New Jersey is seeing an increase in the number of people being diagnosed with diabetes, which now affects more than 9 percent of the adult population, mirroring a nationwide increase.
The dramatic rise in the diabetes rate is now considered a public health crisis, particularly since the Centers for Disease Control and Prevention (CDC) says that about one-third of people with diabetes are undiagnosed.
Reasons for this increase in the diabetes rate are varied: the inclusion of data to include those with undiagnosed diabetes, increasing rates of obesity coupled with physical inactivity, increasing income disparities reflected by the rate of people living in poverty, low education levels, an increase in immigration from countries with vulnerable populations, people living longer with the disease, and the fact that people are living longer in general.
The New Jersey Department of Health and Senior Services (NJ DOH) is funding programs designed to help prevent diabetes and help people to live with the disease. Emphasis is given to programs that link health-care systems to community partners that work directly with patients.
According to 2010 statistics released by the CDC, an estimated 596,000 adults in New Jersey have been diagnosed with diabetes, an increase from 6.8 percent in 2004 to 9.2 percent in 2010.
In 2006, the total cost of treating people with diabetes in New Jersey was estimated at around $5.8 billion. The national cost in 2007 exceeded $174 billion.
Part of the increase in diabetes cases may be due to a change in how the data is calculated.
According to the National Diabetes Information Clearing House (NDIC), 2007 data used the fasting blood glucose level as a measure of diabetes. The 2011 data included both the fasting blood glucose level and the A1C test, which measures blood glucose levels over the last two months and captures data on undiagnosed and prediabetes. Prediabetes is a condition where blood glucose levels are higher than normal but not high enough to be considered diabetes.
The NIH has recently recommended using the A1C test because it does not require fasting. In addition, according to Jennifer Weidenbaum of the American Diabetes Association (ADA), it is a more accurate measure because it tracks the patient’s glucose trends.
The highest percentage of adults diagnosed with diabetes are in Cape May, Cumberland and Ocean, all at 11 percent, and Atlantic, Camden, Essex, Gloucester and Salem at 10 percent, according to 2012 county health rankings. Counties with the lowest percentage (7 percent) of adults diagnosed with diabetes are Hunterdon, Morris and Somerset.
The table indicates rates of obesity, physical inactivity, education level, and low income level as reflected by children living in poverty for the counties with the highest (11 percent) and lowest (7 percent) rates of diabetes.
Another risk factor for diabetes is race or ethnicity, with 2007-2009 NDIC survey data indicating 7.1 percent of non-Hispanic whites, 8.4 percent of Asian Americans, 11.8 percent of Hispanics/Latinos, and 12.6 percent of non-Hispanic blacks having diagnosed diabetes.
Sunil Parik, who runs a diabetic eye-disease detection program in New Jersey, said: “Obesity is a big barrier to improving the quality of life for people. New Jersey has increased its population of Spanish and South Asians, who are at an increased risk for diabetes. A lot of it is (caused by) heredity, the stress of immigration, diet, lack of exercise and access to health care.”
Older age is also considered a risk factor for diabetes. The CDC 2009-2010 BRFSS (Behavioral Risk Factor Surveillance System) data for New Jersey shows that 21.5 percent of adults 65 and older have diagnosed diabetes.
When including people with pre-diabetes, the U.S. figure is estimated to be as high as 50 percent. Reasons for this epidemic in the elderly are being researched; factors cited by the NIH are an accumulation of body fat in the abdomen, muscle weakness, and decreasing rates of exercise as people age.
Weidenbaum,Director of Development and Community Initiative with the New Jersey chapter of the American Diabetes Association (ADA), described this figure as “shocking,” adding that it is because of this increase that “we do a lot of targeted outreach with older adults in community groups, at senior centers and faith organizations such as churches, so they are aware of the signs and symptoms of diabetes.”
To deal with at-risk low income patients, NJ DOH favors programs that link patients, community resources and health-care systems to increase access to care, integrate cself-management programs into care plans at federally qualified healthcare centers (FQHC), and use community health workers who work with patients and go out into communities to promote changes in to diet and physical activity.
An example of such a program is the Commission for the Blind and Visually-Impaired’s Diabetic Eye Disease Detection Program, which was started with NJ DOH funding in 1985. This program enables people with diabetes who cannot afford care to receive dilated retinal eye examinations. Over the years, this program has expanded from providing eye screening at four sites to over 25 sites statewide.
According to Parik, the program coordinator, low income level is one of the major causes of complications from diabetes, because “when people don’t have health insurance, they fail to properly manage their diabetes.”
While funding started at $300,000, it has since been reduced to $95,000, while the program itself has grown. The Commission for the Blind provided additional funding, and Parik replaced the ophthalmologists with ophthalmic technicians in the more general eye-creening programs to support the cost of clinicians in the diabetic eye-disease detection program.
Parik stressed the importance of the program.
“This is one of the most vital programs from the Commission for the Blind, because on average 40 percent (of people) fail the test,” he said.
Screening is offered annually at more than 25 sites annually, including St. Peter’s University Hospital, Bayonne Hospital and CAMcare. The target population consists mainly of people with diabetes who are uninsured and have not had eye exams in the last year.
“And when people become blind (have lost vision of 20/70 or worse in one eye), they are provided with vocational rehab education and independent living services,” said Parik. “Staff go to their homes and work with them.”
Another state program is “Campeones Por La Salud,” which translates from Spanish as “Champions for Health.” Initiated by Emma Lopez at the Vineland City Health Department in Cumberland County, the program trains community health workers to work with a medical provider’s most noncompliant patients to help them follow a diabetes self-management program.
The just-launched “Campeones Por La Salud” initiative follows the ADA 4 Year Family program for Hispanics/Latinos because of the increased risk of diabetes in the Latino community.
Lopez said “I researched programs for years. Other programs that have been done on the West Coast use health education classes. This is one of the first programs to follow along with a medical provider.”
Lopez’s research found that programs using community health workers to provide education and social support, as well as helping to provide access to care, are successful, especially in underserved communities.
The first step was to recruit medical providers in Atlantic and Cumberland counties who might be interested in the program, while outreach workers train and facilitate meetings for community health workers.
When medical providers agree to work with the program, they set up a “Lunch and Learn” for staff to understand how a community health worker can help their organizations. The doctor then sends a referral form for patients who can benefit from the program.
An outreach worker will then contact the patient to see which days they are available to meet with a community health worker. The patient receives home visits from the health worker, who will follow the patient for six months.
The patient will also participate in six workshops based on specific needs as indicated by the medical provider, such as managing blood glucose levels or becoming more physically active.
The community health worker also makes sure the patient attends appointments and follows up with specialists.
“The program is very new for the health department as well,” said Lopez, “We are used to group presentations, not working one-on-one.”
“Campeones Por La Salud” also works with patients who smoke because they are at increased risk for diabetes complications. The Office of Tobacco Control, Department of Rural Health and Office of Chronic Disease are funding this program.
“I hope it changes the lives of a lot of people who live down here,” said Lopez, “and helps change the way our medical system operates. It would be great if a medical practice can hire a community worker to work with patients directly and not depend on our program. Doctors are asking if workers can come into the office and work with them but currently we can’t afford it.
“A lot of people live alone with no family who can help them remember all the things they have to do. Many factors play in, and they get overwhelmed.
“My hope is we can get them on the right path, and a year from now they will be much better than when we met them.”
For fiscal year July 2011 to June 30, 2012, the state Department of Health spent $613,000 on diabetes initiatives.