Tertiary prevention programs aim to improve the quality of life for people with various diseases by limiting
complications and disabilities, reducing the severity and progression of disease, and providing rehabilitation (therapy to restore functionality and self-sufficiency). Unlike primary and secondary prevention, tertiary prevention involves actual treatment for the disease and is conducted primarily by health care practitioners, rather than public health agencies.
Tertiary prevention efforts have demonstrated that it is possible to slow the natural course of some progressive diseases and prevent or delay many of the complications associated with chronic diseases such as arthritis (inflammation of the joints that causes pain, swelling, and stiffness), asthma (inflammation and obstruction of the airways that makes breathing difficult), heart disease, and diabetes.
Tertiary Prevention of Diabetes
Insulin is a hormone produced by the pancreas to control the amount of glucose (sugar) in the blood. Diabetes mellitus is a disease in which high blood glucose levels result from insufficient insulin production or action. When there is not enough insulin produced, the body is unable to metabolize (use, regulate, and store) glucose, and it remains in the blood.
Type 1 diabetes mellitus (also called insulin-dependent diabetes or juvenile-onset diabetes) occurs when pancreatic beta cells, the cells that make insulin, are destroyed by the body's own immune system. It usually develops in children and young adults. Because people with diabetes do not have enough insulin, they must be injected or inject themselves with insulin several times a day or receive insulin via a pump. About 5 to 10 percent of all diagnosed cases of diabetes are type 1.
Approximately 90 to 95 percent of all diagnosed cases of diabetes are type 2 diabetes mellitus (also called non–insulin-dependent diabetes or adult-onset diabetes). Type 2 diabetes occurs when the body becomes resistant to insulin. As a result of the cells being unable to use insulin effectively, the amount of glucose they can take up is sharply reduced and high levels of glucose accumulate in the blood.
People who are older than age forty, overweight, have a family history of diabetes, and are physically inactive are at greater risk of developing type 2 diabetes. (Figure 2.4 shows the increased prevalence of diabetes with age.) African-Americans, Hispanic/Latino Americans, Native Americans, and some Asian Americans and Pacific Islanders are at greater risk for type 2 diabetes. (See Figure 2.5.)
Approximately 1.3 million new cases of diabetes were diagnosed among Americans aged twenty years and older in 2002, and the incidence of type 2 diabetes is increasing among people of all ages, including children. (See Figure 2.6 and Figure 2.7.) Many people with type
Prevalence of diabetes in people aged 20 years or older, by age group, 2002
2 diabetes are able to control their blood sugar by losing excess weight, maintaining proper nutrition, and exercising regularly. Others require insulin injections or orally administered (taken by mouth) drugs to lower their blood sugar.
Other types of diabetes can occur as a result of pregnancy (gestational diabetes) or physiologic stress such as surgery, trauma, malnutrition, infections, and other illnesses. These types of diabetes account for about 5 percent of all diagnosed cases of the disease.
A major public health concern is that 5.9 million Americans are not aware that they have diabetes. The number of adults in the United States with diagnosed diabetes (including women with gestational diabetes) has increased 61 percent since 1991 and is expected to more than double by 2050.
COMPLICATIONS OF DIABETES.
People with diabetes are about twice as likely to die at any given time than people without the disease, but the risk of death from diabetes is even greater for young adults than older adults. Persons with diabetes who are age twenty-five to forty-four are at 3.6 times greater risk than those age sixty-five to seventy-five (who are at 1.5 times greater risk than people in the same age group without diabetes). In 2001 diabetes was the seventh leading cause of death among all age groups. (See Table 1.15 in Chapter 1.)
Age-adjusted prevalence of diabetes in people aged 20 years or older, by race/ethnicity, 2002
Adults with diabetes suffer from heart disease at much higher rates (two to four times higher than people without diabetes)—in fact, heart disease is the number one cause of death among people with diabetes. Similarly, adults with diabetes are also at increased risk for stroke (damage to the brain that occurs when its blood supply is cut off, frequently because of blockage in an artery that supplies the brain) and hypertension (nearly three-fourths of adults with diabetes have high blood pressure). Other serious complications of this disease include the following:
- Diabetic retinopathy—a condition that can cause blindness
- Diabetic neuropathy—damage to the nervous system that may produce pain or loss of sensation in the hands or feet and other nerve problems
- Kidney disease—diabetes accounts for almost half of all new end-stage renal disease cases that require dialysis (mechanical cleansing of the blood of impurities) or kidney transplant
- Amputation—diabetes is responsible for more than half of all lower-limb amputations (surgical removal of toes, feet, and the leg below the knee) performed in the United States
- Dental disease—gum diseases are common among people with diabetes, and nearly one-third of all people with diabetes have severe periodontal (tooth and gum) diseases
- Problems with pregnancy—diabetes may cause birth defects, spontaneous abortion (miscarriage), and excessively large babies that may create additional health risks for expectant mothers
Number of new cases of diagnosed diabetes in people aged 20 years or older, by age group, 2002
- Increased risk of infection—people with diabetes are more susceptible to infection and do not recover as quickly as people without diabetes
Further, poorly controlled or uncontrolled diabetes may produce life-threatening medical emergencies, such as diabetic ketoacidosis (excessive ketones—chemicals in the blood resulting from insufficient insulin and an excessive amount of counterregulatory hormones such as glucagon) or hyperosmolar (extremely high blood glucose, leading to dehydration) coma.
Achieving optimal control of blood glucose levels can prevent many of the complications of diabetes and decrease the risk of death associated with the disease. Optimal control involves aggressive treatment of diabetes with close attention to the roles of diet, exercise, weight management, and pharmacology (proper use of insulin and other medication) in self-management of the disease.
PREVENTING COMPLICATIONS OF DIABETES.
According to the CDC, diabetes researchers have determined that even modest improvement in controlling blood glucose acts to help prevent diabetic retinopathy, neuropathy, and kidney disease. Reducing blood pressure has the potential to reduce cardiovascular complications (heart disease and stroke) by as much as 50 percent and to reduce the risk of retinopathy, neuropathy, and kidney disease by almost one-third. Lowering blood cholesterol (a waxy substance
Percentage of adults with diagnosed diabetes, by state, 1990, 1996, and 2001
produced by the body and also found in animal products), low-density lipoproteins (LDL), and triglycerides also reduces, by as much as 50 percent, the cardiovascular complications of diabetes. (Cholesterol, LDL, and triglycerides are lipids that may be measured in the blood.)
Early detection and treatment of diabetic eye disease can reduce the possibility of blindness or serious loss of vision by about 50 percent. Similarly, early detection and treatment of kidney disease sharply reduces the risk of developing kidney failure, and careful attention to foot care reduces the risk of amputation by as much as 85 percent.
To help increase early detection of diabetes (secondary prevention) and reduce the morbidity (illnesses) and mortality (deaths) associated with it (tertiary prevention), the CDC and National Institute of Diabetes and Digestive and Kidney Diseases of the NIH launched the National Diabetes Education Program (NDEP) in 1998. The NDEP's objectives are to increase public awareness of diabetes, improve self-management of people with diabetes, enhance health care providers' knowledge and treatment of diabetes, and promote health policies that improve access, availability, and quality of diabetes care. To meet these educational objectives, the NDEP, working with a variety of other health organizations, develops and distributes teaching tools and resources.
Print advertising and patient education materials developed by the NDEP focus on personal responsibility for self-management of diabetes. For example, one 1999 print advertisement was translated from Spanish into English after it proved tremendously successful in Hispanic/Latino communities. The ad featured a photograph of a lightning bolt next to the heading: "There are many things in life that can't be controlled. Fortunately diabetes isn't one of them."
Prevention research centers and their research focus
|University of Washington at Seattle
||Keeping older people healthy and independent through community partnerships
|University of California at Berkeley
||Engaging families, neighborhoods, and communities in chronic disease prevention
|University of California at Los Angeles
||Promoting the health and well-being of adolescents
|University of Arizona
||Promoting the health of multi-ethnic communities of the Southwest
|University of Colorado
||Promoting healthy lifestyles in rural communities
|University of New Mexico
||Promoting healthy lifestyles in American Indian communities
|University of Oklahoma
||Promoting health and preventing disease in Native Americans
|University of Texas Health Science Center at Houston
||Growing from healthy children to healthy adults
||Preventing environmental diseases
|Saint Louis University
||Preventing chronic disease in high-risk communities
|University of Iowa
||Improving the health of rural Iowans through nutrition and exercise
|University of Minnesota
||Preventing teen pregnancy and promoting healthy youth development
|University of Illinois at Chicago
||Controlling diabetes in communities
|University of Michigan
||Improving health in partnership with families and communities
|University of Kentucky
||Controlling cancer in central Appalachia
|University of Alabama at Birmingham
||Reducing health risks among African Americans and other underserved people
|Morehouse School of Medicine
||Promoting risk reduction and early detection in African American and other minority communities: coalitions for prevention research
|University of South Florida
||Using community-based prevention marketing for disease prevention and health promotion
|University of South Carolina
||Promoting health through physical activity
|University of North Carolina at Chapel Hill
||Improving community health through workplace health promotion
|West Virginia University
||Promoting health and preventing disease in rural Appalachia
|University of Pittsburgh
||Promoting health and preventing disease among older adults
|The Johns Hopkins University
||Promoting the health of adolescents through families and communities
||Putting health promotion into action
|State University of New York at Albany
||Preventing chronic disease through community interventions
||Creating innovative public health initiatives
||Improving the well-being of public housing residents
||Promoting nutrition and physical activity among children and youth
SOURCE: "Prevention Research Centers, Research Focus," in Prevention Research Centers: Linking Science to Practice 2003, Centers for Disease Control and Prevention, Atlanta, GA [Online] http://www.cdc.gov/nccdphp/aag/pdf/aag_prc2003.pdf [accessed January 28, 2004]
The 148-page NDEP patient information book also emphasizes the importance of self-care in the prevention of complications of diabetes. For example, the section on foot care explains, "There's a lot you can to do prevent problems with your feet. Controlling your blood glucose and not smoking or using tobacco can help protect your feet. You can also take some simple safeguards each day to care for and protect your feet." The section goes on to explain the importance of self-care habits such as having one's feet checked, washing them carefully, trimming toe-nails, taking care of corns and calluses, protecting feet from heat and cold, wearing shoes and socks, and remaining physically active.