Diabetic Epidemic in Jamaica Queens New York

by Dr. Robert Evans & Richard Wildzunas

diabetic foot“Diabetes is a killing disease in the African American community, but a disease that may be controlled, according to James R. Gavin III, MD, chair of the American Diabetes Association’s African-American Program. “By keeping fit, eating right and getting regular exercise, we can decrease our risk for diabetes quite substantially,” he said. “This is a disease about which we can do a great deal, but only when those affected are informed and empowered to take the kind of control of this disease that is now possible”

INTRODUCTION

The NYC Department of Health and Mental Hygiene report, dated November 10, 2010 “Public Health in Jamaica, Queens that “Diabetes” is a primary health concern in that the death rate due to diabetes is higher in Jamaica than in Queens and NYC overall.

Additionally, the NYC DOH has reported that diabetes is epidemic. Diabetes is a serious illness that is increasing rapidly in New York City and around the country and In just the past 10 years, the number of people with diabetes has doubled with 1 in 8 adult New Yorkers (about 800,000 people) have diabetes and a third of them don’t know it yet.

National and State of New York reports support CWCOA healthcare initiative for developing an integrated delivery model including a “Diabetes Center of Excellence”, and establish a continuum of care program for the early detection and treatment of diabetes.

Community Wellness Centers of America, LLC (CWCOA) goal in developing a “Diabetes Center of Excellence” is to bring into the community an integrated private sector and government approach that significantly improves current health disparities throughout the community and addresses the chronic diabetes health issues prevalent with Queens County.

This diabetes initiative will provide pro-active measures required in bringing about the necessary healthcare services and preventive programs into the community of Jamaica which include:

  • A healthcare system(s) that clearly benchmarks as a goal the State of New York’s healthier population goals for 2013, and beyond, which identifies the disparities in healthcare and access to healthcare needs of the community for the treatment and prevention of diabetes;
  • An integrated Diabetes system(s) approach clearly addressing the disparities in healthcare for unnecessary hospital admissions/re-admissions providing financial savings to the State of New York and third party payers;
  • A program that fosters and promotes the hiring of clinicians and staff from the community and training and integration of medical schools and students from local schools;
  • A Center of Excellence that unequivocally is committed to the community and supports and understands our cultural and ethnic needs as it relates to providing excellence in “Diabetes Services” for minority populations;
  • Establishing a strategic partnership with national programs whose main focus is closing the gap in healthcare disparities with a focus on Minority Health Diabetes.

New York State Department of Health

Priority Area: Chronic Disease – Diabetes Objectives
By the year 2013, reduce the prevalence of adult diabetes and hospital complications of diabetes in New York so that:

  • The percent of adults with diabetes is no more than 5.7%. (Baseline 8.2%, BRFSS, 2007)
  • The rate of hospitalizations for short-term complications of diabetes are no more than:
    • 2.3 Per 10,000 (ages 6-17). (Baseline: 3.1 per 10,000, SPARCS, 2005-2006)
    • 3.9 Per 10,000 (ages 18+). (Baseline: 5.2 per 10,000, SPARCS, 2005-2006)

The cost of diabetes in the United States has soared from $174 billion in 2007 to a staggering $245 billion dollars in 2012, according to a new study released today by the American Diabetes Association.

That’s a stunning 41% increase in just five years, far higher than the rate of inflation. The direct cost of the disease for medical care is $176 billion, and the remaining indirect cost of $69 billion includes lost productivity because a person misses work for treatment, gets too sick to work, or dies too young and thus stops contributing to the work force too soon.

“One in 10 health care dollars is being spent directly on diabetes and its complications,” said Dr. Robert Ratner, the American Diabetes Association Chief Scientific and Medical Officer. The ADA considers diabetes a national epidemic, stating that 26 million Americans already have diabetes and that up to 79 million people have prediabetes, meaning that they are at high risk to eventually develop the disease.

Diabetic-Foot-Problems-4CDC data show low prediabetes awareness among Americans Only 11 percent of the 79 million Americans with prediabetes aware they have the condition

The danger of prediabetes is that it can progress to full-blown diabetes, with all the complications that condition entails, including heart, kidney, and circulation and vision problems

African Americans and Hispanics/Latinos minorities continue to have higher rates of disease, disability and infant mortality, cardiovascular disease, diabetes, HIV infection/AIDS, cancer and lower rates of immunizations and cancer screening.

In support of New York State’s Prevention Agenda toward the a Healthier State, the goal is to improve the health status of the residents of Jamaica/Queens Borough, and focus on establishing a “Diabetes Center of Excellence” in the distribution and access to healthcare providing preventative healthcare diagnosis and treatment resulting in a healthier population, and designed to reduce health care costs associated with diabetes.

Minorities continue to experience lower health status when measured against other groups and the population as a whole and without careful integration of a comprehensive healthcare initiative in Jamaica and the Borough of Queens addressing these disparities, the health status of our community will continue to suffer and the cost to the State of New York will continue to spiral out of control.

In support of the State’s Prevention Agenda toward the Healthiest State, our goal is to improve the health status of the residents of Jamaica through increased emphasis on health prevention programs. When you review death rates by race, the statistics are alarmingly disproportionate to African Americans whereby the underlying problem in part due to access of quality healthcare, and the early detection and preventative measures which can be instituted will have a positive effect for minorities.

Preventing illness in the first place makes much more sense than having to treat people when sick, and the identification and implementation of required services in Jamaica and the Borough of Queens will yield savings in health care and Medicare and Medicaid budgets and produce a healthier, more informed population of residents.

The predominant challenges are as follows:

  • An African-American baby boy born in the U.S. today lives 7 fewer years than a white baby boy.
  • People of color account for 80 percent of new HIV infections, with African Americans accounting for 50 percent and Hispanics, 30 percent.
  • Cancer deaths are 35 percent higher among African Americans than whites.
  • African American, Hispanic and Asian American women wait twice as long as white women for diagnostic tests following abnormal mammograms

Establishing integrated preventative health services directly with SUNNY Downstate would enhance our ability to provide the required support to the community and contribute to increased demand for downstream services and enhanced quality of care for the community.

SOUTH EAST QUEENS

Diabetes, an abnormal condition characterized by excessive amounts of sugar in the blood and urine, affects millions of Americans and is particularly prevalent among African-Americans, Asians and Hispanics, the three groups that are predominantly treated at Queens Hospital Center.

Currently, Queens highest concentrations of residents are in South East Queens where our “Diabetes Center of Excellence” services will be located whereby:

  • Queens residents are slightly more likely than New York State residents overall to experience a preventable hospitalization for a condition related to diabetes.
  • Hospitalizations for uncontrolled diabetes and short-term complications of diabetes are well above statewide norms.
  • As is true elsewhere, hospitalizations for congestive heart failure, bacterial pneumonia, and urinary tract infections account for just over half of the preventable hospitalizations in Queens.
  • Overall, preventable hospitalizations are less likely in Queens, but diabetes-related and a few other hospitalizations offer opportunities to conserve hospital beds.

Public Health Information

Primary health concerns in Jamaica and SE Queens Jamaica: Diabetes

Jamaica & SE Queens at a Glance

Total Population: Jamaica – 285,637 & SE Queens – 203,655

 

Neighborhood health

What are the types and risk factors of diabetes?

Type 1 Diabetes, previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes, may account for 5% to 10% of all diagnosed cases of diabetes. Risk factors are less well defined for type 1 diabetes than for type 2 diabetes, it is believed to happen after the body is exposed to an environmental trigger which then causes the body to attack the cells in the pancreas that make insulin.

Type 2 Diabetes, previously called non-insulin-dependent diabetes mellitus or adult-onset diabetes, may account for about 90% to 95% of all diagnosed cases of diabetes.

Risk Factors for Type 2 Diabetes include:

  • older age (45 years and older)
  • overweight and obesity
  • family history of diabetes
  • history of gestational diabetes
  • history of delivering a baby weighing more than 9 lbs.
  • impaired glucose tolerance
  • physical inactivity
  • race/ethnicity (African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Pacific Islanders are at particularly high risk for type 2 diabetes.)
  • physical inactivity
  • high blood pressure (140/90 mm Hg)
  • low HDL cholersterol (<35 mg/dl) and elevated triglyceride level (>250 mg/dl)
  • history of cardiovascular disease
  • women with polycystic kidney disease

What is the treatment for diabetes?

Management strategies should be planned along with a qualified health care team. In addition, quitting smoking is very important for people with diabetes since the majority of people with diabetes die from heart disease and stroke.

  • Treatment of Type 1 Diabetes: Treatment requires a regimen that typically includes a carefully monitored diet, planned physical activity, routine home blood glucose testing, and insulin injections.
  • Treatment of Type 2 Diabetes: Treatment typically includes diet control, regular physical activity, medications taken by mouth or by injection, and for some, routine home blood glucose testing.

Pre-diabetes

Some people have been told by their doctor that they have pre-diabetes. This is a wake-up call–a chance to make some changes in eating and exercise and avoid a lifetime of diabetes.

  • People with pre-diabetes have higher-than-normal blood sugar levels.
  • They are more likely than those with normal blood sugar levels to have a heart attack or stroke.
  • Unless they take steps to control weight and increase physical activity, most people with pre-diabetes will develop type 2 diabetes.

Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011)

After adjusting for population age differences, 2007-2009 national survey data for people diagnosed with diabetes, aged 20 years or older include the following prevalence by race/ethnicity:

  • 7.1% of non-Hispanic whites
  • 8.4% of Asian Americans
  • 12.6% of non-Hispanic blacks
  • 11.8% of Hispanics

Public Health Information 

Office of Minority Health
Center for Community Health
New York State Department of Health

New York is experiencing an epidemic of diabetes, and the disease is most common among ethnic minorities. (Abstract)

  • In 2004, Black non-Hispanics (38.5 per100,000) continued to experience diabetes death rates more than one and one half times greater than Hispanics (23 per 100,000), two and one half times more than White non-Hispanics (15.7 per 100,000) and more than three times higher than Asian/Pacific Islander non- Hispanics (12.4 per 100,000);
  • Of the four race/ethnic groups, Black non-Hispanics (289 per 100,000) continue to experience the highest mortality rate and Asian non-Hispanics (142 per 100,000) have the mortality rate due to heart disease;
  • In 2004, Black non-Hispanic infant mortality (11.1 per 1,000 births) was more than double the rate among Hispanic (4.5 per 1,000 births) and White non-Hispanic (4.6 per 1,000 births) infants and triple the rate among Asian/Pacific Islander non-Hispanic (3.4 per 1,000 births) infants.
  • The prevalence of adult diabetes in the New York State population includes instances where diabetes is diagnosed by a medical care professional

In New York State there is no system for conducting public health surveillance on undiagnosed Diabetes.

Data from the National Health and Nutrition Examination Survey (NHANES), a survey
Designed to enroll a representative sample of the US civilian population, estimate that in 2005-2006, 5.1% of adults above the age of 20 had undiagnosed diabetes. These national estimates can be applied to give a general estimate of the prevalence of undiagnosed diabetes in the New York State population (760,000 adults). However, this estimate does not take into consideration how the population of New York adults differs from adults in the rest of the US population or how rates of diagnostic testing for diabetes differ in New York as compared to other States.

Reducing undiagnosed diabetes is a priority in diabetes prevention and control. Healthy People 2020 includes an objective to increase the percentage of adults with diabetes whose condition has been diagnosed.

Prediabetes

Prediabetes is a condition in which an individual’s blood glucose levels are higher than normal, but not high enough to be diagnosed as diabetes. Like diabetes,

Prediabetes is detected by means of a blood glucose test. The clinical cut-offs for classification depend on the type of diagnostic test used.

In the United States, an estimated 35% of adults aged 20 or older have prediabetes.9 Adults with
prediabetes are 5 to 15 times more likely to develop type 2 diabetes than someone without the
condition, and are also at increased risk of developing heart disease, stroke and eye disease.

New York State
Minority Health
Surveillance Report
September 2007

Of Black non-Hispanic New Yorkers surveyed, 12.3% said they had been diagnosed with diabetes. The Black non-Hispanic rate was significantly higher than the rate for White non-Hispanic (6.5%), Asian non-Hispanic (7.1%) and Hispanic (7.5%) New Yorkers

The Black non-Hispanic population in New York State increased by 10% between 1990 and 2000. In 2005, 21.6% of Black New Yorkers lived below poverty.

NATIONAL DEATH RATES

Age-adjusted Death Rates, Selected Causes, by Race, 2006

Age-adjusted Death Rates, Selected Causes, by Race, 2006

Source: National Center for Health Statistics. (2010). Health, United States, 2009. Hyattsville, MD. (1) Racial categories include individuals of both Hispanic and non-Hispanic origin.

Diabetes New York State Adults 2006

The Behavioral Risk Factor Surveillance System (BRFSS) is an annual statewide telephone survey of adults developed by the Centers for Disease Control and Prevention and administered by the New York State Department of Health. The BRFSS is designed to provide information on behaviors, risk factors, and utilization of preventive services related to the leading causes of chronic and infectious diseases, disability, injury, and death among the non-institutionalized, civilian population aged 18 years and older.

Introduction Diabetes is a chronic disease defined by higher than normal blood glucose (sugar) levels. There are two major types of diabetes. Type 1 diabetes, an autoimmune disease, most often appears during childhood and adolescence. Type 2 diabetes, which is linked to obesity and physical inactivity, usually develops in adults over the age of 40 years, but it is now being diagnosed in younger adults and adolescents. Type 2 diabetes accounts for 90% to 95% of all diabetes cases.1 In the last two decades, the number of people in the United States with diagnosed diabetes has more than doubled, with higher prevalence in racial and ethnic minority populations.2 Diabetes is currently the 6th leading cause of death in the United States.3 Diabetes is an important risk factor for other diseases and disabilities, including heart disease, stroke, blindness, kidney failure, lower-extremity amputations, and complications in infections and pregnancy.

Diabetes among New York State adults: 2006 BRFSS

Race/ethnicity                       %

White non-Hispanic                   7.4

Black non-Hispanic                 12.0

Hispanic                                      5.1

Other non-Hispanic                  8.2

 

 United States compared with New York

National Center for Chronic Disease Prevention and Health Promotion
Chronic Disease Indicators

Diabetes
Indicator

Measure

United
States

New York

Diabetes prevalence among adults aged >= 18 years – 2010 view definition

Prevalence
(CI)

8.7%a

8.9%
(8.2-9.5)

 NEW YORK STATE DEATH RATES FOR DIABETES

Department of Health

Information for a Healthy New York
Diabetes – Deaths and Death Rates per 100,000 Residents
Source: 2007-2009 Vital Statistics Data as of March, 2011
Adjusted Rates Are Age Adjusted to the 2000 United States Population

Deaths

Population

Crude

Adjusted

Region/County

2007

2008

2009

Total

2008

Rate

Rate

Reg-7 New York City
Bronx 371 385 351 1,107 1,391,903 26.5 29.5
Kings 482 513 536 1,531 2,556,598 20.0 19.5
New York 314 298 274 886 1,634,795 18.1 16.9
Queens 325 335 381 1,041 2,293,007 15.1 13.6
Richmond 71 76 111 258 487,407 17.6 17.3
Region Total 1,563 1,607 1,653 4,823 8,363,710 19.2 18.6

SUMMARY

The development of CWCOA “Diabetes Center of Excellence” in South East Queens, Jamaica will provide critical and essential medical services for the treatment and prevention of diabetes predominately affecting African Americans and other minority populations.

Diabetes is particularly common in middle-aged adults and the elderly. It is much more common in obese people and in black Americans than in those of European origin. In African-Americans over 50 years old, 19% of men and 28% of women have diabetes. For every 6 white Americans who have diabetes, there are 20 black diabetics. African-Americans with diabetes have more complications than white diabetics.

There are two different processes that cause diabetes. Type I diabetes is due to problems with insulin secretion. The pancreas, which is an organ in the abdomen located behind the stomach, has cells called islets that normally produce insulin. In type I diabetes, these islet cells stop producing insulin and the result of this is insulin deficiency. Patients with type I diabetes
must receive insulin to be able to control their glucose concentrations.

Type II diabetes occurs when the body cannot effectively use the insulin that the pancreas produces. These patients require medication to help the body use insulin more effectively. In some cases, additional insulin may be needed to control glucose. Diabetes can be associated with serious complications and early death, but people with diabetes can take measures to lower these risks.

Most African-Americans (approximately 90 to 95%) with diabetes have type II diabetes. This type of diabetes generally appears in adulthood and is due to the body’s resistance to the action of insulin. It can be treated with diet, exercise, oral medications (pills) and injected insulin. A small number of African-Americans (between 5 to 10%) have type I diabetes, which generally appears before the age of 20 and is always treated with insulin.

The frequency of diabetes in adult African-Americans is influenced by the same risk factors that are associated with type II diabetes in other Americans. There are two main risk factors that increase the likelihood of developing type II diabetes. The first is genetics. The patient who has diabetic family members is more likely to develop diabetes. The second are lifestyle-related risk factors, which are primarily obesity and physical inactivity.

It is a known fact that diabetes runs in families. Research suggests that there is a strong genetic component in developing both type I as well as type II diabetes. The risk of developing type I diabetes appears to be related to certain genes that affect the immune system. Insofar as type II diabetes, there may be genes that affect insulin secretion and insulin resistance. Some researchers believe that African-Americans inherited a gene from their African ancestors that affects insulin resistance.

Medical risk factors

 

 Impaired glucose tolerance

Impaired glucose tolerance is a condition in which blood glucose concentrations increase to abnormally high levels after eating. These levels are not high enough for a diagnosis of diabetes, but are higher than the normal levels that are expected in non-diabetic individuals. Impaired glucose tolerance may be an early stage of diabetes, and people with this condition are at greater risk of developing type II diabetes than people whose blood glucose concentrations are normal.

Gestational diabetes

Approximately 2 to 5% of pregnant women have mild abnormalities in glucose concentrations and in insulin secretion during pregnancy. This is known as gestational diabetes. Although the glucose and insulin concentrations in these women return to normal after pregnancy, approximately 50% develop type II diabetes later on in life.

Hyperinsulinemia and insulin resistance

Higher than normal fasting insulin concentrations, what is known as hyperinsulinemia, are associated with a greater risk of developing type II diabetes. Hyperinsulinemia often precedes diabetes several years before. In some scientific studies, insulin concentrations were higher in African-Americans than in whites. It was found that African-American women in particular have high insulin concentrations, which indicates their greater predisposition to having type
II diabetes.

Obesity

Besides the degree of obesity, the place where the excess weight is found determines the risk of developing type II diabetes. Excess weight that is found above the waist (the “belly”) is a stronger risk factor than excess weight that is found below the waist. African-Americans have a tendency to gain weight on the upper part of the body. Although African-Americans have higher obesity rates, research suggests that obesity in and of itself is not to blame for the higher
prevalence of diabetes. Compared to white Americans of the same age, socioeconomic status and degree of obesity, African-Americans have a higher incidence of diabetes.

Physical activity

Regular physical activity has shown to lower the risk of developing type II diabetes. Researchers suspect that lack of exercise is one of the factors that contribute to African-Americans having a high incidence of diabetes. How do the complications of diabetes affect African-Americans?
Compared to white Americans with diabetes, African-Americans are more likely to have complications from diabetes. These complications include eye disease, which causes loss of eyesight; renal disease, which can lead to renal failure and require dialysis; and peripheral vascular disease, which can increase the risk of amputation. African-Americans are more likely to have disabilities related to these complications.

Eye disease

Diabetic retinopathy is a disease caused by deterioration of the blood vessels in the retina, which is the back part of the eye. High blood glucose concentrations increase the risk of diabetic retinopathy. It can cause deterioration of eyesight and, subsequently, blindness. The frequency of diabetic retinopathy is 40 to 50% greater in African-Americans.

Renal failure

African-Americans with diabetes suffer from renal failure, also called end-stage renal disease, approximately four times more often than white Americans. Hypertension, the second cause of end-stage renal disease, is also more prevalent in African-Americans and is responsible for 42% of all cases of this disease.

Greater mortality

In every age group, both in men as well as in women, the death rates in diabetic African-Americans were greater than in diabetic whites. The overall mortality rate was 20% higher in black men and 40% higher in black women.

With proper medical care, a healthy diet, exercise and weight control, African- Americans with diabetes can significantly lower their risk of complications and live healthy for a long time.

As previously indicated, Queens’s residents are slightly more likely than New York State residents overall to experience a preventable hospitalization for a condition related to diabetes. Hospitalizations for uncontrolled diabetes and short-term complications of diabetes are well above statewide norms. As is true elsewhere, hospitalizations for congestive heart failure, bacterial pneumonia, and urinary tract infections account for just over half of the preventable hospitalizations in Queens.

Overall, preventable hospitalizations are less likely in Queens, but reducing diabetes-related hospitalizations and other associated medical services through CWCOA “Diabetes Center of Excellence” will offer the State of New York a real opportunity to reduce costs and establish a model program for the entire State.

Potentially preventable readmissions (PPR) are hospital admissions that could potentially have been prevented with the appropriate care during the initial admission, or adequate discharge planning and follow‐up and coordination of care between the inpatient and required outpatient settings.

Prevention quality indicators (PQI) identify ambulatory care sensitive conditions for which hospital admissions might have been avoided if the patient had received timely and adequate care in the community.

CWCOA strategy to reduce PPR and PQI hospitalizations will rely on well-tested interventions addressing the underlying conditions (like diabetes and obesity) or target specific clusters of patients (as part of targeted discharge planning with the “Diabetes Center of Excellence”).

Regardless of the selected approach, the PQI’s that offer the most opportunity for reducing hospital bed use are probably those that have longer lengths of stay or that affect a larger share of patients. A profile of PQI’s at Queens Hospitals shows that such conditions would include diabetic amputations (with an ALOS of 17.8 days), long-term complications of diabetes (ALOS of 7.5 days) and COPD (6.4 days). Our focus in addressing diabetes in concert with Hospitals will undoubtedly have a significant positive effect on the population as a whole integrated with our CCHIT certified Electronic Health Record technologies.

The State of New York has identified two unresolved questions regarding the potential savings from PQI reduction strategies which are:

  1. How much change can be effected over (say) a ten-year period, and
  2. How much increase in primary care and outpatient specialty care is needed to achieve that?

The State of New York DOH continues to examine those important questions and CWCOA will integrate their patient care data with the State’s monitoring program facilitating and recording best patient care practices, improved population health status relating to diabetes, and lastly, but equally important, financial savings realized by our Integrated Diabetes Center of Excellence.
CWCOA “Diabetes Centers of Excellence” will establish a model diabetes healthcare center, integrated with community medical support services, and hospitals in Queens and the surrounding counties.

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