5
Silent Disorders:
Hypertension and Diabetes
Huntstock/Thinkstock
Learning Objectives
1. Describe why hypertension and diabetes are called silent diseases
2. Describe how hypertension and diabetes affect different individual, familial, and social domains
3. Explain how self-management and medication can be used to treat hypertension
4. Identify disparities in hypertension awareness, treatment, and control
5. Explain how both lifestyle changes and medication can be used to treat diabetes
6. Identify relationships between diabetes prevalence and larger social issues
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
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5.1 Introduction to Hypertension and Diabetes
“H
as Barbara been eating a lot of sweets lately?” the pediatrician asked Barbara’s
mother, Margaret, on the phone. “No, she doesn’t have a sweet tooth and we don’t
keep a lot of sweets in the house,” Margaret replied. Barbara was 11 and had come
down with a particularly nasty stomach ailment. “Why do you ask?” “Well, most of the tests we
did suggest that Barbara has a viral infection, but Barbara’s urine had a very high concentration of
glucose. Let’s just monitor it for a while and see what happens.”
Barbara used urine glucose test strips for several months. At first, her urine glucose went back to
normal, but a few months later it climbed back up and stayed there. She was diagnosed with type
1 diabetes, also known as diabetes mellitus. At the time Barbara was diagnosed, the family was
undergoing quite a bit of stress, because Barbara’s teenaged step-siblings were moving into the
family home.
5.2 D
efinition and Brief History of Hypertension
and Diabetes
D
iabetes and hypertension have been called “evil twins” and “bad companions,” because
they are so often found together in the same person. Both are also “silent” disorders, in
that they may cause no early symptoms but create extra work for the heart and blood
vessels. Having hypertension makes it more likely that someone will develop diabetes, and having diabetes makes it more likely that the person will develop hypertension. Both hypertension
and diabetes increase the risk for problems in the small blood vessels, known as microvascular
disease, of the eyes, kidneys, and peripheral nerves, as well as problems in the large blood vessels,
or macrovascular disease, of the heart, peripheral vascular system, and brain. The risk for both
microvascular and macrovascular disease is even higher when a person has both hypertension
and diabetes (see Table 5.1).
Table 5.1: Macrovascular and microvascular complications of hypertension
and diabetes
Macrovascular complications
Atherosclerosis
Disease of the arteries that can result in heart attack
and stroke
Peripheral vascular disease
Narrowing of arteries that can result in ischemia, or
restricted blood supply to tissues, and ulcers
Microvascular complications
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Retinopathy
Damage to the retina that can result in loss of vision
Nephropathy and end-stage renal
disease
Disease of the kidney that can result in kidney failure
Neuropathy
Disease of the nerves that can result in pain, numbness,
and weakness in the hands and feet
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
Table 5.2 gives a side-by-side comparison of the two disorders and their symptoms. In this section we compare and contrast the history of these two disorders, define them, and examine how
the biology of each affects physical, mental, and social functioning. In the next section we apply
Bronfenbrenner’s system of human ecology to each disorder. We then explore hypertension over
the life span, approaches to its treatment, and its relationship to social issues. Finally, we discuss
diabetes over the life span, its treatments, and related social issues.
Table 5.2: Characteristics of hypertension and diabetes
Aspect
Hypertension
Type 1 Diabetes
Type 2 Diabetes
Age of onset
Usually older adults
Often in early
childhood, but can be
as late as adulthood
Usually in older
adults, but recently
seen in children and
adolescents
Early symptoms
None
Excessive thirst and
urination, weight loss
None
Later symptoms
Severe headache,
blurred vision,
chest pain, difficulty
breathing
Fatigue, blurred vision
Excessive thirst and
urination, weight loss,
slowed healing, fatigue
Hypertension
Hypertension is abnormally high blood pressure. Blood pressure is a measure of the force that the
blood exerts against the walls of the arteries as the heart pumps blood through the body. It is
expressed as two numbers, written as if it were a
fraction, for example, 120/70. The upper number is
the force produced during the time the heart is contracting, called systolic blood pressure, and the
lower number is the force produced when the heart
is relaxing between beats, or diastolic blood pressure. The units for blood pressure measurement are
millimeters of mercury, or mmHg. Watch a short
video from Medline Plus for more detail about blood
pressure:
http://www.nlm.nih.gov/medlineplus/ency/anato
myvideos/000013.htm
Mary Evans Picture Library/Everett Collection
Hypertension, or what was then known as
“hard pulse disease” was originally treated
by bloodletting or applying leeches.
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Evidence shows that what was then called “hard
pulse disease” was recognized as long ago as 2600
BCE. Of course, treatment at the time was rather
crude by today’s standards and relied on reducing
the blood volume either by bloodletting or applying leeches (Esunge, 1991). The Reverend Stephen
Hales is recognized as the first to measure intraarterial pressure in a horse in 1733 (Kotchen, 2011).
In the 1800s, Thomas Young and Richard Bright
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
CHAPTER 5
built on Hales’s work and gave us modern descriptions of hypertension (Esunge, 1991). In 1905,
introduction of the blood pressure cuff with mercury columns, or the sphygmomanometer,
together with arterial sounds associated with systolic and diastolic measurement heard via a
stethoscope, allowed objective measurement of blood pressure for the first time (Kotchen, 2011).
The medical community did not think that elevated blood pressure—hypertension—was a problem until well after the insurance industry did. As early as 1918, the insurance industry began
requiring blood pressure measurement for life insurance applicants and gathering actuarial data
that related blood pressure to mortality (Kotchen, 2011). At the same time, the medical community suggested that rising blood pressure was a normal part of aging and that attempts to halt or
reduce the rise were dangerous. Cardiologist J. H. Hay (1931) suggested, “There is some truth in
the saying that the greatest danger to a man with high blood pressure lies in its discovery, because
then some fool is certain to try and reduce it” (p. 26).
We can only wonder what might have happened if President Franklin Roosevelt’s hypertension had
been treated. His blood pressure was recorded as 162/98 mmHg in 1937 at age 54; 180/88 mmHg
in 1940; 188/105 mmHg in 1941; between 180/110 and 230/140 mmHg in 1944, when he had a
series of small strokes at the age of 62; and 260/150 mmHg in early 1945. He died of a stroke later
that year at the age of 63. Just before his death, his blood pressure had been recorded as greater
than 300/190 mm Hg (Moser, 2006).
One reason hypertension was not treated aggressively during the first half of the 20th century
was the lack of treatments. Most of the medications of the time were either ineffective or had
nasty side effects. The first clinical trial demonstrating efficacy and tolerability of a treatment for
hypertension (the diuretic chlorothiazide) was published in 1959 (Moser & Macaulay, 1959). At
first, diuretics were used as adjuncts for hypertension treatment, but later it was recognized that
they could be used effectively alone to reduce the medical problems and death associated with
hypertension (Moser & Hebert, 1996).
At the same time effective treatments were found, the underlying causes of hypertension were
being uncovered, and hypertension was beginning to be understood as the result of multiple
interacting systems, including the heart and the kidneys, and the vasculature, the endocrine, and
the nervous systems. Later, the major proponent of this theory, I. H. Page (1982), added genetic
and environmental aspects, bringing the theory current for the 21th century.
Two large studies published in the 1960s—the Veterans Administration Study (“Effects of Treatment on Morbidity in Hypertension,” 1967) and the Framingham Heart Study (Kannel, Schwartz,
& McNamara, 1969)—finally convinced most medical practitioners that controlling hypertension
reduces the rate of stroke, heart attacks, and kidney damage. At the same time, more medications for treating hypertension were being introduced, including beta blockers and angiotensinconverting enzyme (ACE) inhibitors. Another class of medications, angiotensin receptor blockers
(ARBs), was first introduced in 1995.
The U.S. National Hypertension Program was established in 1972, and the first report of the Joint
National Committee (JNC) on detection, evaluation, and treatment of high blood pressure was
published in 1977. Since then, the JNC has issued updates every few years through publication of
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
the JNC 7 in 2003 (Chobanian et al., 2003). The JNC 7 was the first to describe prehypertension as
blood pressure that is higher than normal but not high enough to be considered hypertension. See
Table 5.3 for blood pressure measurements.
Table 5.3: Blood pressure categories
Category
Systolic Pressure
mmHg
Diastolic Pressure
mmHg
Normal
Less than 120
Prehypertension
120–139
or
80–89
Hypertension Stage 1
140–159
or
90–99
Hypertension Stage 2
160 or higher
or
100 or higher
and
Less than 80
Source: Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., . . . National High Blood Pressure Education
Coordinating Committee. (2003). Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Hypertension, 42(6), 1206–1252.
Most hypertension does not have a clear cause—it is classified as essential hypertension. In contrast, secondary hypertension results from an identifiable cause, such as kidney disease or as the
side effect of a medication. We do know that certain traits and categories put people at higher risk
for developing hypertension, such as:
•
•
•
•
•
•
•
•
being Black,
having diabetes,
drinking too much alcohol (more than one drink a day for women, more than two
drinks a day for men),
being overweight or obese,
being older,
consuming too much salt,
smoking, and
experiencing frequent stress or anxiety.
The two main approaches to care for hypertension are lifestyle modification and medication.
Although no one can control heritage or age, it is possible to modify many of these risk factors, as
we see in the section on treatment of hypertension. Everyone can benefit from the suggested lifestyle modifications, but some people have to add medication (sometimes two or three) to reach
recommended blood pressure goals.
The usual way to define overweight and obesity is by body mass index (BMI), which is calculated
from weight and height. (The formula is weight in kilograms divided by surface area in square
meters [kg/m2], but most people look it up in a table.) Table 5.4 shows the ranges of BMI that categorize normal weight, overweight, and obesity. You can look up your own BMI by entering your
weight and height on this NHLBI website:
http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm
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Table 5.4: Body mass index (BMI) categories
Category
BMI
Normal
18.5–24.9
Overweight
25.0–29.9
Obese
30.0–39.9
Extremely obese
≥ 40.0
Diabetes
Diabetes is characterized by high levels of glucose in the blood. Glucose is a simple sugar that
all cells use as an energy source. The two main types of diabetes are type 1 (T1D), which affects
about 5% of people diagnosed with diabetes, and type 2 (T2D), which affects 90% to 95% of people diagnosed with the disorder. When one or another is specified, we use the terms T1D or T2D,
but when we talk about the disorder in general, we use the term diabetes. A third type of diabetes, which may be becoming more common, is gestational diabetes. New diagnostic criteria for
gestational diabetes have increased the number of women diagnosed to 18% of pregnant women
(American Diabetes Association, 2013).
Type 1 diabetes (T1D) is a disorder in which the body’s own immune system attacks and kills beta
cells in the pancreas that produce insulin, a hormone needed for cells to absorb glucose from
the blood and transport it across the cell’s outer surface to the inside, where it can be used for
energy. As a result, the body produces too little insulin. This kind of misdirected attack on the body
is known as autoimmune disease. T1D was previously called insulin-dependent diabetes mellitus
or juvenile diabetes. It is usually first diagnosed in children and young adults. In order to survive,
people with T1D must have insulin delivered to their blood by injection or a pump.
In contrast to T1D, people with type 2 diabetes (T2D) produce enough insulin at first, but their
cells do not respond to it properly, a condition known as insulin resistance, or insensitivity. As a
result, more and more insulin is required, and the beta cells of the pancreas become exhausted
and lose their ability to produce it. T2D was previously called non–insulin-dependent diabetes, or
adult-onset diabetes. It is associated with older age, obesity, a family history of diabetes, physical
inactivity, and certain racial or ethnic groups. As people have become more sedentary and obesity
rates have risen, T2D is being diagnosed in a younger population.
Both T1D and T2D appear to need both an inherited susceptibility and some environmental trigger
to set the disease process in motion. All the environmental triggers have not yet been identified,
although in some cases, it appears that certain viral infections may trigger the body to produce
antibodies to the virus that cross-react with and destroy pancreatic beta cells. This is probably
what happened to 11-year-old Barbara in the case study at the beginning of the chapter.
Gestational diabetes is defined as excess blood glucose that shows up in the later stages of pregnancy in women who did not have diabetes before they became pregnant. It appears to be a form
of insulin resistance that develops perhaps in response to a hormone produced by the placenta.
Gestational diabetes must be treated to avoid problems for both the mother and the child.
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Egyptian texts as old as 1500 BCE have identified diabetes as a rare condition in which people have
excessive volumes of urine and lose weight. Similarly, Indian texts from the fifth century BCE refer
to people with excessive urine production that is sweet, accompanied by emaciation. The term
diabetes mellitus, reflecting the sweet taste of urine from people with the disorder, was used by
the Greek physician Aretaeus, who lived from about 80 to 138 CE and wrote one of the first accurate clinical descriptions of the disorder. Until well into the 18th century, when Matthew Dobson
measured the concentration of sugar in the urine and blood, diabetes was thought to be a disease
of the kidneys (Eknoyan & Nagy, 2005; Polonsky, 2012).
In 1788, Thomas Cawley became the first to suggest that the pancreas played a role in the development of diabetes. His observations were later confirmed in 1889, when Minkowski and Mering
showed that removing the pancreas from dogs caused diabetes that could be reversed by implanting pancreatic fragments. Edward Sharpey-Schafer suggested that diabetes resulted from the lack
of a single product of the pancreatic cells, which he named insulin (Eknoyan & Nagy, 2005; Polonsky, 2012). In 1922, Banting and Best isolated insulin from cows and were the first to use it to treat
patients with diabetes (Banting, Best, Collip, Campbell, & Fletcher, 1922).
The availability of purified insulin turned an inevitably fatal disorder into one that could be
treated—one of the first instances in which scientific investigation was almost immediately translated into clinical treatment. Insulin’s biology and chemistry became an intense area of research.
Insulin is a peptide hormone made up of two linked chains of amino acids. Insulin was the first
hormone whose amino acid sequence (the order that the amino acids appear in the peptide
chain) was determined. It also became the first hormone to be produced by recombinant DNA
techniques, so that fully human insulin could be produced in vast quantities rather than isolating
insulin from pig or cow pancreas, which had been the method until then (Keen et al., 1980).
During the first half of the 20th century, it became evident that not all diabetes was caused by the
lack of insulin. For a long time, people had noted that those who developed diabetes as children
or young adults were usually underweight, while those who developed it when they were mature
adults were usually overweight. Himsworth (1936) first proposed that some patients had diabetes
because they were resistant or insensitive to insulin. Yalow and Berson (1959) devised the first
immunoassay to measure circulating levels of insulin. Subsequently, they found that obese people
with early diabetes actually released more insulin after an oral glucose tolerance test compared
with normal controls—in other words, they didn’t have too little insulin, but they were insensitive
to it, as Himsworth had proposed (Yalow & Berson, 1960).
Insulin resistance is difficult to measure in a clinical setting; therefore, having high blood glucose
levels (higher than normal but not high enough to qualify as diabetes) is used in its place as a
marker. This intermediate level of blood glucose is termed prediabetes, also known as impaired
glucose tolerance or impaired fasting glucose (fasting plasma glucose [FPG] of 100–125 mg/dL).
There are three main ways of determining whether someone has prediabetes or diabetes:
•
•
•
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hemoglobin A1C (HbA1C) test,
FPG test, and
oral glucose tolerance test (OGTT).
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
The HbA1C test (or A1C test for short) reflects average blood glucose levels over the last 3 months.
It is not as sensitive as the other tests, and certain conditions (e.g., abnormal hemoglobin, anything that changes red blood cell survival, possible racial differences) can alter the results. FPG
measures blood glucose after fasting for at least eight hours. It is most reliable when done in the
morning. OGTT measures blood glucose after fasting for at least eight hours, then drinking a liquid
containing glucose, and measuring blood glucose two hours later. For all three tests, within the
prediabetes range, the higher the test result, the greater the risk of diabetes (see Table 5.5).
Table 5.5: Blood test levels for diagnosing diabetes and prediabetes
Diagnosis
A1C (%)
Fasting plasma
glucose (mg/dL)
Oral glucose
tolerance test
(mg/dL)
Normal
About 5
99 or below
139 or below
Prediabetes
5.7–6.4
100–125
140–199
Diabetes
6.5 or above
126 or above
200 or above
Note. mg = milligram; dL = deciliter.
Even with the advent of insulin by injection in the 1950s, many people diagnosed with T1D went
blind and developed kidney disease, and about one in five people died within 20 years of being
diagnosed. At that time, people monitored their glucose levels with urine tests, which gave readings for what had been true in their blood several hours previously but could not recognize dangerously low glucose levels (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK],
2010). In addition, because the
kidneys do not excrete glucose
into the urine until blood levels
reach 160–180 mg/dL, the urine
test is insensitive.
Home blood glucose monitoring first became possible in the
1970s. At first, test strips similar to urine test strips were
used and compared with a color
chart. This proved impractical,
and meters were developed to
automatically read the strips.
Today’s home glucose meters
require a single drop of blood on
a test strip that is fed into a small
meter for reading.
Joerg Sarbach/Associated Press
A blood glucose meter is used to self-monitor blood glucose.
People with diabetes must learn to keep their blood glucose within a normal range—neither too
high (hyperglycemia) nor too low (hypoglycemia). Blood glucose levels depend on a variety of factors: when and what meal was last eaten, exercise, and other medications. Self-monitoring blood
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Section 5.2 Definition and Brief History of Hypertension and Diabetes
CHAPTER 5
glucose can help keep glucose in the normal range. Results can also be reviewed periodically with
the clinician to determine how well diabetes is being controlled. Self-monitoring is particularly
useful for people who tend to have episodes of hypoglycemia, for instance, after participating in
an active exercise session or sports game. Hypoglycemia can be extremely dangerous, as it can
cause accidents, injuries, coma, or death. More information about hypoglycemia can be found on
the American Diabetes Association website (http://www.diabetes.org/living-with-diabetes/treat
ment-and-care/blood-glucose-control/hypoglycemia-low-blood.html).
Modern technology has changed the experience of people with diabetes. Today, systems allow for
continuous glucose monitoring (CGM) through a small needle inserted beneath the skin. However,
blood glucose still needs to be measured periodically with a conventional meter, as CGM readings
lag about 15 to 20 minutes behind blood levels.
In addition to changes in detecting glucose, technology has affected how insulin is delivered and
the types of insulin available. When insulin was first administered in the 1920s, it was delivered
via glass syringes with rather large needles that were painful to use. Syringes and needles were
reused after sterilization. Disposable syringes with smaller disposable needles that were less painful to use came next. Insulin pens that allow discreetly injected insulin were developed in the
1990s. Pens combine the insulin vial with a syringe, can store a 3- to 5-day supply of insulin, and
are less painful to use.
Insulin pumps were first explored in the late 1970s. The first ones were large, heavy, and not really
suited for home use. Pumps have the advantage of more closely approximating how the pancreas
works, with a steady infusion of insulin that can be tailored to the individual. At first they were used
only for patients who had high insulin requirements. With the development of smaller and lighter
insulin pumps, however, they have been more commonly used by people with T1D. Pumps are costlier than syringes and insulin vials but result in tighter glucose control, as measured by decreased
A1C, and fewer hypoglycemic episodes. Perhaps more important, they allow “more freedom, flexibility, and spontaneity in the person’s daily life” (Yaturu, 2013, p. 2). More detail about delivering
insulin and monitoring glucose can be found online (http://effectivehealthcare.ahrq.gov/index
.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=1240#toc).
Most people are reluctant to begin injecting themselves. Many people would rather not let others know that they need to inject—they find it embarrassing or shameful. For those people with
T1D, there is little choice, and people adjust over time. What may be more surprising is that, for
reasons that are unclear, clinicians tend to avoid prescribing injected insulin for their patients who
have T2D, even if it is the best available option for treatment.
Science and technology continue to advance the treatment of diabetes. Better understanding of
immunology may make it possible to intervene in early T1D and prevent continued autoimmune
attack on pancreatic beta cells. Closed-loop insulin delivery, which has also been called the artificial pancreas, is in the testing stage. Combining glucose detection, wireless communication with
an insulin pump, and software that continuously determines how much insulin needs to be delivered, this technology delivers insulin without the need for intervention (Yaturu, 2013). People
with T1D who were born in the 1970s have gone from having to inject themselves multiple times
daily to using insulin pumps. And they may see the use of an artificial pancreas become common
in the near future.
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Section 5.3 Using Bronfenbrenner’s Model
CHAPTER 5
5.3 U
sing Bronfenbrenner’s Model to Better Understand
Hypertension and Diabetes
B
ronfenbrenner’s bioecological model puts the individual in the center of several concentric
circles of the social world: the family (micro perspective), the immediate community of
school or work (meso perspective), and the larger social society (macro perspective). Bronfenbrenner’s model views the individual’s position within each circle as a two-way interaction: He
or she both affects and is affected by each sphere of influence.
For example, Barbara’s family was going through a period of emotional upheaval at the time she
was diagnosed with T1D. Step-siblings who had been spending summers in the household were
coming to live full time with the family. Although everyone seemed to be fine with this change,
it was a big change in the family structure, and change (even positive change) is stressful. It is
possible that Barbara’s body reacted more strongly to her viral infection because of this change
and developed stronger antibodies to her beta cells than would have been seen at another time.
In turn, it is likely that Barbara’s newly diagnosed T1D added an additional stress to the family
structure.
A recent study convened by the American Diabetes Association has examined “socioecological”
sectors that influence the risk of prediabetes and T2D in the U.S. population (Hill et al., 2013).
Although the categories are drawn somewhat differently (i.e., the surrounding home, work,
school, and community environments as social determinants, and the influence of public policy on
individual behavior), the approach is quite similar to that of Bronfenbrenner, in that the individual
is seen to reside within concentric circles of influence. Thus, clinicians are well advised to look at
the patient’s environment when they treat hypertension and diabetes.
Obesity is closely tied to the development of prediabetes and T2D. Of course, obesity results when
the amount of calories taken in exceeds the energy expended. A number of changes in different
perspectives or sectors have contributed to the rising prevalence of obesity, prediabetes, and
diabetes (see Figure 5.1).
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Section 5.3 Using Bronfenbrenner’s Model
Figure 5.1: Levels and sectors of influence on prediabetes and diabetes risk
For someone with diabetes, making appropriate food choices can have an impact on each sphere of
Bronfenbrenner’s bioecological model.
Social Norms
and Values
• Communities
• Worksites
• Health Care
• Schools and
Child Care
• Home
Sectors of
Influence
Behavioral
Settings
• Demographic
Factors (e.g.,
age, sex, SES,
race/ethnicity)
• Psychosocial
Factors
• GeneEnvironment
Interactions
• Other Factors
Individual
Factors
Food and
Beverage
Intake
Energy Intake
Physical
Activity
• Government
• Public Health
• Health Care
• Agriculture
• Education
• Media
• Land Use and
Transportation
• Communities
• Foundations
• Industry
Food
Beverage
Restaurant
Food Retail
Physical
Activity
Leisure and
Recreation
Entertainment
Energy Expenditure
Energy Balance
Source: Koplan, J., & Institute of Medicine (U.S.). Committee on Progress in Preventing Childhood Obesity. (2007). Progress in preventing childhood
obesity: How do we measure up? (p. 20). Copyright © National Academies Press. Used by permission.
Micro Perspectives
When someone in a family is diagnosed with hypertension or diabetes, the diagnosis affects the
whole family, as most often the person’s diet must change, and a change in the diet of one member of the family usually affects the diet of the whole family. If the family generally goes along with
the dietary changes with good humor and encouragement, it is easier for the person diagnosed
with the disorder to stick to the recommended changes.
It may be particularly difficult for families to adjust to lowering the amount of salt, which is usually
recommended for people with hypertension. Salt is addictive, and food can seem flat and bland
without the usual amount. However, it is possible to slowly cut back on salt used in cooking and to
increase the use of herbs and spices to perk up the taste of dishes so that everyone in the family
still enjoys eating meals together.
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Section 5.3 Using Bronfenbrenner’s Model
How the family responds to the diagnosis of a chronic disorder such as hypertension or diabetes
depends on a number of different factors, for example, how familiar family members are with the
disorder. Sometimes family dynamics have a direct effect on the course of the disorder.
Case Study: Family Dynamics
Kevin was 5 years old when he was diagnosed with T1D. His older sister had been diagnosed when she
was 2, so the family recognized the signs early on—unquenchable thirst and frequent urination. The
family’s attitude to T1D was very matter-of-fact, and Kevin adapted well and learned to inject himself
when he was 6 or 7. He had no trouble with self-injection and at times even injected his sister, who was
7 years older than he, because she didn’t like injecting herself.
* * *
Emily was 15 years old when she was repeatedly admitted to the hospital with hyperglycemia. When
questioned, she insisted that she was injecting herself regularly, as directed by her primary care practitioner. Someone in the hospital thought to test the insulin vial from the refrigerator at Emily’s home,
and it turned out that the girl’s sister, jealous of the attention Emily was getting from their parents, was
diluting her insulin.
The second Diabetes Attitudes, Wishes and Needs (DAWN2) study was a large cross-national survey
of more than 16,000 people that examined diabetes care and management among people with
diabetes, their families, and health care professionals (Peyrot et al., 2013). Although results differed
among countries, overall, 44.6% of people with diabetes experienced diabetes-related distress,
and fewer than half reported participating in educational activities to help manage their diabetes
(Nicolucci et al., 2013). Living with a person with diabetes placed a burden on family members as
well, with 61.3% reporting worrying about hypoglycemia and 44.6% reporting negative effects on
emotional well-being (Kovacs Burns et al., 2013).
Case Study: Coping With Hypertension and Diabetes
Janet was 63 years old when she went for a normal gynecological checkup. Her nurse-midwife asked
her if she had ever been diagnosed with hypertension, because her blood pressure read 138/75. She
had not; in fact, she had always had low blood pressure. Janet agreed to follow up with her primary
care practitioner, which she did about a month later. In his office, her blood pressure was 155/85. It
went down slowly after repeated measure, but he thought she should be treated and prescribed a
single medication. Janet’s husband had been diagnosed with a neurodegenerative disorder about a
year before, and they were preparing to sell their home and move closer to their daughter and Janet’s
family. The need for the move and all the uncertainties around it had greatly increased the stress that
Janet was feeling.
Janet responded well to the medication but realized that she experienced a strong “white coat effect”
(i.e., her blood pressure went up when measured in a clinical setting). So she bought a home blood
pressure monitor that was checked (validated) by her primary care practitioner. After the move, her
(continued)
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Section 5.3 Using Bronfenbrenner’s Model
Case Study: Coping With Hypertension and Diabetes (continued)
new primary care practitioner suggested that she try reducing her medication, and if her blood pressure remained in a good range, she might be able to discontinue it entirely. That was what happened—
her blood pressure remained low when measured at home, although it continued to be high in the
practitioner’s office, particularly when her husband wasn’t doing well. She has been off medication for
five years now, although she still monitors it at home between checkups.
* * *
Dealing with hypertension and diabetes can cause conflict between spouses, as Janet’s friend Helen
recently recounted. Helen’s husband Joe has been on hypertension medication since his heart attack
five years ago. Joe is overweight, and his doctor recently told him that he was prediabetic and should
cut back on salt, lose weight, and increase his exercise levels to lower his risk of developing T2D. However, so far Joe isn’t doing anything to accomplish these goals. Helen asked, “Where does being a
concerned, loving spouse end and being a nag begin? For instance, I leave the salt out of cooking and
I don’t put the shaker on the table, but he just demands that I get it. If I refuse, he gets up and gets it
for himself and slams it down on the table. I feel frustrated and angry—I’m concerned about Joe but
unable to do anything to help him.”
Meso Perspectives
Both hypertension and diabetes affect how a person interacts with work, school, and the immediate
social system and community. In the meso perspective, one determinant of obesity is availability of
calorie-dense foods (items with high calorie content
compared with their nutritional content, such as
most fast-food) in the immediate environment. Currie, DellaVigna, Moretti, & Pathania (2009) investigated the effect of having a fast-food restaurant
within 0.1 mile of school, compared with 0.25 miles
or more from school, on obesity rates in ninth-grade
children. Obesity rates were 5.2% higher in children
attending a school located 0.1 mile, or approximately one block, from a fast-food restaurant. Similarly, pregnant women were more likely to gain
more than 44 lbs. if they lived less than 0.5 miles
from a fast-food restaurant. The likelihood of weight
gain increased as the distance from the restaurant decreased, and the effect was greater in Black
Fuse/Thinkstock
women and women with a high school education or
less. Because obesity is a major factor for developRegular exercise can prevent the developing both hypertension and diabetes, the proximity
ment of hypertension and diabetes.
of fast-food restaurants probably contributed to the
development of both disorders. In addition to the
close proximity of such eating establishments, obesity has been closely tied to poverty and location, which affects the availability of quality food choices, availability of physical activity outlets,
and a social environment that includes ample educational and financial resources.
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Section 5.3 Using Bronfenbrenner’s Model
Sometimes it isn’t what an individual has to eat, but when he or she eats that affects interaction
with the family and the immediate community. A child with T1D who is self-injecting insulin has to
make sure to eat before blood glucose gets too low, and this is usually accomplished by keeping a
fairly rigid schedule for family meals.
Case Study: Interactions With Family and Community
Barbara’s mother, Margaret, had a good friend who was very fond of Barbara and her brother. The
children liked their mom’s friend very much as well, and she was often invited to dinner. However, the
friend really didn’t like eating dinner as early as was necessary for Barbara, and as a result she became
estranged from the family.
Regular exercise is one factor that delays development of both hypertension and diabetes.
Children used to get regular exercise through physical education classes and either walking or
riding bikes to and from school. However, during the period from 1991 to 2009, the percentage of high school students attending daily physical education classes has declined from
42% to 33%. The percentage of trips to and from school by walking or biking has declined by
nearly half between 1977 and 2001 (Hill et al., 2013). Similarly, adult work environments are
becoming more and more sedentary, and fewer people perform even light activity as part of
their jobs.
Macro Perspectives
The broader macro perspective includes factors such as how a disorder affects the person within
the culture, and how the culture and the larger society, including factors such as government and
public health policy, affect the person with the disorder.
Case Study: Interactions With Society
Janet and her husband George obtained long-term care insurance several years before she was diagnosed with hypertension. That was a really fortunate, as she would not have been able to qualify for
it after she was diagnosed, or it would have been much more expensive if she did qualify. This is an
example of how having the disorder affects interaction with the larger society and with a health care
system that does not guarantee support for people with chronic illnesses.
* * *
Kevin did really well managing his diabetes, even through adolescence, when many people find it difficult to stay with the somewhat restrictive program of frequently checking blood sugar and adjusting
insulin dose. Because he grew up in a rural area, fast-food wasn’t really a problem, and his family
served healthy meals with lots of vegetables. Dessert was fruit, often home grown. He found that he
felt awful if his blood glucose went out of bounds, which for him was more likely to be blood glucose
that was too low than too high, so he did what was needed to stay in the healthy glycemic range his
health care provider suggested.
(continued)
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Section 5.4 Hypertension Through the Life Span
CHAPTER 5
Case Study: Interactions With Society (continued)
The first time Kevin encountered a conflict with the larger society resulting from his diabetes was
when he graduated from high school. The managers of a Japanese auto plant located near the high
school offered an all-expense-paid trip to Japan each year for the valedictorian of the graduating class.
Kevin was the valedictorian of his class, but he didn’t get to go to Japan, because the managers of the
plant did not want to deal with the insurance risk they felt his T1D presented should he fall seriously
ill while abroad.
As mentioned, the DAWN2 study took a macro perspective, examining educational and psychological needs from the perspective of people with diabetes, their families, and health care professionals (Peyrot et al., 2013). Though most health care professionals agree that involving patients
with diabetes in their own self-care is optimal, more than half of those from the United States
reported that the health care system lacks the educational resources to make this happen (Holt
et al., 2013). Most health care professionals reported that they have not been trained to promote and support diabetes self-management; thus, it is not surprising that people with diabetes
lack such services. As emphasized throughout this text, health care practice models that incorporate team-based care and include specialists whose job it is to provide management support
for patients with chronic diseases have been recommended for many years. However, in the U.S.
health care system, it is difficult to obtain funding for these services, because in many sectors, the
profit motive is stronger than the efforts to improve the common good.
5.4 Hypertension Through the Life Span
H
ypertension is more likely to affect people older than 45 years, although this tendency
may be changing as obesity increases in younger people. Several surveys of national
health in the United States have found that, between 1963 and 1988, average blood
pressure, prehypertension, and hypertension all decreased in children and adolescents aged 8 to
17 years. Hypertension in children and adolescents is usually defined as systolic or diastolic blood
pressure that is repeatedly measured as in the 95th percentile or higher. After 1988, all these rates
rose. Increased obesity—particularly abdominal obesity—probably accounts for part of the rise
between 1988 and 1999. Similarly, a study in Ohio found that among children and adolescents
3 to 18 years old who were measured three times between 1999 and 2006, 3.6% had hypertension, 74% of whom had not been diagnosed (Go et al., 2013).
As discussed earlier, hypertension and diabetes are often found together, and children are no
exception. The SEARCH for Diabetes in Youth, a multicenter observational study of children aged 3
to 17 years with either T1D or T2D, examined blood pressure among many other factors. Investigators found 5.9% of participants with T1D and 23.7% of those with T2D had hypertension (p , .001,
meaning a very slight probability that the results were by chance), defined as systolic or diastolic
blood pressure values in the 95th percentile and higher. A greater percentage of those with T2D
were aware of their hypertension compared with T1D (31.9% vs. 7.4%; p , .001), although blood
pressure control after treatment was similar for both groups (T1D, 57.1%; T2D, 40.6%; Rodriguez
et al., 2010).
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Section 5.4 Hypertension Through the Life Span
To determine which of three treatments best controlled the need to begin use of insulin, a 5-year
clinical trial—the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY)—
studied youth aged 10 to 17 years with T2D and obesity at enrollment. At the start of the study,
11.6% were hypertensive, and at the end of the follow-up (which averaged 3.9 years later), 16.6%
were hypertensive, despite aggressive treatment. Both increased obesity and male sex increased
the risk for hypertension (TODAY Study Group, 2013b).
Figure 5.2 depicts the prevalence of hypertension in adults by age from the National Health and
Nutrition Examination Survey (NHANES): 2009–2010. Hypertension is defined as systolic blood
pressure of 140 mmHg or above or diastolic blood pressure of 90 mmHg or above, or currently
taking medication to lower high blood pressure (Yoon, Burt, Louis, & Carroll, 2012).
Figure 5.2: Age-specific prevalence of hypertension among adults aged 18
and over in the United States, 2009–2010
Hypertension is more likely to affect people older than 45 years, and the prevalence increases dramatically
with age.
Age group (years)
≥60
40–59
18–39
0
10
20
30
40
50
60
70
80
Hypertension prevalence (percent)
Source: Yoon, S., Burt, V., Louis, T., & Carroll, M. (2012). Hypertension among adults in the United States, 2009–2010. NCHS Data Brief, No. 107.
Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db107.htm
As can be seen by the figure, hypertension increases dramatically with age. In people aged
65 years and older, hypertension is more prevalent among women (57%) than men (54%), whereas
for younger people, it is more prevalent in men (Go et al., 2013).
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Section 5.5 Treatment Approaches for Hypertension
5.5 Treatment Approaches for Hypertension
T
reatment plans for hypertension usually start with lifestyle changes. If these interventions are not sufficient to reach target values, then medication or other approaches are
added. Untreated hypertension can lead to serious outcomes, including microvascular disease, macrovascular disease, and death. The overall mortality rate from hypertension is 18.5 per
100,000. However, the rate differs greatly by sex and race. Although Blacks tend to be more aware
of their hypertension and are treated at higher rates than Whites and Hispanics, their rates of
control (reaching target blood pressure) are lower (Yoon et al., 2012). Through a combination
of lifestyle modifications, medication, and if needed, renal denervation, almost everyone with
hypertension can reach blood pressure goals and greatly reduce the risk of microvascular disease,
macrovascular disease, and premature death.
Lifestyle and Diet Modifications
Recommended lifestyle changes for people with prehypertension or hypertension include:
•
•
•
•
•
•
not smoking,
increasing physical activity to 30 minutes a day most days of the week,
following a healthy diet,
maintaining a healthy weight,
reducing salt intake, and
limiting alcohol intake.
Dietary Approaches to Stop Hypertension, better known as DASH, is a
clinical study that found diet to be
effective for lowering blood pressure
and preventing hypertension in people at risk for developing it (Appel et
al., 1997). The DASH diet encourages
hypertensive individuals to eat fruits,
vegetables, and low-fat dairy foods;
to include whole grains, poultry, fish,
and nuts; and to reduce amounts of
fats, red meats, sweets, and sugared
beverages.
Digital Vision/Thinkstock
Managing one’s diet can be effective for lowering blood
pressure and preventing hypertension.
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Section 5.5 Treatment Approaches for Hypertension
CHAPTER 5
Web Field Trip
Visit the National Heart, Lung, and Blood Institute’s website to learn more about the DASH eating
plan (http://www.nhlbi.nih.gov/health/health-topics/topics/dash/followdash.html). The website provides information about appropriate daily calorie consumption, based on gender, and identifies calorie
ranges for certain food types and serving sizes.
Critical Thinking Questions
1. Based on the recommendations made, what do you think some of the barriers to compliance
might be?
2. How do community and family settings differ in encouraging healthy behaviors and food
choices?
The follow-up DASH-Sodium Study found that restricting salt intake, combined with the DASH diet,
lowered blood pressure more than either alone (Sacks et al., 2001). Current recommendations
call for people with prehypertension and hypertension to restrict salt intake from all sources to
less than 1,500 mg/day (approximately two thirds of a teaspoon). To reduce blood pressure, men
should consume no more than two alcoholic beverages per day and women should consume no
more than one per day.
Experiencing frequent stress or anxiety can increase blood pressure, so it follows that by decreasing
stress and anxiety, it might be possible to lower blood pressure. For example, lower income groups
and non-Whites are more likely to work in high-stress jobs that are also physically demanding and
offer workers less opportunity to control the nature of their work, compared with middle and
upper income groups and Whites. Also, chronic stress and anxiety may stem from poor housing,
financial insecurity, and uncertainty in employment. In addition to improving these social factors,
rebalancing the autonomic nervous system can decrease stress. The American Heart Association
recently reviewed evidence in the literature about the efficacy of alternative ways to reduce blood
pressure. They concluded that it was reasonable for people with prehypertension and hypertension to consider using alternative approaches in addition to traditional lifestyle changes. Their
strongest endorsement was of aerobic physical exercise or resistance exercise, because these
modalities have the strongest level of evidence for efficacy in lowering blood pressure. There is
some support for several other alternative therapies, including device-guided breathing, transcendental meditation, and biofeedback, but the evidence is not as strong (Brook et al., 2013).
Medication
If prehypertension or mild hypertension does not respond to lifestyle or alternative changes
within 6 to 12 months, or if hypertension is more than 20/10 above goal, then medication should
be started. The usual first medication is a thiazide diuretic. Diuretics are often called water pills,
as they reduce water and sodium in the body by causing it to be excreted in the urine. Often, one
medication is not sufficient to bring blood pressure down to target levels, so others may be added.
Classes of medications that are usually considered include:
•
•
•
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ACE inhibitors,
ARBs,
beta blockers,
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Section 5.5 Treatment Approaches for Hypertension
•
•
CHAPTER 5
calcium-channel blockers, and
renin inhibitors (Mayo Clinic, 2012).
Health care providers consider the needs of the patient to decide on the right type of medication
to prescribe. Often, different medications are tried to find what works best for the individual. For
instance, people with prediabetes or diabetes and hypertension tend to do better with ACE inhibitors or ARBs (van der Zijl, Moors, Goossens, Blaak, & Diamant, 2012); they should probably not be
treated with beta blockers or thiazides, as these medications tend to increase insulin resistance
(Standl, Erbach, & Schnell, 2012).
If a person begins treatment with Stage II hypertension (blood pressure higher than 160/100),
two medications are usually prescribed from the start: a thiazide diuretic, along with a medication
from one of the classes previously mentioned. Sometimes two medications are not enough to
reach target blood pressure, so a third is added.
Keeping track of medications can be a challenge. Combination treatment, which unites two or
more drug classes in a single pill (thus decreasing the number of pills needed each day, or “pill burden”), can be helpful. Also, printed charts to keep track of medications can be downloaded from
several sites. Some people find online tools helpful for keeping track of daily medications and for
seeing progress as they work toward a target blood pressure.
Many clinicians think that frequent home blood pressure monitoring yields more accurate
results than monitoring done in the clinician’s office. Of course the person’s technique and
the home monitor must be validated in the clinician’s office first. A video from the Mayo Clinic
shows techniques of home blood-pressure monitoring (http://www.mayoclinic.com/health
/how-to-measure-blood-pressure/MM00785).
Surgery
If people with hypertension taking medications from three different antihypertensive classes still
have blood pressure of 140/90 or higher, or if they take drugs from four or more antihypertensive medication classes, regardless of their blood pressure, they are defined as having resistant
hypertension. People with resistant hypertension are more likely to be older, obese, and Black
compared with those whose hypertension can be controlled with three or fewer medication
classes (Persell, 2011).
Kidney sympathetic nerve activity appears to play a key role in hypertension developing and progressing. Renal denervation (destruction of the kidney sympathetic nerve) has been recognized
for many years as a way to treat hypertension, although it has fallen into disuse with the advent
of effective antihypertensive medications. Owing to better and less invasive surgical techniques
developed over the last decade, however, there has been increased interest in using catheterbased sympathetic renal (kidney) denervation for treating resistant hypertension (Symplicity
HTN-1 Investigators, 2011). The renal sympathetic nerves play an important role in increasing
blood pressure, so destroying them using a minimally invasive approach (through a catheter rather
than a surgical incision) decreases blood pressure. The effect of the procedure, which requires
great skill, is not immediate, and kidney function should be monitored for up to three years, but
experts agree that catheter-based sympathetic renal denervation is useful for treating resistant
hypertension in selected patients (Pathak et al., 2012). In addition, preliminary data suggest that
the procedure reduces FPG in the blood and decreases insulin resistance, so it may be particularly
useful for those with both T2D and resistant hypertension (Hering, Esler, & Schlaich, 2012).
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Section 5.6 Social Issues in Hypertension
CHAPTER 5
5.6 Social Issues in Hypertension
M
any aspects of the “silent disorders” of hypertension are set in motion by genetics and
the prenatal environment. For instance, low birth weight, which is often a marker of
poor prenatal nutrition, is associated with high blood pressure, and this association
gets stronger with age (Chen, Srinivasan, & Berenson, 2010). Childhood obesity, which is at least
partly a result of the intrauterine environment, leads to increases in both hypertension and T2D.
Over the last 30 years, childhood obesity has increased tremendously, and racial or ethnic disparities in obesity are already evident in preschool children (Dixon, Pena, & Taveras, 2012). These
observations emphasize the importance of public health initiatives to improve the health and
nutrition of pregnant women and young children. Hypertension awareness, treatment, and control have increased tremendously between the late 1970s and the early 2000s, although much
needs to be done.
The most recent NHANES found that racial or ethnic disparities in hypertension awareness, treatment, and control persist (Yoon et al., 2012). For example, for 2009–2010, 81.4% of Whites were
aware of their diabetes, 76.6% were treating it, and 56.3% were controlling their diabetes. Awareness was higher (87.7%) among Blacks, but control was lower (47.9%). Among Hispanics, awareness, treatment, and control were lowest, at 77.7%, 69.6%, and 40.7%, respectively.
An analysis of how race and ethnicity affect hypertension among residents of two midwestern
cities, Detroit and Chicago, found that residents of urban areas lag behind the rest of the nation
in terms of awareness, treatment, and control of diabetes. Similar to the results from NHANES,
Blacks were more likely to have hypertension and to be aware of their hypertension status, but no
less likely than Whites to be treated. In contrast, Hispanics were less likely to have hypertension
and less likely to be aware of their hypertension status than Whites. The authors concluded, “To
achieve the proposed national hypertension-related goals, future policies must consider the social
context of hypertension within central cities of urban areas” (Hunte et al., 2012, p. 391).
A closer look at people with Stage I and Stage II hypertension by race and ethnicity within the
2003–2010 NHANES finds that native Mexicans and Blacks were more likely to have Stage I and
Stage II hypertension than Whites. Although the treatment rate for people with Stage II hypertension was similar across racial or ethnic groups, less than 60% of those with Stage II hypertension
were being treated. For Stage I hypertension, native Mexicans were less likely to be treated than
Blacks or Whites (Centers for Disease Control and Prevention [CDC], 2013 l).
It has been suggested that much of the discrepancy between hypertension treatment and hypertension control may be caused by poor medication adherence. Maimaris et al. (2013) conducted
a review of factors within the health care system that affect hypertension awareness, treatment,
and control. They found that the presence of health insurance, reduced copayments for medical
services, and having a routine place of care or physician significantly increased hypertension control and treatment adherence.
Another factor in poor hypertension control may be failure to intensify therapy when hypertension
is poorly controlled—so-called therapeutic inertia. It has been suggested that therapeutic inertia
is a result of the complex interaction between the patient, the clinician, and “other components of
the health care delivery system including health plans, formularies, pharmacies, and government
agencies” (Basile & Bloch, 2012, p. 268). This conclusion is supported by the CDC (2012f) study
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Section 5.7 Diabetes Through the Life Span
CHAPTER 5
that found almost 90% of adults with uncontrolled hypertension have a routine place of care and
insurance. “Improved hypertension control will require an expanded effort and increased focus on
BP [blood pressure] from health-care systems, clinicians, and individuals” (p. 704).
One measure of therapeutic inertia is the reluctance of many clinicians to start people on combination treatment, even when guidelines suggest that they are appropriate candidates (Chobanian
et al., 2003). A comparison of initial combination therapy with initial single medication and a
second medication added later (add-on therapy) showed better hypertension control with initial
combination therapy (Gradman et al., 2013). In addition, initial combination therapy was shown
to reduce cardiovascular events, including heart attacks and strokes, or death by 23% in the
following two years.
Home self-monitoring, as with diabetes management, with a validated blood pressure device
may improve hypertension management. Review of the literature suggests that self-monitoring
reduces blood pressure by a small but significant amount (Bray, Holder, Mant, & McManus, 2010).
In addition, a randomized controlled trial of self-management (compared with usual care) among
people with poorly controlled hypertension found that self-management reduced blood pressure
significantly (McManus et al., 2010). This study was done in Great Britain, and many questions
would need to be answered before results might be applied in the United States. Would clinicians be compensated for overseeing at-home blood pressure management? Which patients are
the best candidates for self-management? Would the same approach be possible for people who
required three or more antihypertensive medications?
Similarly, in the United States, a randomized trial of a Web-based self-management program
(compared with usual care) found that participating in the program resulted in improved blood
pressure among people with prehypertension and hypertension (Watson et al., 2012).
5.7 Diabetes Through the Life Span
R
isks for developing diabetes can start very early. Nutritional stresses or stimuli at critical
developmental periods permanently affect the body’s metabolism in ways that may not be
apparent until much later in life (Dyer & Rosenfeld, 2011). Examples of this process, which
is termed metabolic programming, include the association of low birth weight with hypertension
later in life (Chen et al., 2010) and excess risk for developing diabetes as adults among people born
during times of famine (Thurner et al., 2013).
Pregnancy and the period just after birth are prime times for metabolic programming. Either too
much food (overnutrition) or too little food (undernutrition) during these times is associated with
development of T2D, hypertension, and cardiovascular disease (Dyer & Rosenfeld, 2011). Overnutrition is one outcome of gestational diabetes: When the mother’s blood glucose rises, the baby
receives more glucose than normal. Although gestational diabetes does not appear until late in
pregnancy, excessive weight gain during the first three months of pregnancy predicts total weight
gain in pregnancy and raises the risk of gestational diabetes and newborns who are larger than
normal (Carreno et al., 2012). In addition to gestational diabetes increasing problems during birth
and for the baby, having gestational diabetes increases the mother’s risk of developing T2D within
the next 10 to 20 years (CDC, 2011a).
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CHAPTER 5
The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study followed 25,505 pregnant
women at 15 centers in nine different countries. Women underwent an OGTT at 24 to 32 weeks
of gestation. Those who had normal levels (defined as FPG ≤ 105 mg/dL and 2-hour plasma
glucose ≤ 200 mg/dL) remained blinded (unaware of the treatment protocol). Among those with
normal plasma glucose levels, strong associations were found between increased plasma glucose
and adverse outcomes, such as increased birth weight, percentage of body fat in the newborn,
and inflammatory indicators in cord blood (Metzger et al., 2008).
Further analysis of the HAPO data found that both obesity and plasma glucose were independently
associated with adverse pregnancy outcomes and that the combination had a greater effect than
either alone (Catalano et al., 2012). The HAPO study and other supporting data led a consensus
panel of the International Association of Diabetes and Pregnancy Study Group to issue new, lower
plasma glucose guidelines for gestational diabetes that caused a storm of controversy: The new
guidelines classify almost 18% of pregnant women as having gestational diabetes (International
Association of Diabetes and Pregnancy Study Groups Consensus Panel Writing Group [IADPSG] &
the Hyperglycemia and Adverse Pregnancy Outcome [HAPO] Study Steering Committee, 2012).
The interval immediately after birth, or the perinatal period, appears to be another critical time for
determining metabolic programming. Breast-feeding for any length of time appears to decrease
the chance of the child developing T2D at 10 to 21 years of age. This is true for all racial or ethnic
groups. Part of this association was probably a result of lower obesity among those who were
breast-fed (Mayer-Davis et al., 2008).
For people younger than 20 years, there are great differences in the rate of diagnosing new cases
of diabetes according to racial or ethnic group. White youths have the highest rate of T1D; probably some genetic factors account for this difference. They also have lower rates of T2D than other
ethnic groups. Native American youths have the highest rates of T2D and lowest rates of T1D.
As can be seen in Figure 5.3, the rate of diabetes increases tremendously in adults older than 20
years, going up almost fourfold from the youngest to the middle-aged group, and almost doubling
again from the middle to the oldest age group. Most of these are cases are T2D, as T1D is a smaller
percentage of the total for people older than 20 years.
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Section 5.8 Treatment Approaches for Diabetes
Figure 5.3: Estimated percentage of people aged 20 years or older with
diagnosed and undiagnosed diabetes in the United States, 2005–2008
The rate of diabetes significantly increases in adults older than 20 years.
30
Diabetic (percent)
25
20
15
10
5
0
20–44
45–64
≥65
Age group (years)
Source: Centers for Disease Control and Prevention. (2011b). 2011 national diabetes fact sheet: National estimates. Retrieved from http://www.cdc.gov
/diabetes/pubs/estimates11.htm
5.8 Treatment Approaches for Diabetes
T
1D by definition requires treatment with insulin. There are many choices in how insulin is
administered. Treatment plans for both hypertension and T2D usually start with lifestyle
changes. If these interventions are not sufficient to reach target values, then medication
or other approaches are added. Depending on the patient’s baseline starting values for FPG and
HbA1C, treatment may begin with a two-pronged approach: lifestyle changes and medication.
People who have diabetes are at approximately twice the risk for death compared with people of
similar age who do not. They are also at increased risk for heart disease, hypertension, stroke, eye
problems and blindness (diabetic retinopathy), kidney disease, nervous system problems (e.g.,
neuropathy), and circulatory problems that require a lower limb amputation. However, people
with diabetes can decrease their risk of heart disease, hypertension, and stroke by controlling
their blood glucose, blood lipids, blood pressure, and weight. Preventive care for eyes, feet, and
kidneys can also reduce the risk for severe vision loss, amputations, and severe kidney disease
(CDC, 2011a).
Self-Monitoring and the ABC Goals
Stark Casagrande, Fradkin, Saydah, Rust, and Cowie (2013) looked at cross-sectional data on
meeting A1C, blood pressure, and low-density lipoprotein (LDL) cholesterol goals in people with
self-reported diabetes from the NHANES performed 1988–1994 compared with 2007–2010. The
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Section 5.8 Treatment Approaches for Diabetes
National Diabetes Education Program (NDEP; n.d.-b) recommends a combination of A1C lower than
7%, blood pressure of 130/80, and LDL cholesterol lower than 100 mg/dL; these are sometimes
referred to as “ABC goals.” In people with diabetes, target levels of A1C and blood pressure are
associated with a lower risk for microvascular disease, and target levels of LDL cholesterol and
blood pressure are associated with lower risk for cardiovascular disease. Investigators found that
a greater percentage of people were meeting these ABC goals in the more recent survey, but
still fewer than ideal. Although more than half reached each separate ABC goal, fewer than 20%
reached all three (Stark Casagrande et al., 2013).
Controlling blood glucose to keep it in an optimum range—neither too high (hyperglycemia) nor
too low (hypoglycemia)—is the primary goal for everyone with diabetes. The initial approach
should include weight control, physical activity, and dietary modification, although the details
depend on the type of diabetes and characteristics of the individual. For many people with T2D,
these approaches are sufficient to control their blood glucose, but others need to add medication.
As can be seen in Figure 5.4, not everyone who has diabetes receives treatment with insulin or
oral medication.
Figure 5.4: Percentage of adults with diagnosed diabetes in the United States
who are receiving treatment, 2007–2009
An individual with diabetes can use several different methods, such as medication, to maintain an optimum
blood glucose level.
Insulin only
16%
Insulin and oral medication
12%
Oral medication only
14%
No medication
58%
Source: Centers for Disease Control and Prevention. (2011b). 2011 national diabetes fact sheet: National estimates. Retrieved from http://www.cdc.gov
/diabetes/pubs/estimates11.htm
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Section 5.8 Treatment Approaches for Diabetes
CHAPTER 5
Type 1 Diabetes: Insulin Therapy, Closed-Loop Systems,
and Immunotherapy
People with T1D must receive insulin to replace the insulin their body no longer makes. Choices
include rapid-, intermediate-, and long-acting insulin, depending on a number of different factors.
Choices for administering insulin include injection with a syringe, injection with an insulin pen, or
an insulin pump.
The Diabetes Control and Complications Trial (DCCT) randomly assigned people with T1D to either
conventional insulin therapy (one or two injections per day) or intensive insulin therapy (via either
an insulin pump or three or more insulin injections per day, guided by frequent blood glucose
monitoring). The trial ran between 1983 and 1993, and at the end it was clear that intensive
insulin therapy delayed the onset and progression of diabetic eye, kidney, and neurologic disease
(DCCT Research Group, 1993). This trial established the current standard practice of intensive
insulin control for T1D.
At the end of the trial, participants were all advised to switch to intensive therapy, and observations continued. More than 93% of the original group went on to the Epidemiology of
Diabetes Interventions and Complications (EDIC) study (Diabetes Control and Complications
Trial/Epidemiology of Diabetes Interventions and Complications [DCCT/EDIC] Study Research
Group, 2005). Analyses of the DCCT/EDIC data have found continued better outcomes in the original intensive treatment group for both microvascular (eye, kidney, and neurologic) disease and a
42% decrease in cardiovascular disease (DCCT/EDIC, 2005; 2009).
Many younger people use insulin pumps because of convenience. Although pumps free people
with T1D from having to eat on a rigid schedule, they still need to determine their blood glucose
frequently to adjust the amount of insulin the pump delivers as they exercise, eat meals, or snack.
One drawback of intensive insulin treatment (also known as tight control) is the risk of severe
hypoglycemia—dangerously low levels of blood glucose requiring the assistance of another person. If untreated, hypoglycemia can result in coma and death. The use of insulin pumps, particularly when combined with CGM, decreases the risk of hypoglycemia, at least during the day.
But hypoglycemia is a particular danger during sleep, when people are unlikely to be aware it is
happening.
Closed-loop systems that continuously monitor circulating glucose levels use software to determine how much insulin should be delivered. They then automatically deliver that amount of insulin—like an artificial pancreas. These systems are in clinical trials and are expected to radically
change the experience of living with T1D (Yaturu, 2013).
One approach to avoiding hypoglycemic events is to have a single closed-loop system that can
deliver both insulin and its companion pancreatic hormone glucagon, which acts to raise blood
glucose. A pilot trial of a dual-hormone (insulin plus glucagon) closed-loop delivery system guided
by advanced software was found to improve glucose control and decrease the risk of hypoglycemia in a group of 15 adults with T1D (Haidar et al., 2013).
Because T1D is an autoimmune disorder, clinicians and scientists have been looking for an immune
system therapy (immunotherapy) that might be an effective intervention—particularly in early
stages of the disorder—to halt or reverse destruction of pancreatic beta cells and thus preserve
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Section 5.8 Treatment Approaches for Diabetes
CHAPTER 5
normal insulin production. So far, these trials (although yielding valuable data) have not found a
workable clinical intervention. However, hope remains that this approach will eventually yield a
treatment and possibly a cure for T1D (Chatenoud, Warncke, & Ziegler, 2012; Staeva, Chatenoud,
Insel, & Atkinson, 2013).
Other radical approaches to restoring beta-cell function include transplanting pancreatic tissue
that generates insulin (McCall & Shapiro, 2012) or an entire pancreas (Tavakoli & Liong, 2012) for
people with T1D that does not respond to normal insulin therapy. In addition, various types of
stem-cell therapy are under investigation (Chhabra & Brayman, 2013).
Type 2 Diabetes: Preventive Measures, Medication, and Surgery
As mentioned earlier, people with blood glucose levels higher than normal but lower than those
seen in diabetes (FPG of 100–125 mg/dL) are considered to have prediabetes. Prediabetes is associated with several other traits that together are known as the metabolic syndrome. Aspects of
the metabolic syndrome include:
•
•
•
•
•
higher than normal blood glucose levels (prediabetes),
large waist circumference (≥ 40 in. in men or ≥ 35 in. in women),
high blood triglycerides (≥ 150 mg/dL),
low blood high-density lipoprotein (HDL, or “good”) cholesterol (, 40 mg/dL for men,
, 50 mg/dL for women), and
hypertension.
Metabolic syndrome puts people at risk for developing T2D as well as cardiovascular disease, so
people who have it should take preventive measures.
Case Study: The Diabetes Prevention Program
The Diabetes Prevention Program (DPP) was a clinical trial that found preventive measures reduce
these outcomes, and the effects last at least 10 years (DPP Research Group, 2002; 2009). The DPP
found that either lifestyle intervention or treatment with the oral diabetic medication metformin was
able to reduce the development of T2D by more than half in people who were overweight and had
prediabetes. Lifestyle intervention (in the form of modest weight loss by changing diet and increasing
exercise) was more effective than medication for most of the end points, although both significantly
reduced the risk of developing T2D (DPP Research Group, 2002).
The DPP Outcomes Study—a follow-up program that continued to study most of the participants in
the DPP for 10 years after original enrollment—found that the benefits of lifestyle intervention and
metformin last for at least 10 years:
• Those in the lifestyle intervention group had a 34% lower risk of developing T2D, even though
they took less medication.
• People in the lifestyle intervention group who were older than 60 years had an even greater
benefit, a 49% lower risk of developing T2D.
• People in the metformin group had an 18% lower risk of developing T2D (DPP Research
Group, 2009).
• For more information about the DPP, consult the NIDDK website (http://diabetes.niddk.nih.gov
/dm/pubs/preventionprogram/index.aspx).
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Section 5.8 Treatment Approaches for Diabetes
CHAPTER 5
Preventive Measures
It was thought from the DPP (see feature box) that lifestyle intervention would decrease the risk
for cardiovascular events in overweight or obese adults with T2D. However, after almost 10 years,
the Look AHEAD (Action for Health in Diabetes) trial, which compared intensive lifestyle intervention (focusing on weight loss and increased exercise) with advice alone, found no difference in rate
of cardiovascular events between the two groups (Look AHEAD Research Group et al., 2013). This
result held true despite significantly more weight loss, increased fitness, and decreased A1C in the
intensive lifestyle group.
As obesity in the population increases, the prevalence of T2D in young people increases. And the
effects on health are devastating. The TODAY Study, mentioned previously, looked at maintaining
target blood glucose levels, or glycemic control, in children and adolescents with T2D. Treatment
with metformin resulted in long-lasting glycemic control in approximately half of the participants;
the other half needed insulin. In contrast to results in adults, intensive lifestyle intervention in
addition to metformin did not improve glycemic control, although adding another drug, rosiglitazone, did (TODAY Study Group, 2012). (Because of data suggesting that rosiglitazone raises cardiovascular risk, it has generally been replaced with pioglitazone [Nathan et al., 2009]).
T2D appears to be more aggressive in youths than it is in adults. Glucose tolerance tests repeated
over time suggest that beta-cell function and insulin sensitivity deteriorate more rapidly in these
children and adolescents than they do in adults (TODAY Study Group, 2013a). Also, microvascular
disease, including eye and kidney function, appeared to be more aggressive in these young people
with T2D than is seen in adults (TODAY Study Group, 2013b; 2013c).
Although we generally think of T1D as a more severe disorder than T2D, that may not be true
for T2D diagnosed in adolescence or early adulthood. A retrospective 20-year follow-up study of
people in Sydney, Australia, diagnosed with T1D or T2D between ages 15 and 30 years found double the risk of dying in the group with T2D (Constantino et al., 2013). A greater proportion of the
deaths were from cardiovascular disease in the T2D group (50%) compared with the T1D group
(30.3%). These results make a good case for more aggressive measures to prevent development
of T2D in young people.
Medication
A number of different classes of medication are used to prevent or slow the progression of T2D:
•
•
•
•
•
Biguanides (metformin) block the liver from releasing glucose and lower LDL
cholesterol.
Meglitinides (repanglinide, nateglinide) raise the amount of insulin.
Thiazolidinediones (pioglitazone) help the body use insulin more efficiently, lower
triglycerides, and may protect kidney function.
Dipeptidyl peptidase-4 inhibitors (sitagliptin, saxagliptin) raise the amount of insulin
released after a meal; they are less effective than some others in decreasing A1C.
Glucagon-like peptide-1 receptor antagonists (exenatide, liraglutide) raise the amount
of insulin in the body; they cause less weight gain than other medications.
Most of these medications lower A1C about a percentage point (Agency for Healthcare Research
and Quality [AHRQ], 2011). Several combination medications are available as well, and their
effects on HbA1C appear to be additive. Metformin can also be taken with insulin. Many factors
go into the decision about which medication is best for each person, including baseline A1C levels,
glycemic control, tolerance for side effects, and the patient’s insurance coverage.
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Section 5.8 Treatment Approaches for Diabetes
CHAPTER 5
Web Field Trip
Check out the AHRQ website for more information about medications for T2D, including their comparative costs (http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?page
action=displayproduct&productID=721). The available information helps a T2D patient better understand the condition and the options for care.
Critical Thinking Questions
1. What side effects of medication do you see could complicate the treatment of diabetes?
2. How do the costs of certain brand-name drugs for diabetes raise obstacles to treatment?
As mentioned earlier, people with T2D often have hypertension as well, and the preferred medication for treating their hypertension is either an ACE inhibitor or an ARB (van der Zijl et al.,
2012). Because medications in the same class may differ, Antoniou et al. (2013) examined the
effectiveness of different ARBs for preventing macrovascular disease in people aged 66 years and
older with both diabetes and hypertension. They found that two ARBs, valsartan and telmisartan,
significantly reduced the risk of admission to the hospital for heart attack, stroke, and heart failure
compared with the others.
Surgery
As we have seen, obesity has reached near epidemic levels in the United States, and rates of
hypertension and T2D rise with obesity. Obese people with diabetes who fail to lose significant
weight with lifestyle interventions and medication are candidates for surgery on the stomach
or intestines, known as bariatric surgery, which increases weight loss by restricting food intake.
There are at least four different surgical approaches to bariatric surgery. For more information, see
the NIDDK website (http://win.niddk.nih.gov/publications/gastric.htm).
Several randomized trials have found that bariatric surgery is more successful than medical efforts
in achieving weight loss and in keeping weight off in people with a BMI of 35 higher (Mingrone
et al., 2012; Schauer et al., 2012). Surprisingly, bariatric surgery also reverses diabetic metabolic
changes, resulting in decreased insulin resistance and significantly lower A1C. Recent studies have
found that bariatric surgery yields the same advantages as medical efforts alone in people who
are less obese, with BMIs of 30–35 (Maggard-Gibbons et al., 2013; O’Brien, Brennan, Laurie, &
Brown, 2013).
Patient Education
Education is an important part of helping people and their families manage diabetes. The NDEP,
a joint effort of the CDC and the NIDDK, was founded in 1997 to “improve diabetes management
and outcomes, promote early diagnoses, and prevent or delay the onset of diabetes in the United
States” (NDEP, n.d.-a). More information about the NDEP is available on their website (http://
ndep.nih.gov/index.aspx).
As a result of research proving the benefits of blood glucose self-monitoring materials and diabetes education services (Boren, Fitzner, Panhalkar, & Specker, 2009), Medicare covers the cost of
these services.
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Section 5.9 Social Issues in Diabetes
CHAPTER 5
5.9 Social Issues in Diabetes
A
s with hypertension, many aspects of diabetes are set in motion by genetics and the prenatal environment. For instance, adults whose mothers had gestational diabetes are more
likely to have T2D than those whose mothers did not (Vrachnis et al., 2012). Similarly,
through use of a unique data set for the entire population of Austria, Thurner et al. (2013) found
that those born in places where food was scarce around the time of birth and immediately after
have a 40% increased chance of developing diabetes compared with those born where food was
in ample supply. In their words, their results “underline the importance of ensuring sufficient
nutrition in prenatal and early stages of life” (p. 4703).
The HAPO study, which lowered the guidelines for gestational diabetes so that almost 18% of
pregnant women were classified as having gestational diabetes, has raised a good deal of controversy (IADPSG & HAPO, 2012), in large part because of the costs. At least two separate analyses
found that the new guidelines, although expensive, were cost effective in reducing maternal and
infant birth complications and later life T2D (Mission, Ohno, Cheng, & Caughey, 2012; Werner
et al., 2012) particularly when care included counseling the mother after delivery to reduce T2D
(Werner et al., 2012). But the unanswered questions remain: How will the health care system
provide increased care for these women, and who will pay?
Bills have been introduced in the U.S. House of Representatives every congressional session since
2007 that would provide funding “to develop a multisite gestational diabetes research project
within the diabetes program of the CDC to expand and enhance surveillance data and public
health research on gestational diabetes” (H.R. Bill 1915, 2013). Similar bills have been introduced
in the U.S. Senate, but all have died in committee. Although gestational diabetes is (or ought to be)
a public health priority issue, given the current political climate, there is little hope for passage.
As can be seen by Figure 5.5, a disparity has developed in the United States in the prevalence of
diabetes between Whites and Blacks (CDC, 2013b).
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CHAPTER 5
Section 5.9 Social Issues in Diabetes
Figure 5.5: Age-adjusted percentage of the U.S. population diagnosed
with diabetes, 2000–2011, by race
As the figure depicts, there are racial or ethnic disparities among the population of adults diagnosed
with diabetes.
White
Black
Asian
10
9
Diabetic (percent)
8
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Year
Source: Centers for Disease Control and Prevention. (2013b). Age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes,
by race, United States, 1980-2011. Retrieved from http://www.cdc.gov/diabetes/statistics/prev/national/figbyrace.htm
Diabetes-related preventive services, including A1C tests, diabetic foot exams, and eye exams, play
an important role in avoiding adverse outcomes of the disorder. Pu and Chewning (2012) explored
the factors that go into observed racial or ethnic disparities in receiving these preventive services.
Disparities remained after controlling for patient age, income, and health insurance status; for
example, Hispanics were the least likely to receive all three preventive services.
Similar disparities are seen in rates of T2D among young people, as seen in the TODAY and SEARCH
studies. T2D disproportionately affects White and low socioeconomic status (household income
less than $25,000) youths (Linder, Fradkin, & Rodgers, 2013).
The pension file for U.S. Civil War veterans from a century ago paints a very different picture.
Around 1900, approximately 67% of men had a normal BMI, and the overall rate of T2D was much
lower. The rate of T2D diagnosis was higher among White men than Black men (Humphreys et al.,
2007), and there was no evidence of racial discrimination in testing. The authors remarked that
Black men had a higher rate of work-related physical activity, which may have accounted for at
least part of the difference between the two groups.
Although not a large percentage of the overall United States population, Native American/
Alaskan Native is the ethnic or racial group with the highest rates of diabetes (Figure 5.6). Subgroups within these groups may be quite different. For example, in 2009, the age-adjusted rate of
diagnosed diabetes among Native American/Alaskan Natives was 5.5% for Alaskan Native adults
and 33.5% for Native American adults in southern Arizona. Similarly, among Hispanics, the rate of
diagnosed diabetes was 7.6% for native Cubans or South Americans, 13.3% for native Mexicans,
and 13.8% for native Puerto Ricans (CDC, 2011b).
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CHAPTER 5
Section 5.9 Social Issues in Diabetes
Figure 5.6: Age-adjusted percentage of the United States population, aged 20
or older, with diagnosed diabetes, 2011
Members of the Native American/Alaskan Native population have the highest rate of diabetes.
18
16.1
16
14
Diabetic (percent)
12.6
11.8
12
10
8.4
8
7.1
6
4
2
0
European
descent
African
descent
Asian
descent
Hispanic
descent
Native American/
Alaskan Native descent
Racial/ethnic group
Source: Centers for Disease Control and Prevention. (2011b). 2011 national diabetes fact sheet: National. Retrieved from http://www.cdc.gov/diabetes
/pubs/estimates11.htm
To combat the growing rate of T2D among Native American/Alaskan Native communities, the
National Indian Health Board (NIHB), in conjunction with the CDC, has promoted the Traditional
Foods Project, which will “encourage Tribal communities to incorporate traditional, sustainable,
ecological approaches to diabetes prevention that focus on community based efforts to reclaim
traditional foods, increase physical activity and strengthen social support networks” (NIHB, n.d.).
Web Field Trip
In addition to the Traditional Foods Project, the CDC has partnered with Native American/Alaskan Native
groups to create public service announcements entitled, “Our Cultures Are Our Source of Health.”
These messages, featuring Hollywood actor and Cherokee tribal member Wes Studi, are available at
http://www.cdc.gov/CDCTV/OurCultures30/index.html and http://www.cdc.gov/CDCTV/OurCultures
/index.html.
Critical Thinking Questions
1. What are the unique challenges facing this ethnic minority in fighting T2D?
2. Do you believe the messages in the video would be effective for educating this group in preventing the disease?
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Chapter Summary
CHAPTER 5
In urban areas, it may not be so easy for people with diabetes to achieve healthy eating habits.
Breland, McAndrew, Gross, Leventhal, and Horowitz (2013) interviewed low-income Black and
Hispanic people with diabetes living in East Harlem, New York, to better understand the factors
that go into their food choices. The authors found several negative trends: The environment limited participants’ access to healthy foods; the participants did not fully understand diabetes and
the consequences of their food choices; the short-term negatives of healthy eating seemed to
outweigh the benefits; and stress from poverty and discrimination seemed to be the major cause
of their disorder.
Diabetes is costly in terms of higher mortality rates, decreased quality of life, and economic burden. Diabetes costs in the United States for 2007 were estimated to be $116 billion for total direct
medical costs and $58 billion for indirect costs, including disability, work loss, and premature mortality. Average medical expenses for people diagnosed with diabetes were 2.3 times higher than
for people without diabetes (CDC, 2011a).
Despite the many barriers to prevention, how to prevent or delay prediabetes from becoming T2D
is well understood. Programs such as the one sponsored by the CDC have proved useful.
A 5-min video shows how a 16-week program can help implement lifestyle changes to prevent or
delay T2D (http://www.cdc.gov/CDCTV/ChangeForLife/index.html).
Even so, until now, the U.S. health care system has not been set up to implement such programs
for the general public. Pilot programs have been shown to be useful and cost-effective, but no one
has been willing to pay to set them up, as preventive care does not fit in with the model of private
health insurance (for more on this topic, see Chapter 10).
There is hope that systemic changes in the U.S. health care system will alter this picture. Multidisciplinary team care, including physicians, nurses, pharmacists, dieticians, and health educators,
can provide better overall care at a lower cost than individual primary care providers, but the
question of who will pay remains. More extensive use of self-management models for diabetes
care may be one useful approach. To this end, a recent study compared usual care with an intensive intervention to control cardiovascular risk factors: A1C, BMI, blood pressure, LDL cholesterol,
HDL cholesterol, and triglycerides. Not surprisingly, the intensive intervention was significantly
more successful in altering all the risk factors (Vaccaro et al., 2013). However, if it were to be
widely implemented, the public policy issue remains: Who bears the cost?
Chapter Summary
Hypertension and diabetes are often found together in the same person—and frequently in the
company of obesity. These silent disorders pose a challenge for everyone: individuals with the
disorder, their health care providers, and the larger society. Because these disorders are silent
(asymptomatic in the early stages), people are unaware their condition and therefore are unable
to take preventive measures unless they are seen by a health care provider.
Self-management of both hypertension and diabetes leads to better outcomes. The control of
hypertension to prevent heart attacks, strokes, and kidney damage was first recognized widely by
the medical profession in the 1960s. If lifestyle changes are not sufficient to reach blood pressure
goals, then medication must be added—often two or more medications are needed. Insulin was
first isolated in 1922 and immediately became available for treating T1D, one of two types of the
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Key Terms
CHAPTER 5
insulin disorder known as diabetes. In T1D, a lack of insulin must be replaced by injections or a
pump, and in T2D insulin resistance may be treated with lifestyle changes. If changes are insufficient to control the disorder, then medication, sometimes including insulin, is added.
Although we know how to prevent or delay the consequences of both these silent disorders, there
are two major stumbling blocks to reaching that goal: understanding how to change people’s
behavior and finding a way to pay for the interventions needed to succeed. Both hypertension and
T2D rates increase dramatically with age and differ according to racial or ethnic groups. Diabetes
education is an effective intervention for prediabetes, but it is not available to many people in the
U.S. health care system. It also isn’t clear how hypertension self-management might be supported
in the current health care system.
Key Terms
autoimmune disease Disorder in which the
immune system mistakenly attacks the person’s own body organs or systems.
insulin Hormone secreted by the pancreas
needed for cells to take up glucose from the
blood.
diabetes A chronic disease characterized by
high levels of glucose in the blood caused by a
lack of insulin.
insulin resistance A state that precedes the
onset of diabetes, in which sufficient amounts
of insulin are produced, but cells do not
respond to it properly.
essential hypertension Hypertension that
develops with no clear cause.
gestational diabetes Excess blood glucose
that appears later in pregnancy in women who
did not have diabetes before they became
pregnant. It appears to be a form of insulin
resistance that develops in response to a hormone produced by the placenta.
glucose Simple sugar that all cells use as an
energy source.
hyperglycemia Blood glucose levels that are
too high: fasting levels equal to or greater than
100 mg/dL, or levels immediately after a meal
of more than 140 mg/dL.
hypertension Abnormally high blood
pressure.
hypoglycemia Blood glucose levels that are
too low: usually fasting levels less than
70 mg/dL, but depends on the individual.
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macrovascular disease Disease of large blood
vessels, such as coronary artery disease, heart
attack, stroke, congestive heart failure, and
peripheral vascular disease.
metabolic programming Exposure to nutritional stresses or stimuli during critical developmental periods that affects the body’s
metabolism much later in life.
metabolic syndrome A combination of
medical conditions that includes elevated
blood glucose levels (prediabetes), large waist
circumference, high blood triglycerides, low
blood HDL cholesterol, and hypertension.
microvascular disease Retinopathy
(microbleeds in the eye that destroy vision),
kidney disease, and neuropathy (nerve pain,
numbness, and weakness).
prediabetes Also known as impaired glucose
tolerance or impaired fasting glucose, the
condition that precedes diabetes in which
blood glucose levels are elevated beyond the
normal range.
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CHAPTER 5
Critical Thinking and Discussion Questions
resistant hypertension Blood pressure of
140/90 mmHg or higher when taking medications from three antihypertensive drug classes,
or any blood pressure that requires four or
more antihypertensive medication classes.
secondary hypertension Hypertension
that results from an identifiable cause, such
as kidney disease or as the side effect of a
medication.
type 1 diabetes (TD1) A disorder in which the
body’s own immune system attacks and kills
beta cells in the pancreas that produce insulin, resulting in the body producing too little
insulin. Previously called insulin-dependent
diabetes mellitus or juvenile diabetes.
type 2 diabetes (TD2) A disorder in which the
body produces enough insulin at first, but cells
do not respond to it properly. As a result, more
and more insulin is required, and the beta cells
of the pancreas become exhausted and lose
their ability to produce it. Previously called
non–insulin-dependent diabetes or adult-onset
diabetes.
Critical Thinking and Discussion Questions
1. Describe microvascular and macrovascular disease that can result from untreated or
inadequately treated hypertension or diabetes.
2. Define prehypertension and prediabetes. Explain why they should or should not be treated.
3. What are the dangers of hyperglycemia and hypoglycemia? Which is more of a
crisis situation?
4. Define metabolic programming and give an example of the results of this process.
5. Describe the barriers to self-monitoring for hypertension. What do you believe would
have to change to remove these barriers?
6. What actions might prompt successful passage of U.S. Senate and House legislation to
fund cost-saving programs that would prevent and treat gestational diabetes?
7. As a health care provider, investigate the question of how to better promote diabetes
self-management among your patients.
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SOC313 Family Document
Throughout this class, we will meet two families, the Maldonado’s and the Olson’s. The two families are
considered extended family via Sarah and Joe Miller. We will learn about their relationships, work
environments, and the psychosocial effects related to health challenges faced by each family. You will
use this document for the discussions and written assignments. We begin with the Maldonado family.
Manny and Donna Maldonado have been married for 42 years. Manny is age 65 and Donna is 63. Sarah,
Mike and Becky are the children of Manny and Donna Maldonado. Sarah is the eldest daughter,
followed by her brother, Mike, and her sister, Becky.
Manny is Hispanic American and owns a 20,000-acre produce farm that has been in his family for
three generations. Although Manny speaks and understands English, he prefers to speak Spanish.
This creates a language barrier between Manny and other family members who do not speak
Spanish. Donna is fluent in Spanish, having learned the language from Manny and his family.
Donna works on the farm with her husband. She has long suffered from mood swings, which is
mostly frustrating to Manny. He says it is “brujeria,” meaning her moods are caused by witchcraft
and “mal d ojo” or “evil eye.” He believes someone put a spell on Donna. When this is believed to
be the case, the person will visit a Curandero (healer) who will perform a healing ritual.
o Sarah works as a nurse, and recently took Family Leave of Medical Absence (FMLA) due to
her children’s recent issues.
o Joe is the President of Illusion Technologies. Joe’s parents are John and Ella Miller. More
details about Joe are shared in the Olson family section below.
Lucy, age 20, has a history of severe substance use disorder, along with having been
diagnosed with bipolar disorder. In the past two years, Lucy has had four different jobs.
o
o
o
She is unable to hold a job long-term. She now works on her grandparent’s produce
farm.
Josh, age 17, has been sneaking away with friends, smoking marijuana and skipping
school.
Evan, age 10, was recently diagnosed with leukemia; however, he has not yet started
treatments. Evan’s doctors have recommended chemotherapy, radiation, and a bone
marrow transplant. Sarah and Joe intend to follow this treatment plan.
Mike Maldonado is age 36. He currently works for a state University as a tenured faculty of
the College of Agriculture and Life Sciences. Mike was recently diagnosed with HIV.
Dan was Mike’s husband. He recently passed away at the age of 38 due to an AIDS-related
illness. They were married for 10 years. Mike and Dan did not have any children.
Becky is age 33. She is divorced and working on the family produce farm as well as
attending a local college at night to complete her bachelor’s degree in Child Psychology. She
has one child, Abe.
Abe is age 12. He is a good student, but his behavior has changed recently, showing
anger and defiance towards both of his parents and several teachers at school. His
mother, Becky, has been treating Abe’s behavioral changes with diet and alternative
medicines.
Next, we will meet the Olson family.
Frederic Olson was married to Mary Olson. Mary passed away 10 years ago at the age of 77. Frederic is
age 87. Ella is the only child of Frederic and Mary Olson.
Fredric has pronounced symptoms from Parkinson’s disease. He has tremors and balance problems,
along with muscle stiffness and gait (manor of walking) changes. He struggles to beg...
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