UH faculty tackles growing disease through research and public education
Despite public awareness, improved diagnosis and treatment and new drugs, diabetes afflicts nearly 18 million people in this country and costs us billions of dollars a year. In Hawaiʻi, the state Department of Health estimates that 100,000 people have diabetes, 25,000 of them undiagnosed. "Without better ideas for intervention, diabetes could become the major U.S. health issue," says UH Hilo Professor of Anthropology Daniel Brown.
Jane Kadohiro is confident diabetes will be beaten. "That’s why it’s very important that people take care of themselves—so they are around when there is a cure," the Mānoa assistant professor of nursing says.
Diagnosed with type 1 diabetes at age 8 half a century ago, she has firsthand reason for optimism. "I know I should have died probably a long time ago," she says frankly. "Diagnosed in the era I was, statistics were against me. Treatment was in its infancy. So it’s like, OK Lord, maybe you have kept me here for a reason."
Healthy lifestyle choices are important for everyone, especially diabetics
Kadohiro travels up to five or six times a year around the world, spreading a message of hope, perseverance and self-management. Every day, she tests her sugar levels four to six times and takes five insulin shots.
"People don’t understand that when you live with diabetes you have to make many decisions throughout the day," she says. "You have to adjust your insulin, take your meds, watch what you eat, exercise. That’s not easy."
She’s not alone. Experts call diabetes a worldwide epidemic. "While the largest increases are in type 2, there is also a global increase in type 1," Kadohiro observes.
Investigators have identified factors that may contribute to diabetes—obesity, family history and behavioral patterns. Still, they are at a loss as to why some people, including Native Hawaiians, are more prone to diabetes than others, says Margaret West, a research associate in the John A. Burns School of Medicine’s Department of Native Hawaiian Health.
Anthropologist Brown has studied obesity in children for two decades, most recently under a five-year, $4 million NIH grant. While he found that Native Hawaiians children are significantly heavier than their classmates, genealogical studies show that children with high percentages of Hawaiian ancestry are not fatter (on average) than classmates with less Hawaiian ancestry.
"This suggests that genetics is, perhaps, not as important as social factors in determining risks for being overweight," Brown says.
He also observed that Native Hawaiian children with high percentages of Hawaiian ancestry exhibit more fat around their stomachs than other children. "We suspect that Hawaiians have a tendency to place excess fat on their abdominal areas, and that this increases their diabetes risk. In general, metabolically active fat (present in abdominal areas) causes more health risk because the fat gets into the blood more easily."
"Health disparities" is the term experts use to describe ethnic differences in disease rates and outcomes. "While we know the basics of treatments for both types of diabetes, it is critical that we individualize treatment and address cultural and social issues in the population with which we are working," says Kadohiro.
Health disparity is a complex process involving many variables, including socio-economic factors, says Mānoa Instructor in Nursing Anne Leake, who teaches diabetes self-management to Filipinos in Waipahu. "You can have a well-informed and motivated person who is receiving culturally competent care, but if it is being provided within an environment that does not meet their needs, the outcomes will be poor," Leake says.
The Department of Native Hawaiian Health collaborates with other agencies to target education programs. Its four-year-old Native Hawaiian Diabetes Intervention Program is a community-based diabetes lifestyle program that includes traditional healing methods and cultural values. Studies show that participants who received support from ʻohana (family) are more likely to healthier and be more active.
A 2004 Diabetes Worksite Project used diabetes education in the workplace to focus on diet, exercise and clinical measures (weight, blood pressure, glucose, cholesterol and A1c—a test that measures glucose over three months). Participants showed a marked improvement in their clinical tests and self-care.
Not everyone is sold on self-management education programs.
"We’ve been telling people for years about the dangers of obesity, and it’s gotten worse," says physician Richard Arakaki, who has been involved with the national Diabetes Prevention Program for many years.
"I’m not a big fan of behavioral change. It requires a team—health practitioners, dietician, family—and there are so many socio-economic barriers," the Mānoa professor of medicine continues. "I take a more clinical approach. I look at therapeutic options to improve the care of diabetic patients and their quality of life."
Among the advances: improved monitoring devices and a variety of oral medications and insulins as well as insulin pumps worn outside the body. The Food and Drug Administration is expected to approve an insulin inhaler this year, and it recently approved Byetta, a twice-daily injectible drug derived from the saliva of the Gila monster that helps control sugar levels and doesn’t appear to cause weight gain.
"Science will help us in the future," says Arakaki. "It will help us understand what influences obesity and what happens physiologically."
Despite his skepticism, Arakaki is conducting a lifestyle intervention study with Professor of Nursing Jillian Inouye "because I think she’s on the right track; she’s trying to impart change." Inouye received a five-year, $1.2 million grant from the National Institutes of Health to look at the effectiveness of cognitive/behavioral intervention on self-management among Asians and Pacific Islanders with type 2 diabetes.
"The main focus is on changing people’s thinking about how they can better manage their disease," says Inouye. "We also look at cultural aspects, people’s values and how that can fit into a healthy lifestyle."
Participants meet weekly with a clinician to discuss specific concerns and find solutions. "Susan" lost 80 pounds after undergoing gastric bypass surgery and wants to lose 50 more. She watches her diet, goes to the gym and will soon return to playing tennis. One of her solutions? Even when she can’t exercise, she picks pua kenikeni flowers from her tree each day so the tree will keep blooming and she’ll keep moving.
A College of Tropical Agriculture and Human Resources program in Hilo teaches people with diabetes the value of five medical tests—hemoglobin Alc, blood pressure, cholesterol levels, microalbumia (a test of kidney functioning) and annual eye exams.
"We explain what the tests are and how to read them so that when people go to their doctor, they will ask for the numbers and not be satisfied with just knowing their hemoglobin levels are OK," says nutritionist and project coordinator Julia Zee.
Her advice is familiar—more plant products and fiber in the diet—but she understands that restricting a staple closely tied to the culture (like rice) can be very difficult, even leading to depression, a condition that affects 30 percent of diabetics.
"I tell them, ʻdon’t try to change your diet all at once. There isn’t any food that absolutely you cannot have. It’s knowing how much to eat. Take small steps."
Echoing optimist Kadohiro, she concludes: "We can’t give up.’"
Definitions of type 1 and type 2 diabetes
Type 1 diabetes is an autoimmune disorder that mostly strikes in childhood. For reasons unknown—scientists believe genetic and environmental factors play a role—the immune system destroys insulin-producing beta cells in the pancreas. Symptoms include increased thirst, frequent urination, constant hunger, weight loss, blurred vision and extreme fatigue. People with type 1 diabetes must take insulin shots to live.
Type 2 diabetes results when the pancreas produces too little insulin or the cells do not absorb it, a condition called insulin-resistance. It occurs mostly in people over 40, although the number of children diagnosed with type 2 diabetes has increased significantly. The Pacific Health Research Institute reports there are 50 new cases annually in Hawaiʻi. Healthcare professionals say obesity is a major culprit.
Current UH projects related to diabetes research
NERVE DAMAGE Autonomic neuropathy (nerve damage) often accompanies diabetes and leads to amputations or blindness. Researchers aren’t sure why, but they suspect insulin may play a role independent of high blood sugar. The Kohala Health Research Study indicates that while diabetes is as common among people of Asian ancestry as among Hawaiians and part-Hawaiians, the prevalence of excess weight and body fat distribution differs significantly, as does insulin levels. "This indicates to us that insulin resistance may have differing importance in the cause of heart disease, diabetes and diabetes complications," says Andrew Grandinetti, associate specialist with Mānoa’s Pacific Biosciences Research Center.
CHOLESTEROL CONNECTION Although pharmaceuticals have made major strides in treating low density lipoprotein (LDL) or "bad cholesterol," controversy over the optimal diet for this disorder continues. "Other than unsaturated fats and fiber, little is known about what nutrients may be beneficial in treating LDL associated with type 2 diabetes," says Andre Theriault, professor in Mānoa’s Division of Medical Technology. He and colleagues study effects of plant nutrients on LDL. A low dose of xanthohumol (a compound extracted from hops) reduced the production of LDL by inhibiting lipogenic (fatty) enzymes in a liver cell grown in a petri dish, but Theriault isn’t promoting beer drinking as a way to lower bad cholesterol.
SKIN SCREENING Acanthosis nigricans, or AN, is a skin disorder characterized by large brown areas on the back of the necks, arms and knuckles of children and adolescents. AN is associated with obesity, insulin resistance, hypertension, high cholesterol and type 2 diabetes among some ethnic groups, but there is no data for Pacific Islanders. Maui Community College Instructor in Nutrition Karen Kay Robbins has partnered with Hui No Ke Ola Pono to determine whether Native Hawaiian youngsters with AN are predisposed to diabetes. "We’re hoping that this will be an effective, simple, noninvasive tool for identifying children and adolescents who need to be checked for type 2 diabetes," she says.
MUSCLE MAN Jinzeng Yang, Mānoa assistant professor of human nutrition, food and animal science in the College of Tropical Agriculture and Human Resources, explores the role of muscles in processing fats. Yang created transgenic mice by tweaking a protein (myostatin) found in muscle cells. After two months on a high-fat diet, regular mice became obese and insulin resistant. Fed the same diet, the more muscular transgenic mice remained healthy with normal fat mass and hormone levels. "The research strongly suggests that muscle build-up during growth stages plays a significant role in preventing obesity," Yang says.
HEART HEALTH John A. Burns School of Medicine physician Richard Arakaki participates in an international study called ORIGIN, for Outcome Reduction with Initial Glargine Intervention, which tests insulin treatment and Omega-3 fatty acids in the prevention of heart disease in pre-diabetics and diabetics. "Heart disease is commonly seen in diabetics, but interventions to lower blood sugars have not yielded a reduction of heart disease in type 2 diabetics," he says. The project aims "to be very aggressive" at getting blood sugar down to near normal levels or lower using insulin plus Omega-3.
TELEHEALTH Nancy Johnson, nursing division chair at Maui Community College, has implemented TeleHealth, a phone and video system that allows nurses to care for patients via a home TV monitor. Another project uses the Internet to monitor the progression of renal disease in diabetics of Native Hawaiian ancestry. "The study showed that renal disease progressed more rapidly in patients with standard treatment, which suggests that renal disease may be significantly slowed by intervention of e-health visits," she observes.
ONLINE ADVICE Dubbed "Mr. Telemedicine" by Wired magazine, Mānoa Professor of Electrical and Computer Engineering David Yun developed a website for diabetes self-management with Hawaiʻi Medical Services Association physician Joseph Humphry. Patients input their test results; ʻOhanaHealth responds automatically if their glucose levels are too high or too low and provides advice. "The website tells you how you’re doing," says Yun. "You can ask questions and look at your charts." ʻOhanaHealth targets economically disadvantaged groups in Hawaiʻi and the Marshall Islands. Patients must be monitored by a doctor who must also participate in the program. Results are promising—80 percent of Waiʻanae control group participants maintained their glucose levels within the acceptable range. Yun says the program could cut down on doctor’s visits and allow doctors to care for more patients.
Diabetes curriculum earns alums award
Diabetes and You, a curriculum for fourth graders, won the 2004 American Diabetes Association’s Outstanding National Youth Initiative Award for its creators, Department of Education retirees and UH Mānoa alumni Carl (BEd ’63, PD ’:64) and Irene (BA ’66) Takeshita.
Developed at the request of the state Department of Health out of concern for the increasing number of young children diagnosed with type 2 diabetes, the curriculum focuses on symptoms, risk factors and complications associated with the disease and how proper nutrition and exercise can prevent or delay its onset.
Beginning in 1999, the Takeshitas have presented the two-session program to more than 2,000 students and adults on Oʻahu, Hawaiʻi, Molokaʻi and the mainland over four years.
Teachers interested in learning to use the curriculum can call the American Diabetes Association Hawaiʻi office, 8(808) 947-5979 or DOEʻs Health and PE section, (808) 733-9141 ext. 311 or email Irene Takeshita