Running head: THE IMPLICATIONS OF DIABETES MELLITUS 1

The Implications of Diabetes Mellitus in Lowndes County, Alabama

Alexandra N. Huechteman

March 10, 2016

HHE 273-002

Ashley White, MPH

THE IMPLICATIONS OF DIABETES MELLITUS 2

The Implications of Diabetes Mellitus in Lowndes County, Alabama

Introduction

As both an economic burden and global epidemic it is no wonder that the U.S.

Department of Health and Human Services is taking diabetes mellitus more seriously than ever

before. This disease occurs when the body cannot produce or respond appropriately to insulin

(United States Department of Health and Human Services [HHS], 2014). There are three

common types of diabetes mellitus that currently afflict around 23.6 million people (HHS, 2014).

The government has spent increasing amounts of money each year to deal with both the

incurable and preventable category of this disease. The prevalence of diabetes and obesity are

simultaneously impairing quality of life across the nation. The Healthy People 2020 Initiative

seeks to improve many components of this disease, including prevention. This paper intends to

highlight the highest rates of type 2 diabetes in Alabama, explain cultural and social contributing

factors, and suggest possible intervention strategies.

Health Issue

As described by the Journal of Physiology and Pathophysiology, the estimated worldwide

prevalence of diabetes is estimated to rise to 7.7% by 2030 (Ozougwu, Obimba, Belonwu, &

Unakalamba, 2013). With links to lower life expectancy and increased risk for heart disease and

kidney failure, diabetes mellitus demonstrates it does not work alone. To understand the

encroaching disease, it is important to recognize the biological impact. Each type of diabetes

deals with the hormone insulin. Insulin works in a negative feedback loop with glucagon to

regulate how much glucose is available for the bodys cells to utilize as its energy source.

According to the American Diabetes Association, Type 1 diabetes is responsible for

around 10% of all casesand the incidence is rising (as cited in Ozougwu et al., 2013, p. 46).
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G. I. Holt (2004) published that this type of diabetes is most often diagnosed in early childhood

or adolescence, and is the result of an autoimmune reaction to the proteins of the islet cells of

the pancreas, particularly by islet cell cytoplasmic antibodies (ICCA) and islet cell surface

antibodies (ICSA) (as cited in Ozougwu et al., 2013, p. 48). When antibodies reject antigens on

the islet cell, the functional -cells are unable to secrete appropriate levels of insulin. As

antibodies degrade -cells, recruited cells such as T-lymphocytes and CD4+ cells create a long

standing immune response, possibly contributing to the chronicity of type 1 diabetes (Ozougwu

et al., 2014). If the islet cell is under immune attack, it cannot control the transfer of dietary

glucose to the bodys cells for energy. It is important to note that it is difficult to follow this

process because of irregular pancreatic lesions and scarring (Ozougwu et al., 2013). As a result,

hyperglycemia, extreme thirst, frequent urination, drowsiness, glycosuria, increased appetite, and

labored breathing can occur if the condition goes undiscovered (Juvenile Diabetes Research

Foundation International, 2016).

Currently, type 1 diabetes is incurable. Sadly, the disorder [occurs] in genetically

susceptible individuals where there has been an environmental insult to the aforementioned -

cells (Casey, 2012, p.21). The complex relationship of genetic and environmental factors has yet

to be understood, though some genes have found to be protective (Al Homsi & Lukic, 1992).

Insulin therapy via pumps and injections has increased maintenance success for these cases.

The predominant form of diabetes, type 2, is described as a break-down of mechanisms

responsible for maintaining a narrow range [of blood glucose levels] despite wide fluctuations

in supply and demand [through] the dynamic interaction between tissue sensitivity to insulin

(especially in the liver) and insulin secretion. (Defronzo & Ferrannini, 1988). Holt (2004) states

that the two main pathological defects in type 2 diabetes are impaired insulin secretion through
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a dysfunction of the pancreatic -cell, and impaired insulin action through insulin resistance (as

cited in Ozougwu et al., 2013, p. 51). Insulin resistance is discussed by the Joslin Diabetes

Center of Harvard Medical School (2016, para. 2):

In many cases, the person may actually be producing more insulin than one might

reasonably expect that person to need to convert the amount of food they've eaten at a

meal into energy. Their pancreas is actually working overtime to produce more insulin

because the body's cells are resistant to the effects of insulin. Basically the cells, despite

the presence of insulin in the bloodstream, don't become unlocked and don't let enough of

the glucose in the blood into the cells. Scientists don't know exactly what causes this

insulin resistance, and many expect that there are several different defects in the process

of unlocking cells that cause insulin resistance.

In conjunction with these deficits of understanding, Dr. Kaku reports that type 2 diabetes is also

affected by environmental factors such as obesity, over eating, lack of exercise, and stress as

well as aging (as cited in Ozougwu et al., 2013, p. 51). This category of diabetes is not

autoimmune and the possible genes of predisposition have not been identified in most patients

(Ozougwu et alk., 2013, p. 51). This acquired form of diabetes is often plagued by similar

symptoms as type 1, but could also include blurred vision, slow healing sores, areas of darkened

skin, and weight loss as the body uses alternative fuel stored in fat to compensate for the inability

to metabolize glucose. (Mayo Clinic, 2016). According to Ozougwu et al., fatty acids are

introduced into mitochondrial oxidation instead of glucose to create acetyl COA. In liver cells,

acetyl COA is metabolized into ketone bodies, and the increased availability of these bodies in

the blood decreases glucose uptake and vexes hyperglycemia (2013).

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The causes of type 2 diabetes fall under the category of epigenetic, a combination of both

genetic predisposition and lifestyle factors. For the purposes of public health and Healthy People

2020, prevention strategies exist to elicit lifestyle changes and reduce the net risk of developing

type 2 diabetes. A publication from the Japanese Medical Association Journal identifies factors

causing an increase in visceral fat, a possible causation of this conditions development. These

include: Stress related factors overeating (especially excessive intake of simple sugars),

smoking, increased alcohol intake, and disorders of nervous and endocrine systems, specifically

increases in cortisol or abnormalities in sex hormone secretion. Also included is lowered energy

consumption due to lack of exercise, and aging (Kaku, 2010). JC Chan of the Journal of the

American Medical Association sums up these behaviors and type 2 diabetes as inextricably

linked [from] changes towards a Western lifestyle (high diet with reduced physical

activity)and the rise in prevalence of overweight and obesity (as cited in Ozougwu et al.,

2013, p. 51). Healthy People 2020 is growing more concerned about complications and further

economic expense as the cases steadily increase.

Targeted Population

The CDC released a statement in 2010 that 1 in every 10 U.S. adults has diagnosed

diabetes (Centers for Disease Control and Prevention [CDC], 2010). The state of Alabama is

among the top 5 states with the highest rates of Type 2 diabetes. The total crude rate for all forms

of diabetes collected in 2013 was 13.8 per 100 people, stacking above the national crude rate of

9.8. (CDC, 2010). The county with the highest incidence rate (per 1000) from 2010-2013 was

Lowndes County, closely followed by Greene County (CDC, 2013).

Lowndes County is part of Alabamas Black Belt and includes the towns of Benton, Fort

Deposit, Hayneville, Lowndesboro, and White Hall. The closest metro area is Montgomery.
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During the Civil Rights era, Lowndes County was highly involved with efforts to reform

suffrage and was the home of the Lowndes County Freedom Organization, an early incarnation

of what eventually became the Black Panther Party. Lowndes County commemorates its rich

history with the Interpretive Center to celebrate the people and events of the march on Selma.

The majority of jobs exist in manufacturing and educational services, and the economy remains

largely rural and agricultural (Siebenthaler, 2007).

The Selected Health Status Indicators of Lowndes County published by The Office of

Primary Care and Rural Health in 2013 provides imperative statistics about this communitys

health. In 2011, the total population was 11,147, wherein 8,111 of these residents were African

American. The highest margin of the population at this time was age 19 or less. Important to note

is that over half of the population was under 200% poverty level (Alabama Department of Public

Health, 2013).

According to the CDC, the demographic with the highest prevalence of diabetes during

2011 was American Indian/Alaskan American, however this ethnicity only accounted for 27

residents in Lowndes County (CDC, 2013, Alabama Department of Public Health, 2013).

Therefore, majority of diabetes cases in this county were African Americans. (Alabama

Department of Public Health, 2013). The difference in statistics among ethnicities provides

evidence for the epigenetic claims about this disease.

Integration of the Health Issue and Target Population

To investigate why Lowndes County tops the charts with health issues, it is important to

consider the risk factors. In 2011, there were over 200,000 primary care physicians for every

10,000 people in the U.S. However, in Lowndes County there were only 2, without (and still

without) a single hospital. There were over 500 households without a vehicle, and over 1600
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people under the age of 65 without insurance (Alabama Department of Public Health, 2013). It is

highly likely that the prevalence of chronic disease, including diabetes, is so great due to the lack

of healthcare access. An unfortunate key factor is the lack of diabetes public health programming

from the Lowndes County Health Department. According to their website, the clinic does not

provide any services for chronic disease, including diabetes (Alabama Department of Public

Health, 2015). Without the income or insurance to pay for professional healthcare service, there

exists a deficit of primary health maintenance. Type 2 diabetes can quickly compromise the body

via conditions such as cardiovascular disease or vision problems. Without proper diagnosis,

treatment, and lifestyle change, it can debilitate life very quickly.

Other social determinants of health in Lowndes County are 17.34% of the population

holding less than a high school education, and 45.5% of adults with obesity (Alabama

Department of Public Health, 2013).

Positive risk factors in this area could include lifestyle of Lowndes County residents.

With a historically African American population, the popularity of soul food is likely. According

to Robert Dirks, an anthropologist from Illinois State University, soul food originated out of

necessity of African-American slaves. Passed through generations, social gatherings often

include rich cuisine such as chitterlings, cracklins (fried pork skin), country fried steak, fried

chicken, black eyed peas, okra, biscuits, cornbread, rice, watermelon, and sweet potatoes. Soul

food recollects familial ties, feeds the spirit as well as the body and is regarded as an emblem

of ethnic identity (Dirks, 2016, p.2). It has been highlighted that a diet heavy on soul foods is

unhealthy, and concerns arise primarily from the common convention of cooking and seasoning

with pork fat because so many dishes are friend, usually in lard or hydrogenated vegetable oil

(Dirks, 2016, p. 2). As with any food heavy in fat, absence of moderation can lead to an increase
THE IMPLICATIONS OF DIABETES MELLITUS 8

in visceral fat, a strong correlate to the development of insulin resistance and possibly type 2

diabetes.

Lowndes County also presents with protective factors to prevent diabetes. According to

Google Maps, the county has a Wal-Mart Supercenter, Kroger grocery store, and Piggly Wiggly

market. These stores provide access to healthy options including low-fat/low-sodium meats,

fruits, vegetables, and other sources of vitamins and minerals. There are also notable parks in

many cities in Lowndes County available for recreational exercise such as walking or jogging

(Google Maps, 2016). However, the exercise/activity level of residents is unknown, as no

commercial gyms or fitness centers exist in this county.

Between the cultural food expectations and lack of preventative measures regarding

diabetes, Lowndes County is susceptible to increasing cases of diabetes.

Conclusions and Recommendations

The U.S. Department of Health and Human Services has forewarned the current

population about the coming complications if the presence of diabetes continues to climb. Some

of these complications include overwhelming the healthcare system with diabetic difficulties and

increased government expenditure for medical treatment and equipment costs (HHS, 2013).

To summarize the literature, there is still ongoing research about how diabetes develops

and what biological factors contribute to the progression of the disease. However, type 2 diabetes

accounts for 90-95% of cases and has been shown to be related to population determinants of

health such as physical inactivity, unbalance diet, and obesity (Fianu et al., 2016). These

lifestyle choices increase body fat percentage and have a cycle of effects on glucose metabolism.

More research is emerging on prevention programs. Regarding these studies, a long term

study on Reunion Island found that exposure to lifestyle intervention resulted in a 2.32 kg mean
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weight loss after 12 months (Fianu et al., 2016). Other conclusions state that health benefits can

last up to 14 years after intervention. The most notable part of this study is recommendations that

are made. From the literature, four suggestions arise (Fianu et al., 2016, para. 4):

I- start lifestyle intervention early with a primary prevention approach; II- implement

community-based efforts in real-life settings; III- focus on vulnerable groups such as

communities with low socio-economic status; IV- study duration of effect . Indeed, very

few studies have evaluated long-term benefits of T2D prevention after lifestyle

intervention discontinuation, beyond three years of follow-up.

Concerning Lowndes County, the first step to decreasing diabetes would be merely

implementing a primary level prevention program. This would require bringing in competent

public health professionals, or utilizing staff in the health department, to distribute up-to-date

information about diabetes, as well as provide blood sugar testing. For secondary prevention, a

larger staff of physicians is needed to manage these cases and prescribe medication, whether they

be permanently moved to the area or visit regularly. Tertiary prevention could include the

construction of a diabetes clinic for both insured and uninsured patients. This clinic could

provide a pharmacy for medication, sell glucometers, and provide diabetes support groups.

Aside from a prevention program, Lowndes County could greatly benefit from

affordable or even free exercise facilities so residents can safely exercise regardless of weather.

To achieve the highest level of use, transportation could be provided from local neighborhoods

to the exercise facility. Frequent exercise can delay, prevent, or reverse risks for diabetes.

To execute these suggestions, a great amount of funding and compassion for this area is

needed. Awareness of the diabetes situation should be brought to the attention of local

philanthropies and state government to petition for funding, as this is a necessary public health
THE IMPLICATIONS OF DIABETES MELLITUS 10

issue. If these parties attended to this situation in its fullness, an example could be made of the

consequences to the absence of health care access. Lowndes County shall be used as a model

research community to implement longitudinal epigenetic studies for both disease progression

and effectiveness of prevention. For America, diabetes does not have to inevitable, and there can

be hope for Lowndes County.

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References

Alabama Department of Public Health (2015). Lowndes County health department. Retrieved

February 27, 2016 from http://www.adph.org/lowndes/Default.asp?id=2701

Alabama Department of Public Health (2013, April). Selected health status indicators: Lowndes

County. Retrieved February 27, 2016 from

http://adph.org/ruralhealth/assets/Lowndes13.pdf

Al Homsi M.F., Lukic M.L. (1992). An update on the pathogenesis of diabetes mellitus,

Department of Pathology and Medical Microbiology (Immunology Unit) Faculty of

Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates

Casey, G. (2012). Type 1 diabetes and insulin therapy. Kai Tiaki Nursing New Zealand, 18(3),

20-24 5p

Centers for Disease Control and Prevention (2010, October 22). Press Releases. Number of

americans with diabetes projected to double or triple by 2050. Retrieved February 24,

2016 from http://www.cdc.gov/media/pressrel/2010/r101022.html

Centers for Disease Control and Prevention (2012). Diabetes, county data. Retrieved February

24, 2016 from http://www.cdc.gov/diabetes/atlas/countyrank/atlas.html

Defronzo RA, Ferrannini E (1988). Lily Lecture 1987. The Triumvirate: beta cell, muscle, liver.

a collusion responsible for niddm. Diabetes. 37:667-687.

Dirks, R. (2009). What early dietary studies of african americans tell us about soul foods.

Retrieved February 27, 2016, from

http://www.academia.edu/231486/WHAT_EARLY_DIETARY_STUDIES_OF_AFRIC

AN_AMERICANS_TELL_US_ABOUT_SOUL_FOODS
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Fianu, A., Bourse, L., Naty, N., Le Moullec, N., Lepage, B., Lang, T., & Favier, F. (2016). Long-

term effectiveness of a lifestyle intervention for the primary prevention of type 2 diabetes

in a low socio-economic community - an intervention follow-up study on reunion island.

Plos ONE, (1), doi:10.1371/journal.pone.0146095

Google Maps. (2010). [Lowndes County, AL] [Street map]. Retrieved February 28, 2016 from

https://www.google.com/maps/place/Lowndes+County,+AL/@32.1844138,-

86.932676,10z/data=!3m1!4b1!4m2!3m1!1s0x888e5dcc75b0006f:0x5e5f3b1a6b65b6a0

72.688916&spn=0.008981,0.01929&z=16

Holt G. I. (2004). Diagnosis, epidemiology and pathogenesis of diabetes mellitus an update for

psychiatrists. Br. J. Psychiatry. 184:s55- s63.

Joslin Diabetes Center (2016). What is insulin resistance? Retrieved February 27, 2016 from

http://www.joslin.org/info/what_is_insulin_resistance.html

Juveile Diabetes Research Foundation International. (2016.) Type 1 diabetes warning signs.

Retrieved February 26, 2016, from http://jdrf.org/t1d-resources/type-1-diabetes-warning-

signs/

Kaku K (2010). Pathophysiology of type 2 diabetes and its treatment policy. JMAJ, 53(1):41-46.

K.

Mayo Clinic Staff (2016). Type 2 diabetes: symptoms and causes. Mayo Clinic. Retrived

February 26, 2016 from http://www.mayoclinic.org/diseases-conditions/type-2-

diabetes/symptoms-causes/dxc-20169861

Ozougwu, J. C., Obimba, K. C., Belonwu, K. D., & Unakalamba, C. B. (2013). The pathogenesis

and pathophysiology of type 1 and type 2 diabetes mellitus. Journal of Physiology and

Pathophysiology, 4(4), 46-57. Retrieved February 24, 2016.

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Siebenthaler, D. J. (2007). Lowndes county. In Encyclopedia of Alabama. Retrieved February

28, 2016 from http://www.encyclopediaofalabama.org/article/h-1349

United States Department of Health and Human Services. Office of Disease Prevention and

Health Promotion. (2014). Healthy People 2020. Washington, DC: Retrieved February

25, 2016 fromwww.healthypeople.gov