Chronic disease management - Support for rural diabetics

I'll admit that chronic disease management is a topic I tend to neglect. Vaccines, superbugs and exotic diseases are sparkly and controversial, but I've been focused on wildlife parasites and global diseases when examples of the effects of chronic disease seem to be everywhere I turn.

Chronic disease is a growing problem that correlates with our lengthening life span, and diabetes has become a hugely common disease worldwide associated with lifelong illness, mortality and other diseases such as obesity and cardiovascular disease. 

According to the American Diabetes Association, 8 percent of Americans suffer from diabetes, an alarming number that reinforces the idea that the modern American lifestyle is not a healthy one. Add in a family history of diabetes and late diagnosis or inadequate management of the disease, and diabetes becomes a serious public health problem. In Georgia, the incidence of diabetes has expanded from 4.4 per 1000 in 1999 to 10.7 in 2008, a 143 percent increase.

The issue may be further compounded in rural areas, which are typically poorer, where access to proper resources like nutritious food and health education services may be lacking. 

So when I began to visit Hartwell, I expected to hear about diabetes as a common health concern. I was right. And while the prevalence of diabetes itself is worrisome, I learned that many diabetic patients in Hart County don't, or can't, comply with the directions their doctors give them to manage their diabetes. 

Noncompliance stems from a number of causes: Unemployment in Hart County is near 13 percent, and people eat what they can afford. The same goes for medications. Still others just aren't willing to change their lifestyles, or aren't aware of what they're eating. Some find the effort of checking glucose levels and monitoring food intake to be too much, and just don't do it.

But in Hartwell and surrounding areas, a local health care system has attempted to give diabetic residents a chance to get the education they so badly need to deal with the disease properly.

Ty Cobb Healthcare System, which serves both Hart and Franklin counties, offers an outpatient diabetes education center as a part of its health and wellness services. Patients can meet with a dietician, receive one-on-one, individualized consultations and attend group sessions on various topics related to diabetes. 

Rene Starrett, the clinical wellness coordinator for Ty Cobb, sees patients regularly upon referral from local primary care physicians. Most of her patients are Type 2 diabetics who experienced adult onset, and are usually over 50. She offers them a comprehensive overview of diabetes and helps them understand what changes they will need to make in their lifestyles, how to take their medications and how to monitor effectively. Many of the patients Starrett sees can get more in-depth, instructive knowledge from her than a physician who can tell patients to eat well, but not what eating well means.

Part of Starrett's approach to diabetes education is that support is just as important as knowledge when it comes to diabetes, a disease that requires intense personal management and surveillance. "A support system is very important," said Starrett. "Diabetes is very much about the patient."

I saw evidence of this at one of the free group sessions focused on monitoring strategies. Most of the attendees were older women, and I was surprised by the number of pre-diabetics who came for information. They came from several nearby towns, since these groups are the only free available group resource for pre-diabetics and diabetics.

Starrett acted as a member of each patient's support team, offering empowerment and advice for long-term health goals. For those suffering from diabetes, action in the now is most important, but it's easy to get discouraged or overwhelmed. 

What quickly became apparent was that this group is a way for those experiencing the same issues to help each other cope, share what they'd learned and encourage healthy behaviors in others. One woman expressed that fear of pain kept her from checking her blood sugar, which elicited a huge response and an influx of advice. Others expressed the difficulties of watching diet and understanding what causes changes in blood sugar, whether it's stress or eating an extra piece of bread at dinner. 

Regardless of the concern, someone always had an answer. These support groups show that diabetes, and chronic diseases, aren't just about managing the physical aspects of illness. They are just as much about having the mental resources and support to lead a healthy, productive life. 

The word of the day is: FOOD

In researching my feature story and attending the Association of Health Care Journalists Conference in Philadelphia, I have spent the better part of the month immersed in the broad topic of food.

A pig house at Wilson Swine Farm in Hartwell, Ga. 

I discovered the smell of a swine house, the ins and outs of a cattle farm and the changing regulations applied to what eventually ends up in our stomachs.

Food is much more than what we buy to satisfy hunger, whether it's a box of off-brand pasta or a hunk of fancy cheese. There is a complex process that lies behind what we see on our shelves; but for most of us, food just magically appears on our plates, and we leave it at that. What I've learned about the process of making our food products is troubling, to say the least.

Around 80 percent of the antibiotics consumed in this country are given to livestock, or close to 18 million lbs. And that's not because all the cows have bacterial infections. Antibiotics, the same ones prescribed to us when we get an infection, are encouraged as a way of speeding up the growth process in these animals. The big issue here is that, while eating a steak that was once fed antibiotics won't hurt you personally, everyone is affected collectively by resistance to drugs that we rely on to save lives.

Last year the FDA, CDC and US Department of Agriculture all testified before Congress that there is a link between overuse of antibiotics in food animals and the rising incidence of antibiotic-resistant strains of bacteria.

And while it may seem as simple as cutting down on the wanton use of antibiotics in healthy animals, industry officials will always fight it.

The idea of antimicrobial resistance is a beast, but the message I got out of this session at AHCJ is that current regulations and public education on the subject are inadequate, a theme that seems to be recurrent when talking about food safety.

And food safety is on everyone's minds lately due to recent outbreaks of salmonella that leave the entire country, and my mother, in a panic over what's safe to buy.

The new Food Safety Modernization Act was signed into law in January, marking some major changes in how food production is regulated. The panel at AHCJ focused on how far the bill goes in actually making a difference in food safety for the United States. The act is focused on prevention rather than reaction, which has been the FDA's primary role for years.

Surprising to me was the fact that the law had not been modified at all since 1938, and little had changed since its creation in 1908.

With one in six people becoming sick from food-borne illnesses annually (CDC), it seems obvious that the bill needed to be updated along with the evolving nature of our food industry.

So what does the new bill do for us as consumers?

For starters, under the new bill, not only can the FDA now mandate recalls of products, but it will also conduct more frequent inspections of facilities. If a company is associated with unsafe food, the FDA will be able to suspend its registration, halting distribution of the affected product. Retailers will also be required to place placards advising customers of a recalled product.

For the first time, there will be standards for the safe and correct production and harvesting of produce, with exemptions for smaller farms and individually-produced food.

Organic tomatoes in a greenhouse at the
UGA Horticulture Farm in Watkinsville.

Additionally, suppliers must now produce written safety plans to be provided to the FDA, who will also have access to any food safety records. And international suppliers, who bring in about 15 percent of our food, won't be left out. Before, only around 1 percent of imports were checked; now international suppliers must provide proof of certification and can be barred from entry into the US if found in violation of standards or if they deny an inspection by the FDA.

So there is now more real-time protection of consumers, with better prevention methods in place and the FDA taking on extended monitoring responsibilities.

But while the bill seems like a major step up, there are still problematic areas. For example, 20 percent of the food industry (meat and dairy production) is actually regulated by the USDA. The FDA also has no authority to issue civil penalties to violators of safety standards, only administrative detention.

This is, however, where collaboration becomes key. Without partnerships among national, state and local government agencies, food producers and other stakeholders, real progress in food safety won't happen. Because of the complexity of the bill, we aren't likely to see any immediate changes, but hopefully it will result in safer, more reliable food production.

Our local Subway just started to stock spinach again ... and I'm hoping it stays that way.

Sustainability on the farm

Scott Fleming, manager of Wakefield cattle farm in Hartwell, was kind enough to tell me about the farm and what sustainability means to him. Not only is the farm beautiful, with acres of forested land alongside green pastures, but it is also known as an example of environmental consciousness in an industry where sustainability is rare.

Check out the video, featuring photos of Wakefield and the University's organic farm in Watkinsville. Farming really is a way of life in Georgia, but it doesn't have to harm the land that feeds us.

A more high quality video is available at http://vimeo.com/22782695