupeducation to preventdiabetesNorth Carolina’s Guide to Diabetes Prevention and Management 2015–2020Diabetes management and p reventionof complicationsDiabetes(A1c 6.5)DiabetesComplicationsOnceblood sugarincreases tothe level shownabove, diabetesneeds to be managed andcomplications prevented by:To manageand preventdiabetescomplications,work with yourhealth care team to protectyour: Maintaining a healthy weight Eating healthy Engaging in physical activity Living tobacco free Getting adequate sleep Participating in individualand/or group education tomanage diabetes Adhering to personalizeddiabetes treatment plans Brain or cognition Ears Emotions/mental health Eyes Feet Heart Kidneys Nerves Reproductive organs Skin Teeth and gums
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b. Follow healthy eating guidelinesIn addition to being an important part of any weight loss program, healthy eating and increased physical activity can have a big impact on the risk oftype 2 diabetes.A HEALTHY DIET INCLUDES:21Fruits, vegetables, wholegrains and fat-free orlow-fat milk and milkproducts. There is convincingevidence that diets richin whole grains protectagainst diabetes, whereasdiets rich in refined grainslead to increased risk.22 Strong evidence supportsa diet high in fruits andvegetables for weightmanagement. They arelower in calories and highin volume and fiber.9Lean meats, poultry, fish,beans, eggs and nuts. There is growing evidencethat consumption of redmeat (beef, pork, lamb)and processed red meat(bacon, hot dogs, delimeats) increases the riskof diabetes, even amongpeople who consume onlysmall amounts.North Carolina’s Guide to Diabetes Prevention and Management 2015–2020Moderate amounts ofsaturated fats, sodiumand added sugars, and notrans fats. The types of fats in yourdiet can also affect thedevelopment of diabetes.Good fats, includingpolyunsaturated ormonounsaturated fatsfound in liquid vegetableoils, nuts and seedscan help ward off type 2diabetes.Calorie needs to achieveand maintain a healthyweight. The key to maintaining ahealthy weight is keepingthe number of caloriesconsumed equal tothe number of caloriesexpended. Researchshows that portionsize influences howmany calories a personconsumes and may hinderthe ability of individualsto accurately assess theamount of calories he/sheis consuming. Becauseoversized portions arepervasive in restaurants,supermarkets andvending machines, it isimportant to be aware ofand regulate portion size.23
c. Participatein regularphysicalactivityIncreased physicalactivity plays a majorrole in the preventionand control ofinsulin resistance,prediabetes,gestationaldiabetes, type 2diabetes and diabetes-related health complications. Both aerobic andresistance training improve insulin action and can assist with longterm management of blood glucose levels, lipids, blood pressure,cardiovascular risk, mortality and quality of life.The American Diabetes Association and the National Academy ofSports Medicine recommend at least 150 minutes of moderate intensity,mostly aerobic physical activity, per week, spread over at least threedays per week with no more than two consecutive days without.According to the Centers for Disease Control and Prevention (CDC),moderate activity can be assessed using the Borg rating of perceivedexertion or how hard one feels he/she is working based on: Increased heart rate. Increased respiration or breathing rate. Increased sweating. Muscle fatigue.24Unless your health care provider recommends otherwise, resistancetraining should also be included at least twice per week, with one ormore sets of at least five different resistance training exercises.Efforts to promote physical activity should focus on developing selfefficacy and fostering social support from family, friends and healthcare providers and working with communities on accessible, affordable10physical activity options. Encouraging mild or moderate physicalactivity may be most beneficial to adoption and maintenance of regularphysical activity participation.d. Live tobacco freeSmoking is a proven risk factor for diabetes, with smokers being 3040 percent more likely to develop type 2 diabetes compared to nonsmokers.25 The more someone smokes, the greater his/her chance ofdeveloping diabetes. Studies report that compared to non-smokers,heavy smokers ( 20 cigarettes /day) had a 61 percent higher risk ofdeveloping diabetes, compared to a 29 percent increased risk amongthose who smoked fewer than 20 cigarettes per day, and a 23 percentincreased risk among former smokers.26 While smoking can increasethe risk of developing diabetes, it can also make diabetes managementmore difficult. Among those with diabetes, smokers are more likelyto have problemsmaintaining properblood sugar levelsand may requirelarger doses of insulinto control their bloodsugar. Smokers withdiabetes are at aheightened risk ofpremature death andmorbidity from seriouscomplications suchas heart disease andstroke, circulation problems, nerve damage, eye problems leading toblindness and kidney disease.Given the serious implications of smoking, living tobacco free is akey public health strategy to prevent and control the epidemic ofdiabetes. It is extremely important for people to stop smoking, butprevention is critical, and a multi-component approach is required to
prevent people from starting to use tobacco. According to the SurgeonGeneral’s report, nearly all tobacco use begins during youth and youngadulthood. Policies and programs that make tobacco use more difficultand less accepted can help prevent young people from using tobacco.Policies that change the environment to support and encourage atobacco-free life have also been found to be very effective in smokingpreventio
The North Carolina Diabetes Advisory Council supports efforts to find a cure for type 1 diabetes. A major focus of this guide and the Diabetes Advisory Council is on type 2 because it is more common and is preventable. For the remainder of this document, references to “diabetes” will be referring to type 2 diabetes unless indicated otherwise.
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