9UNP0427SD_Linda Baumann_WordPress

- Heidi Zoerb: Good afternoon, everyone. My name is Heidi Zoerb and I'm here to welcome you to the third session of Day on Campus Food Summit lectures. I'm an assistant dean in the College of Agricultural and Life Sciences and I certainly hope you're enjoying today's program. Thanks to our partnership with the Wisconsin Alumni Association, we've been able to bring you a diverse lineup of speakers designed to really feed your mind. And now we are excited to welcome Professor Linda Baumann from the School of Nursing at UW-Madison. Professor Baumann received her nursing degrees from the University of Michigan and a PhD in psychology from UW-Madison. She teaches community health nursing and international health, and is the faculty advisor for a graduate Certificate in Global Health. Professor Baumann's research examines how beliefs about health and ailments influence self-care behaviors. Her current research is examining strategies to promote diabetes self-care in both Vietnam and Uganda. She is active in many national and international professional organizations and in 2007 was selected as a Paul G Rogers Society Global Health Research Ambassador. 

Please join me in welcoming Professor Baumann as she presents "A Global View of Diabetes." 
(applause)
 
- Linda Baumann: Thank you very much. I'm very pleased to be here and to speak to some familiar faces in the audience. My goal is going to be to try to give my remarks in about 30 to 35 minutes and then to allow some time for questions. I could speak on this topic and provide details for many hours on this topic. But I want to talk to you about a global view of diabetes, and my purposes today are to give you a picture of diabetes worldwide, to talk about some strategies for controlling NCD or non-communicable disease, and then to have the opportunity, of course, to talk about the research that I do in this area. So globally, there is something called the epidemiological transition. And that is that worldwide, especially in developing countries, there is a drop in infectious disease and an increase in chronic disease. 

And some people will also sometimes talk about the triple burden of disease, and that is injury, is one that is also increasing, specifically traffic accidents and injuries largely in developing countries. The burden of non-communicable disease in 2003 was considered to be 60% of what we talk about as the burden of disease worldwide. And you can see that projections for 2020 is that this is going to increase substantially. And what is of even greater concern is that most of this increase is going to occur in the poorest countries of the world. Now, how much is the World Health Organization spending on controlling or on their efforts to manage infectious and non-communicable disease? At an International Diabetes Federation meeting in Montreal just a few months ago, one of the speakers gave these figures, that the World Health Organization in the 2008-2009 period spent $1.6 billion on infectious disease control. It's an important area, certainly, but in contrast, less than $200,000 in the control of non-communicable disease. This was a figure that I didn't believe. When I'd show this slide, people would say, "That can't be right." So we actually looked it up right to the accounting pages and these are correct figures. 

Another phrase that stuck with me was, at this meeting, this diabetes meeting, the UN secretary general said that the increase in non-communicable disease is a public health emergency in slow motion. That it doesn't quite get the reaction that you can get when people certainly are affected by HIV/AIDS worldwide. This is a bit of a complicated slide, but it shows the predicted change in the global burden of disease over the next 20 years or so. And what you will notice is, and I'm not sure if there's a pointer here, but diabetes, ischemic heart disease, cerebral vascular disease are all going to increase. And along with that, you'll notice depression as one of the highest disease burdens worldwide and it's predicted to be very high in the future, and that's measured largely by suicide rates worldwide. And the other thing to notice is that lower respiratory infections and diarrheal diseases, often diseases that affect children most dramatically, are going to drop over the next 20 years. That's good news, to say that it reflects an expectation that child health will improve worldwide, but non-communicable diseases certainly will continue to grow. I use diabetes because diabetes often is a non-communicable disease that is associated with other non-communicable diseases. So about 60% of people that have diabetes also have hypertension, or they have some degree of heart disease. This shows the prevalence of diabetes worldwide and comparing it from 2000 to 2030. 

And you'll see that areas of exponential growth almost are going to be in the developing regions. India right now has the greatest number of people in the world with diabetes in their country, but it's a population of one billion in the country, so it's a lot. Saudi Arabia right now has the highest percentage of adults with diabetes of any country in the world. And the Pacific islands, Nehru and Polynesia, have historically had very high rates of diabetes in their population. So diabetes does occur more in non-Caucasian populations, but it's growing everywhere. We used to think of it as a disease of excess. It's not exactly that anymore. As I mentioned, more will occur in developing areas of the world, and the concern is that these are countries that don't have the resources to put into control or health care systems, that many are bankrupt and have little to invest. We're also concerned that we see diabetes diagnosed in younger people, especially type 2 diabetes. And a lot of this increase worldwide is type 2 diabetes, which is more common than even the type 1 or completely insulin-dependent type. 

When diabetes is occurring in younger people, and we're talking people that are 12 to 20 years old, because of its association with complications the longer you get it, it removes people from their greatest years of productivity, where they can contribute to economies. And that diabetes is associated with complications. It is the most common cause of blindness worldwide, as well as limb amputation and renal failure. 95% of people with diabetes globally don't receive optimal care, and the United States is part of the statistic, that even in the US it's estimated that 30% to 40% of people who have a diagnosis of diabetes never receive diabetes education. And what has gotten more attention recently globally is the link between depression and diabetes. I'll show you in a second the increased risk of just being depressed with any chronic condition. Now, why is late diagnosis a problem? Retinopathy is a disease of small blood vessels and it occurs all over the body when you have diabetes, and it causes something called neuropathy, where it reduces the blood supply to nerves so you develop numbness of your feet, lack of sensation, which puts you at risk for developing sores that you don't know about until they're infected. This study was data from something called the Longitudinal Retinopathy Study done in Beaver Dam by Dr. Ron Klein and his wife. 

They're ophthalmologists at Wisconsin, and it's quite famous in the world because of the finding that even in Beaver Dam, Wisconsin, which most of this data is from, it shows that most people have already had diabetes for about six and a half years before they're diagnosed, before their symptoms bring them to a health care facility where they have a blood sugar test. And what this shows is, already at the time someone was told, the day they were told they had diabetes, retinopathy is already beginning to develop. And as I mentioned, with that being untreated, it can be a cause of blindness or reduced vision. This is the slide that shows the connection between diabetes and depression, where the small bar is where you have no diabetes, no depression. This is mortality data from about a half a million people based from US data. The mortality rate goes up if you have depression. It goes up even higher if you have diabetes. But if you have the combination of diabetes and depression, death rates go up significantly. What causes this increase? Is it because you're losing interest in self-care? 

Is it because of some biological mechanisms? We really don't know the answer, but we know there's a very strong association. But most of my work in diabetes is in the developing country, and I'd like to just give you this global view. There are different types of diabetes, as I mentioned. Type 1 is the insulin dependent, that you lose your ability to produce insulin at all. Type 2 diabetes is diabetes where you have some insulin to produce, but it's not enough and your body also becomes resistant to the insulin that you do produce, so your cells don't lose it. That is the most common form of diabetes. There is also malnutrition-related diabetes, and tropical diabetes, or calcific pancreatitis. So in the developing world, type 1 diabetes is less commonly diagnosed. It's usually diagnosed in children. 

The data on this is not very optimistic, that a child living in the developing country who's diagnosed with type 1 diabetes has a life expectancy of about one year. The reason for that is very simple and yet very profound, is a lack of access to insulin. And luckily, there are declarations by the World Health Assembly that insulin is an essential drug. There are programs right now, one being launched called Life for a Child, where there's a commitment worldwide of a number of partners to provide insulin to children all over the world. One of the problems with that program is that you get it until you're 18. After 18, you still need insulin, we need to figure out how to get it to them. Diabetes type 1 requires insulin shots, it requires monitoring your blood sugar, and it can be very difficult when you don't have monitors, and when you don't have people that can help you manage diabetes, because health care providers in developing countries, this was never the top of their list of medical school or nursing school topics, because it was not a common disease. I should say that a lot of people often, when we go for self-monitoring or talk about that, there are a lot of glucometers where you can do it at home, and many people donate glucometers. I've been to hospitals in Vietnam where they've had an entire wall of a supply room with glucometers, but there are no strips, so people can't use any of these. Or someone donates strips that don't fit the machines they have. 

So it can be quite complicated. Type 2 diabetes is the most common form, and the causes of this world pandemic, and the data show that it is a pandemic, has to do with some very simple, really simple factors. One is diet, and physical activity. The dietary factors have been called Westernization of food around the world. That worldwide people are eating more refined sugars, more calorie-dense food, and more prepared and convenient food. I've been working in Vietnam with nurses for 30 years and when we teach a class, our tea break would include green tea and fruit in season. The last time I was there about three years ago to teach a course in diabetes management, when we had our tea break, we were given little foil packages of tea and coffee that already had powdered creamer and sugar added to them, and our snack were little Hostess cupcakes. 
(laughter)
 And one of the nurses, I said, "What happened to the fruit and the green tea?" She said, "Oh, this is so convenient. 

Isn't this neat?" I said, "It's neat, but it has all this sugar in it that we wouldn't really want to have." People are less physically active. And you'd say, how can this poor Ugandan farmer or somebody in Vietnam rice fields be less physically active? Well, a lot of people are leaving the rice fields and they're leaving the farms. And there's a massive migration to urban areas for jobs. What are the jobs? The jobs are being a taxicab driver, being a clerk in a store, jobs that are relatively sedentary, and people don't get adequate physical activity. It's even estimated that by 2020, which isn't that far away, about 75% of Africans are going to live in urban areas. So it's not this agrarian society in developing countries. 

There are also a lot of cultural beliefs about food. For example, in Uganda, where I try to talk to people about food, but sometimes our understanding is very different about, what kind of insects do you eat? Do you eat white ants or grasshoppers? When I order food if I go to a cafeteria and I'd say, "Green vegetables and maybe some beans," and the waitress would say, "Well, what kind of food do you want?" And I said, "This is food." She said, "No, I mean food. Real food, like potatoes, rice, matoke." Food really is carbohydrates. And some people will even say, why are you eating all those green vegetables? Vegetables are for sheep and the animals, they eat it in the field. 

We want our carbohydrates and our meat. Some of the cultural beliefs are that fat is beautiful. And when you are in cultures where there's been long-term deprivation and poverty, to be robust shows that you eat well and have money. In parts of Uganda, they literally put new brides, for a month, they force feed them with dairy products so they might gain 20 or 30 pounds in a period of a month to be ready for marriage. Exercise also has a lot of cultural aspects to it. That in some cultures it's not very ladylike to run or to be out in physical activity. And how do you do this with the kind of traditional guard that it's not okay to wear pants or shorts or clothing that would facilitate exercise? Exercise can be very challenging in tropical climates. When you're in Vietnam, you wake up at 4:30 in the morning. From 4:30 to 5:30 is when everybody's exercising out in the parks. 

By 6:00 there's too much traffic and it's already about 95 degrees, so you can't do it. And in some areas, it's not safe to be outside because of crime or even the natural environment. Medications for diabetes and type 2, usually people can be controlled with oral medications, but in many parts of the world, these are in limited supply. There are a lot of counterfeit drugs made so when people do buy them they may not be getting the potent version of the medication. People that are very poor might try to ration their medicine. When I was on sabbatical two years ago in Uganda, I worked as a nurse in a clinic. And I'm a nurse practitioner and I'm used to prescribing drugs and I was always amazed at how the physicians would say, "This is the simple clinic where we let the nurses manage it." And you see a woman who's pregnant, who's diabetic, and "How much insulin do I need? I've been cutting mine in half for the last month because I'm afraid I'm running out of money. And I can't monitor my blood sugar, and I really have no idea what to do." 

In those situations, you don't have the tools that you would in this country. Most people in most countries I've visited use traditional medicine before they go to the Western medicine. So they've tried herbal teas and other treatments that they think might help, and often they just delay care. And there's often, this is probably universal, fear of getting injections. And fear of insulin, that's a very potent drug, that can kill you, but it can also keep you alive and going. And in many parts of the world, there's still a great stigma to having something wrong with you. That if you have diabetes, nobody will marry you. You won't be able to have children. You're not going to be employed. Because your physical fitness is such a part of what you can contribute to your family's economy. 

It can be even a reason that people get divorced, that they have an existing condition. Malnutrition-related diabetes occurs when there is not enough food. It's protein and calorie, people are underweight, there's insulin resistance developed, and it occurs largely in developing areas of the world. Another type of diabetes is called "tropical diabetes," sometimes people call it "rice-induced." But actually it occurs in younger people who have a history of poor nutrition. They have very high blood sugars and they develop calcification and abnormality of their pancreas. And what's believed to contribute to this is diets high in cassava. And cassava is a root vegetable that is pretty much carbohydrate. And it's fine to eat if you can balance it with protein. But when it is just eaten without protein, the metabolic breakdown has a cyanide effect, essentially, on the pancreas and literally poisons the pancreas. 

And this is found a lot in the Caribbean, as well as Africa and Asia. Now, what is the big problem? The big problem with diabetes globally is that health systems aren't designed to manage chronic disease. They manage acute care. That diabetes is largely caused by lifestyle. And lifestyle is not something that you often go to the doctor for, that's something you have to do on your own. And that chronic disease worsens poverty. And many countries worldwide, and the World Health Organization has management of chronic disease as a very high priority of world health, and it's not only because they're so worried about health, but it really is devastating to economies and economic growth if you have a population in poverty not able to work at their highest productivity level and affected by this at very young ages. So it's kind of the perfect storm of effects. Epigenetics comes up a lot in this discussion of diabetes. 

And what epigenetics says is, we have genetic predispositions to be a certain way, but these genetic predispositions can be altered by the environment we're in. That different gene expressions will occur affected by environment. There's something, this Dr. Barker, it's a Barker hypothesis that's referred to often, that deprivation in utero really leads to increased metabolic disease in adulthood. And he did studies to show that low birth weight babies who gained weight very rapidly, and that was seen as a sign of health and recovery by many people, showed that those people followed into adulthood had higher rates of cardiovascular disease and obesity. And his hypothesis was that this rapid growth rate was a metabolic disorder that was going to continue in adulthood. I also like this quote from an article that I read, that "Children in utero experience an environment of low nutrition and find themselves in a land of plenty. Epigenetic software is programmed for one scenario but encounters another, often with disastrous results. " And I would say that my work in Vietnam is a good example of this. Historically and especially post-war, post-Vietnam War, Vietnam was a population in mere starvation for at least about 25 years. 

And those women who were pregnant were probably not getting good nutrition during pregnancy. Then Vietnam experienced this rapid economic growth over the last 20 years or so. And along with this, importing more Westernized food, reduced physical activity with urbanization, that diabetes is a growing problem. In Vietnam, it's not associated with obesity. People are still of normal weight, but even normal weight in a population historically deprived of food is more than they would be expected to weigh. And it's not just Western food that causes the problem. Vietnamese food, the staple food is pho. This is pho ga, which is chicken soup. And they talk about how this is 458 calories. Then this is rice noodle soup, and it has about the same number of calories, but a little bit more. 

But now more of this pho is being supersized, so that even if you eat the traditional, very healthy chicken noodle soup, you're still getting about 20% more calories than you were 10 or 15 years ago before supersizing was a concept in food. In Uganda, Uganda's an interesting place, it's a very fertile land. It has the ability to grow lots of food, but the diet is predominantly carbohydrate. Matoke is a plantain that is steamed. And this is a pile of it on the dish here. That's a very modest pile, because we were at a fancy restaurant that served food where we took this plate. But if you even look at what's on this plate, the vegetable is a slice of avocado and a little bit of this green stuff. Otherwise, it's rice, matoke, potato, pocho, cassava. It's "food." 
(laughter)

 And with these foods, frying is a common way to cook it in countries where fuel is at an economy, you have to cook food fast. This to me is a perfect example of lifestyle. We think about the Asians riding bicycles, certainly Vietnam. This was in 2003, an article about how bicycles are being banned in Beijing because they can't handle the traffic anymore. What can we do to control this? We need to change health care systems worldwide. I've listed here some of what we call "paradigm shifts," or real fundamentally different ways that we have to think about what health care people are going to need. Much more of it has to be this activated patient that knows what to do for themselves. To enter in early so that we can prevent complications and to engage an entire team of people. In diabetes management in the US we count on dieticians. 

There are no dieticians in Uganda or Vietnam. They are not clinical disciplines. It's basically the doctor and the nurse that are there to deliver care. And more of the care is going to have to be given in the community. Now I'd like to talk about some of my research. I'm doing research under a grant program called Peers for Progress in Diabetes. It's being funded by Eli Lily, which is a drug manufacturer, and they manufacture insulin. And the mission of this grant program is to demonstrate the role of peer support managed diabetes around the world. And they funded 14 grants right now, worldwide, and our grant happens to be one of them in Uganda. Part of this peer support for diabetes worldwide is also to acknowledge the fact that we have a shortage of health care workers in the world. 

So as we have more need for continuous care, who is going to be delivering that care? And it can't be doctors and nurses because there aren't enough of them at this point. This is a picture of a program in Cambodia that's very successful. And it's where peers are trained to be advocates for patients. Even with patients in their community, when they go to a clinic, to even encourage people to check them for diabetes, which often is not done. In Uganda, diabetes affects about 4% of the population in adults. This is compared to about 12% of the population in the United States, but we anticipate growth. It's diagnosed late and a concern is, in Africa, the majority of people don't even know that they have it, and there are not many physicians or nurses that really know how to manage this and there aren't screening programs to identify it early. The goals of our intervention were to enhance social support and emotional well-being, to encourage people to engage in self-care, to improve their metabolic control or their blood sugar, as well as to enhance their linkage with the health care system. To make it more timely that they get care when they need it. 

This is what diabetes self-care involves, and this 8,760 are the number of hours per year that somebody with a chronic disease is not in a doctor's office. So it's really up to them to implement a lot of this on their own and to do it completely on your own is difficult. We want to provide education and other kinds of support. We picked a rural community in Uganda, Mityana, which is west of Kampala, for our study because there weren't other researchers there. We met with some of the community leaders and they were interesting. They said that they'd met many researchers from the United States and told us all the funny stories of, they'd come in and one group from Johns Hopkins put Xs on doors in the community and didn't tell anybody what that was and everybody was questioning what that was, and they figured the way to respond to that was, they went and X-ed every door in the community the next day and the Johns Hopkins people didn't know what to do. So we did meet with people. This is the district hospital. It's quite small and quite poorly supplied. The program that we had, we identified people who went to this clinic who had diabetes. 

And they were either partners or champions. And partners were given education. Champions were given education, plus some instruction on therapeutic communication. And they were going to, over this four-month period, contact each other either by telephone or in person. And the cell phone, as you might know, everyone in Africa has a cell phone. But they don't have any money to use it. So in our study we were able to pay for free airtime so people could talk to each other and call the clinic without paying. And in one of our final evaluations, one man was just amazed, he said what he learned is that he could have a normal conversation on a telephone, that he talked for 20 minutes to his friend and never even looked at his watch to see how much airtime he was using. So we wanted people to talk about just daily problems they encountered, to provide some support, and to be encouraging to them. They were not there to deliver health care. 

This is one of our peer education classes, and this is Dr. Agatha Nambuya, who is a Ugandan physicians who is one of the leading experts in diabetes in the country. The communication skills we trained people in were really to be very supportive. Ask an open-ended question, "How are you feeling today?" Be a good listener. Provide messages that say, "You can do a lot. You can improve. Things will get better." And not to be unrealistic. So we tried to recruit about 30 people in each of these groups and we didn't recruit as many champions. 

Sometimes when you do research you encounter the unexpected. There happened to be a national road rally that day that blocked off all the roads to the place that we were having our meeting and so a lot of people couldn't get there, but we managed to retain most of the people that did join us throughout the grant period. The participants, the profile is here. People did have diabetes for an average of about six years. The only difference between our champions and our partners were the champions had higher education level. And this was expected because we did a lot of our materials in English, and the champions had to be able to read English, so they most likely had more education. We were able to get people to participate. They contacted peers, most of them did it weekly. Most of them did it over the telephone. And they also called the clinic nurse. 

And to just give you an example of what this means to somebody, a man was telling us that he was in his hut, his leg was swollen, that if he didn't have that phone, he would've had to get on a public taxi, probably travel three to four hours to the clinic, wait to be seen, and then have that journey home, which would have cost him money. He was able to call the nurse on the phone. She gave him some advice and said if he didn't get better to come to the clinic, and he said in two days he was better. And he said, "I got treated from my hut." It was an amazing experience for him. We were lucky enough in this community to work with a group of people who had been trained in another program to manage diabetes, some nurses and lab technicians. We also found that most people don't monitor blood sugar and that medication access was very difficult for most people. We also noticed that the physical space to come to this clinic was grossly inadequate. This is where people waited, and it was in the sun, it was exposed to rain. This was the clinic. 

And when it rained, everything had to be covered in plastic because it just poured on things. And so the people felt that even just the diabetes resources meant that there was not importance to this problem. I'm going to show you some of the results. I've highlighted those that are significant differences, but to note that we actually, over four months, reduced people's confidence and reduced their sense of helpfulness from their family and friends. Now, this was not what we wanted to do, but our explanation is, we provided a lot of education that they didn't have, and made them aware of the many things that needed to be done in self-care that may have made them wonder, "Can I do this all?" And because we were introducing this peer program, they really relied less on their family for some of their information. We got people to report that they dramatically changed their eating behavior. Whether this really happened or not, I don't know. And what was really impressive is that over this just four-month period, people's blood sugars improved significantly, as well as their blood pressure dropping. So as somebody said, just emotional support can make a difference in some of these health outcomes. 

When we asked people what was helpful, these are some of the things they mentioned. Many patients have never had written information about diabetes before. They appreciate the encouragement. One man said, just to read in the book that it says, "You are not alone with diabetes," was very emotional to him. That was the first time it was explicitly said. We found that both champions and partners were equally helpful and equally had questions, so making somebody a champion, we're not sure that we'd do that again. And the cell phone network was amazing. And if you look at research on using the cell phone for health care delivery in HIV/AIDS, in diabetes, in reducing risky behavior, it's very successful in the most developing areas of the world. And one has to wonder, how can that system be incorporated in delivering health care. To use technology that's available. 

In doing this research, I ran into a lot of issues and I could probably give a lecture on each of these topics. But one of the things I wanted to just emphasize are some of the ethics of research and doing it in developing areas. We're very vigilant about IRBs, the Institutional Review Boards, to protect the rights of human subjects, that they consent to participation, they know what's going on. That we strive for consistency. Two countries had to approve this study. But what we were encountering in the clinical setting is, there is no ethical standard that's violated when people that have diabetes don't have access to drugs. When they don't have access to health care providers who could help them save their lives, save their vision. And it's a dilemma. It's something I think the world has to address as we move on. And finally, when we first met with our community, they said, so many researchers have come here and done studies and told us how it's going to help them, and then they're gone, and could you please leave something concrete behind with this study? 

So we literally bought a lot of concrete and the hospital donated this end of a ward that they weren't using, and we had it remodeled. We created consulting rooms. We developed this Mityana diabetes clinic. Here is the lab tech drawing a blood sample. And now what's really neat is that this porch that was built now has shelter, they can be out of the rain and the sun, and they have diabetes education classes here. And this is the group, our partners, our champions, and the health care workers that helped make this project possible. So thank you. 
(applause)