Diabetes: determinants and solutions

Adam Penrose

Healthy beta cells of the Islets of Langerhans in the pancreas release insulin in response to increased blood glucose concentrations- insulin stimulates GLUT transporters in cells which transfer glucose into the cytoplasm and allow fed-state cellular metabolism to occur. Diabetes mellitus is a breakdown of this system- type I diabetes is a problem with the beta cells. The causes vary but are typically autoimmune, causing beta cells to not release insulin in response to increased blood glucose levels. Type II diabetes is a decreased sensitivity to insulin in otherwise healthy cells due to a depressed production of insulin receptors. (Mussmann et al. 2007)

The cause of this physiological breakdown in type I diabetes varies, and is typically due to genetic factors or random genetic events which lead to an autoimmune disorder where the immune system targets beta cells for destruction. Type II diabetes mellitus is caused by an overabundance of blood glucose, usually due to high-sugar and carbohydrate diets, rare physical activity, and a general sedentary or food-insecure lifestyle. Overabundance of glucose causes an insulin-resistance in cells leading to the condition described as “starvation in the midst of plenty,” as the patient’s cells cannot absorb the glucose which is concentrated in the blood. Increased blood glucose as a result of this lack of absorption is typically treated with supplemental insulin to kick-start absorption or drugs like metformin, which suppresses hepatic glucose release. (Zhao et al. 2001)

Overestimating or underestimating choice in this matter is an issue- people have agency over what they eat and do, while often insurmountable social and economic barriers stand between individuals with chronic diabetes and changes in lifestyle or medical care that would mean relief from the destructive symptoms. Rural areas experience decreased access to medicine- through a lack of providers (a 2015 study predicts a shortage of at least 60,000 physicians, and 20% of nonmetropolitan counties are considered to be health provider shortage areas while only 5% of metropolitan counties are included in this designation) (AAMC 2015), cultural boundaries to accessing medicine, and less resources in systems which are present in rural areas. Meanwhile, at-risk populations in urban areas often exist in geographic spaces called “food deserts,” which are massive swaths of urban land which do not contain an affordable source of fresh, healthy food (Whelan et al. 2002). Economic barriers affect economically unstable groups in all regions, those without insurance tend to not access primary care and present far more advanced cases in emergency rooms, which are costly (to the patient and the hospital system) and also lower quality care than would be provided had the patient been able to begin treatment with a primary care provider at the beginnings of their symptoms.

Diabetes doesn’t singularly effect patients’ glucose intake- there are many comorbidities that make the disease difficult to manage and the symptoms even more uncomfortable. Increased blood glucose in diabetic patients causes widespread oxidative stress on many tissues. Nervous tissue is particularly susceptible to this type of stress, which leads to neuropathy, or nerve damage, in diabetic patients. This is a dangerous condition to present; extremities go numb after continual nerve damage, which leads to increased risk of injury, calluses, and eventual amputation. Retinopathy is the result of increased oxidative stress on the walls of capillaries and venules in the retina. This causes them to tighten and eventually calcify and harden. Angiogenesis in the retina compensates for the sudden lack of blood supply, but the newly-formed vessels undergo the same type of damage and the disease is compounded, leading to pain and blindness. Other significant comorbidities of diabetes include heart disease, fatty liver disease, hypertension, depression, obesity, and sexual dysfunction (Kalyani et al. 2010).

All of this is to say that diabetes is an extremely uncomfortable disease, and those who have it deal with an unfair amount of pain and suffering. Treatment options are often expensive, especially to already economically at-risk people who are more susceptible to diabetes in the first place. Patients with diabetes go through a lot of pain and worry, including psychological stress. The lifestyle change associated with a diabetes diagnosis is drastic. The fear of losing toes and feet, a perceived negative social attitude towards people with diabetes, and depression resulting from stress and physiological effects of diabetes on neurology all contribute to a general feeling of alienation.

Diabetes is particularly devastating in minority and economically at-risk populations, and affects a disparate amount of people in these groups for reasons discussed previously (as well as many other social explanations including general wealth inequality).

There’s also a widespread economic impact of the diabetes epidemic. Taking into account factors such as comorbidities, indirect costs such as work absenteeism and presenteeism (a condition where someone attends their work but is not productive) and premature mortality, researchers finally settled on a conservative estimate of $245 billion dollars from the market lost in 2012 due to diabetes (Yang et al. 2013).

Recent innovations from health systems try to mitigate the human suffering and economic cost of diabetes by clearly defining the course of action required once a patient is diagnosed with diabetes. One idea is Geisinger Health Plan’s Diabetes Bundle reimbursement model, which was authorized among other preventative measures by the affordable care act. The diabetes bundle tries to acknowledge the social determinants, patient behavior, and provider actions that affect a patient’s experience with diabetes. Using electronic medical records to monitor progress, the patient and providers receive a “report card” which reports progress on different fronts of the treatment. There are 9 categories of care in this report, and their presentation together emphasizes the collaborative approach to diabetes treatment:

CATEGORY	GOAL
A1C measurement	Every 6 months
A1C control	Patient goal, <7% or 8%
LDL measurement	Annually
LDL control	Patient goal <70 or <100 mg/dl
Blood pressure	<150 SBP, <80 DBP
Urine protein testing	Annually
Influenza vaccine	Annually
Pneumococcal vaccine	Annually
Smoking status assessment	Try to quit smoking, cessation program involvement

(Bloom et al. 2014) Other changes in healthcare structure, such as accountable care organizations and the healthcare.gov insurance marketplace, try to incentivize frequent primary care encounters and preventative medicine. Time and careful analysis will show which aspects of these changes are effective on a population level and which hare not, and hopefully population health will improve with changes in philosophy and policy.

Other proposed methods to increase chronic disease recovery despite disparities in healthcare access include modifications to current delivery models, such as the patient-centered medical home model, or the PCMHM. The patient-centered medical home model is a style of primary care delivery designed in part to help patients from at-risk populations manage chronic disease such as diabetes. It’s a coordinated effort across multiple care roles, from receptionists who greet and call patients to the physicians who manage midlevel practitioners, and report to officials who design strategies for population recovery and disease management. The PCMHM clearly defines the responsibilities of all people involved in a patient’s recovery from diabetes, including those of the patient themselves. The clinic serves as their medical “home,” from which they’re held accountable to meet with behaviorists, nutritionists, social workers, physicians, nurses, and community health representatives as needed to improve their chronic condition. By increasing coordination and continuity across the entire spectrum of care, proponents of the model believe they can begin to break down barriers of access stemming from geographic and social isolation. (Cramm and Nieboer, 2016)

Another action medical professionals and systems are taking against the diabetes epidemic is experimentation with fresh food vouchers. This is meant to be a prescribed form which can be traded for fresh fruits or vegetables at little cost to the patient. This is intended to ease the financial barrier between economically burdened folks and fresh food, allowing cultivation of healthy eating habits and changes in lifestyle.

Work to ease the diabetes epidemic is also done on a community level, by advocates and members of at-risk populations. To try to solve the lack of access to healthy food in urban areas, charities and cooperatives purchase space in food deserts and begin community gardens. These provide a place for people to get fresh vegetables and fruits, an opportunity for physical activity in the form of volunteering in the garden, and a sense of community in what are occasionally socially isolated neighborhoods. There’s not much evidence about community garden’s effects on their surrounding populations’ health, but they serve as an aspirational example of the potential for good-natured effort and community collaboration to help solve the diabetes epidemic (Glover and Parry, 2005).

Overall, some of these proposed solutions will likely be shown to have little effect in the continual diabetes epidemic. We must keep trying, advancing processes that work and culling those that do not. Compassionate effort towards a systemic change which recognizes the great and varied effects of social determinants, individual choice, personal empowerment, community involvement, healthcare access, delivery methods, and economic inequality in diabetic patients’ conditions will be the solution. To paraphrase H.L. Mencken: Every great and complex question has a simple answer, and that answer is wrong. There’s a lot of moving parts on many different levels which cause diabetes to occur in individuals, populations, and nations, but we have the intellectual and organizational capabilities to do something about it.

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REFERENCES:

American Association of Medical Colleges. 2015. The complexities of physician supply and demand: projections from 2013 to 2015. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport

Bloom F.J., Yan X., Stewart W.F., Graf T.R., Anderer T., Davis D.E., Pierdon S.B., Pitcavage J., and G.D. Steele Jr. 2014. Am. J. Manag. Care. 20: 175-182.

J.M. Cramm and A.P. Nieboer. 2016. Is “disease management” the answer to our problems? No! Population health management and (disease) prevention require “management of overall well-being”. BMC Health. Serv. Res. 16: 500.

Kalyani R., Saudek C.D., Brancati, F.L., and E. Selvin. 2010. Association of diabetes comorbidities and A1C with functional disability in older adults. Diabetes Care. 33: 1055-1060.

Mussmann R., Geese M., Harder F., Kegel S., Andag U., Lomow A., Burk U., Onichtchouk D., Dohrmann C. and Austen, M. 2007. Mechanisms of signal transduction: inhibition of GSK3 promotes replication and survival in pancreatic beta cells. J. Biol. Chem. 282: 12030-12037.

T.D. Glover and D.C. Parry. 2005. Building relationships, accessing resources: mobilizing social capital in community garden contexts. J. Leis. Res. 4: 450-474.

Whelan A., Wrigley N., Warm D., Cannings E. 2002. Life in a ‘food desert’. Urban Studies (Routledge). 39: 2083-2100.

Yang W., Dall T., Halder P., Gallo P., Kowal S.L., and P.F. Hogan. 2013. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 36: 1033-1046.

Zhou G., Myers R., Li Y., Chen Y., Shen X., Fenyk-Melody J., Wu M., Ventre J., Doebber T., Fujii N., Musi N., Hirshman M., Goodyear L., and D.E. Moller. 2001. Role of AMP-activated protein kinase in mechanism of metformin action. J. Clin. Invest. 108: 1167-1174.