Can We Stop Diabetes?

A

 lot of people in India are already affected by the condition diabetes. Many studies have shown that Indians are particularly prone to develop diabetes and its complications. Experts have warned that about 9% of our population will soon be affected by this condition. For a country with over a billion population, this forms a huge number. Isn't it important for us to look for solutions?  

A study by Ramachandran and others in India have shown some promising answers. The study tried to understand the benefit of different interventions in preventing diabetes. It was conducted among people aged between 35 to 55 years who have not become diabetic, but shown a relatively high level of sugar in their blood, a condition known as pre-diabetic stage. Among the 531 people who were included in the study by dividing them into four groups, the first group was given medicines to lower their blood glucose levels and the second group was helped though regular classes and counselling to change their lifestyles including adherence to a better healthy diet and consistent moderate daily physical activities. The third group of people received both medicine and help for lifestyle modification. The fourth group was not any intervention.

Then, what happened to them?

After three years of follow-up of all the four groups, the researchers calculated the number of people who moved from a pre-diabetic stage to diabetic condition. The maximum benefit of the interventions was shown by the group which received regular help for their lifestyle modification. Compared to the group which did not receive any intervention, the group which modified their lifestyles had shown 28.5% less chance of developing diabetes. Even the group which had received both medicines and guidance for lifestyle modification had slightly lesser benefit than the group which only modified lifestyles

Though the benefit of lifestyle modification in preventing diabetes has already been established in several populations across the world, this study has confirmed the beneficial effect in the Indian population.  Interestingly, the study also showed that even though there was no overall weight reduction in the group that was helped to change lifestyles, the intervention benefited in terms of reducing their potential to develop diabetes in the future.

What does this study implicate?

The increasing prevalence of diabetes in our population is explained at least partly by the changing lifestyle in recent years in relation to diet and physical activity. These life-style choices are fueled by the development model that we pursue. It is important that we reverse these trends to the extent possible to stop diabetes from crippling more and more people. The core of such a change should be at two levels. The first and foremost is a change at the level of individuals, families and communities who are to embrace healthier choices.  Equally important is the creation of a facilitative environment that helps individuals, families and communities to choose healthier lifestyle choices in relation to diet and physical activities. This requires a stronger political commitment to regulate unhealthy foods and invest in policies and programs that promote healthier habits.

It is always better to turn off the faucet than mopping up the floor when the sink overflows!  

Reference

Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006 Feb;49(2):289-97. PMID: 16391903.

It's fun to stay at the Y-M-C-A….!

Really…you want to order that extra-large fries? Why not buy a YMCA membership instead? It’ll probably be more worth your while considering the skyrocketing number of people that have pre-diabetes these days. What is that huge number you ask – well, it’s over 60 million Americans! YES, you read it right. 60 million. That also means 60 million people who are at risk of a heart attack, stroke, blindness or other obesity-related health problems.

The YMCA is doing something great - it has partnered up with Indiana University School of Medicine to deploy a real-world adaptation of the Diabetes Prevention Program. The YMCA’s Diabetes Prevention Program is meant to help people learn about and adopt healthy eating and exercise habits that have been proven to reduce the risk of developing Type 2 diabetes.  The program gives people with pre-diabetes support and encouragement from both a trained lifestyle coach, and fellow classmates to develop a plan for improving and maintaining overall well-being.

To potentially be eligible to join this program, one should have a body mass index higher than 24, more than 2 diabetes risk factors (which include age, personal history, family history, race and ethnicity, weight and waist measurement, smoking, physical activity, diet and alcohol consumption) and a blood glucose level within a specified range. 6 months after the pilot program was deployed, it was found that the 92 participants, who were more often woman of non-white race, had lost 5.7 kgs on average compared to only 1.8 kgs in control participants. Cholesterol levels of participants also dropped significantly compared to the control group. These differences were sustained for 12 months.

What are some things you should take away from this pilot program?

1)   Lifestyle modification is very effective to prevent or delay the onset of diabetes. People at high risk for developing diabetes were able to achieve and maintain a reduction in body weight and a significant reduction in total cholesterol levels.

2)   The YMCA is a great place for wide-scale spread of this low-cost approach to lifestyle diabetes prevention! Soon this program may be offered at a YMCA near you. So keep your eye out for it. Go ahead, get involved, and improve your health today!

Quote from an expert:

"We are leveraging our national health care resources, the YMCA's and Walgreens' presence in local communities, our combined wellness expertise and the experience of two innovative, proven pilot programs to help people make lifestyle changes to prevent or control diabetes."

-Stephen Hemsley, president and CEO of UnitedHealth Group

Rita Wakim, MA., is interested in diabetes research: prevention and health outcomes. She is currently working towards a doctoral degree in Health Policy and Management at Emory University.

                                    

Reference:

Ronald T. Ackermann, MD, et al " Translating the Diabetes Prevention Program into

the Community The DEPLOY Pilot Study." American Journal of Preventive Medicine (2008): 357-363.

A Desert within a Desert: NYC’s Green Cart Program Fails to Reach Neediest Areas (Brooke Hixson)

NYC’s Green Cart program, designed to increase the availability of fresh produce in disadvantaged neighborhoods, has not been successful in reaching those the most in need. Researchers at Montefiore Medical Center, a Bronx hospital, investigated the Green Cart program, looking at how well the carts were fulfilling their intended purpose of selling fresh produce in areas where fruits and vegetables were otherwise unavailable. They found the carts were unevenly distributed around the Bronx with clusters of carts in some areas and no carts in others.

A woman buys produce at a Bronx Green Cart

The Green Cart program began in 2008 when the NYC City Council approved a measure allowing mobile food carts selling fresh produce to operate in areas with traditionally low consumption of fresh fruits and vegetables (often caused by a lack of supply in local stores). Neighborhoods where fresh produce and other healthy foods are difficult to find are often referred to as “food deserts.” Green Carts were touted by anti-hunger and child-advocacy groups as one solution to food deserts in poorer areas of NYC.

While the NYC Department of Health backed the Green Cart program and administers the permits, they also acknowledged that it was not a comprehensive solution to community health issues such as obesity and diabetes. Dr. Thomas Frieden, then city health commissioner and current CDC Director, expressed measured support, saying, "This is not going to end the obesity epidemic, but it is an important step to increase access to healthy food in the communities that need it most."

Despite fierce opposition from local bodega owners, support from the NYC DOH and a $1.5 million grant to provide microloans to cart vendors has resulted in Green Carts appearing across all five boroughs. However, the Green Carts must follow specific guidelines on where they can sell (only in food deserts determined by the NYC DOH) and what they can sell (only raw unprocessed fruits and vegetables – no peeling, chopping, etc.). Since the program's implementation in 2008, public reaction has been generally positive with some carts operating 24 hours/day, 7 days/week to meet demand.

Researchers looking at Green Carts in the Bronx, however, found the Green Carts tended to cluster in "hotspots" around hospitals, schools, subway stops, libraries, and the Bronx Zoo. As a result, some of the neighborhoods in the greatest need of fresh produce still did not have local access. Thus, even within an area generalized as a food desert, some areas are “drier” than others. Researchers also found a few carts operating outside the legal zone in areas that are not considered food deserts.

Maps of Green Cart Locations in the Bronx

Most disturbingly, researchers found about 10% of the carts were selling sugary drinks and cookies, defeating the entire purpose of the carts. Although selling anything other than fresh produce is expressly forbidden (and results in a $550 fine), there appears to be little oversight on the street.

During this time of skyrocketing obesity and diabetes rates, any effective intervention that reduces the risk of these diseases is important to invest in and to implement correctly. If NYC can work out the kinks in their Green Cart program and get its most at-risk residents to eat more fresh produce, the program is likely to expand to other metropolitan areas across the country. Government officials need to provider stricter oversight of current Green Carts’ inventory. Program coordinators should work with community groups to create local demand in Green Carts deserts and to enlist local residents to become vendors. Green Carts should also be designed to accommodate electronic benefit transfers (i.e., food stamps). Finally, public health officials must continue to work with established community businesses (such as bodegas) to encourage them to supply their communities with affordable fresh produce rather than relying on Green Carts alone to provide much needed nutrition in food deserts.


Brooke Hixson has worked in various aspects public health for almost 10 years. She is currently a doctoral student in Biostatistics at Emory University studying spatial analysis. She enjoys both fresh produce and NYC.


Source: Lucan SC, Maroko A, Shanker R, Jordan WB. Green Carts (Mobile Produce Vendors) in the Bronx-Optimally Positioned to Meet Neighborhood Fruit-and-Vegetable Needs? J Urban Health 2011 Oct;88(5):977-81.

A Social Experiment

You are where you live. A new study shows that low-income individuals who move to high-income neighborhoods have less obesity and better blood sugar control than individuals who stay in low-income neighborhoods. Past studies have shown that neighborhoods impact their residents’ health, but this is the first to show that changing from one kind of neighborhood to another can positively benefit an individual, even if most other things about that person’s life stay the same.

In the October 20^th issue of the New England Journal of Medicine, Dr. Jens Ludwig, et al. published a paper on the health effects observed in the Department of Housing and Urban Development (HUD)’s Moving to Opportunity (MTO) demonstration project. MTO was a case-control study designed to measure the role that neighborhoods play in health. Participants in MTO were randomly selected Section 8 housing recipients in high-poverty neighborhoods in five major US cities. They were divided into three groups. The first group was given vouchers to allow them to move to a new neighborhood with a low level of poverty. The second group was given vouchers to allow them to move to a new neighborhood that was not necessarily different socioeconomically. The third group was not given vouchers. The health of individuals in all three groups was tracked over time.

Those participants who received vouchers to move to higher-income neighborhoods and chose to move were less likely to be obese and less likely to have uncontrolled diabetes than those who did not receive vouchers, even though the two groups were initially very similar. This is an important finding because it highlights the way that where one lives impacts one’s health and that moving can change that impact. Though the reductions in obesity and diabetes were small (around 2-3% overall), they were significant—few other interventions even come close. As Dr. Thomas W. McDade, a coauthor  of the study notes, “The magnitude of the effects of the experiment are striking, and are comparable in size to the effects on diabetes we see from targeted lifestyle interventions or from providing people with medication to prevent the onset of diabetes.”

However, it’s important to keep in mind that the study is, at its most fundamental, a social experiment. HUD does not have the resources or ability to incentivize all Section 8 housing recipients in high-poverty neighborhoods to move to more healthful areas. Even if they did, there are not enough housing options for that to be a feasible option. So, if it cannot be widely implemented, why does this matter, other than to satisfy the curiosity of public health researchers and urban developers? This study opens the door to asking what it is that makes low-poverty neighborhoods that much healthier. Past studies have shown that some features of many low-poverty neighborhoods, like lower crime rates, better access to fresh fruits and vegetables, and parks may have positive effects on wellbeing. MTO is a chance to reexamine these factors and see if there are others, like transportation options and school quality, which might also play a role. Determining which of these are effective can help guide city planners in improving existing high-poverty neighborhoods to make them healthier, even if they do not become wealthier.

This study also makes a case for adding more mixed-income housing in low-poverty neighborhoods. While it is important to not abandon high-poverty neighborhoods (hence the role of city planners and ongoing urban improvement), incorporating more Section 8 housing into low-poverty areas may serve as a stop-gap. Ethically, financially, and logistically, it is not possible to clear out all high-poverty neighborhoods and relocate former residents to low-poverty neighborhoods in the name of public health, but providing individuals with options to live in more mixed-income areas may show a benefit.

Sources:

Anyaso, Hilary Hurd. “From High to Lower Poverty.” Northwestern University News Center. Accessed Nov. 7, 2011 http://www.northwestern.edu/newscenter/stories/2011/10/poverty-study-mcdade.html

Ludwig, Jens, et al. Neighborhoods, Obesity, and Diabetes—A Randomized Social Experiment. New England Journal of Medicine 2011; 365: 1509-1519. October 20, 2011.
Wheeler, Helen Rippier. "Berkeley's Housing Authority Administers Section 8, Public Housing." Accessed Nov. 7, 2011 http://www.berkeleydailyplanet.com/photos/05-14-04/5%253A14%2520rectangle.jpg

Author:

Kira Newman is a second year MD/PhD student beginning the PhD portion of her education in epidemiology.  Her research interests focus on the nexus between environment and health.  Kira brings a broad background to translational research including primary research in historical epidemiology and practical epidemiology experiences at CDC and state levels.  Biking, climbing, and scavenging free food are her passions.