FREDD: First Response to Eating Disorders and Diabetes

SarahBlennerBy Sarah Blenner, JD, MPH

Approximately one out of every 300-400 high school-aged children has diabetes and 151,000 youth under the age of 20 have diabetes.  A person with diabetes must carefully balance food, insulin, and activity levels to keep blood glucose levels within a normal range.  Yet girls with type 1 diabetes are more likely to develop an eating disorder or engage in disordered eating behaviors than their peers.  To address this issue, the IIT Center for Diabetes Research and Policy conducted training sessions across the Chicagoland area during National Women’s Health Week.

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Diabetes on the Go

SarahBlennerBy Sarah Blenner, JD, MPH

If you’ve travelled lately, you know the drill.  You pack your carry-on bag, making sure not to bring any liquids or gels that are in a container larger than 3.4 ounces.  You put the small containers of liquid in one plastic Ziploc bag that is easily accessible so that you can take it out quickly when going through security at the airport.  You know to bring shoes that you can easily slip on and off.  Perhaps, you even avoid wearing any metal or jewelry.

However, for someone with diabetes, extra precautions need to be taken.  Diabetes is a chronic health condition that must be managed throughout the course of the day, including in the security line.  And a person with diabetes has to be prepared at all times to deal with high and low blood glucose levels—meaning, they need to have supplies such as insulin and glucagon with them at the airport.

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You are What You Eat: Vulnerable Populations, Access to Healthy Foods, and Diabetes

SarahBlennerBy Sarah Blenner, JD, MPH

As the saying goes, you are what eat.  If that’s the case, what are we? Fat and sweet.  The American diet derives approximately 40% of its daily energy from added sugars and fats.  In 2000, low cost potatoes (i.e. potato chips), canned tomatoes, and lettuce constituted 48% of the average American’s total vegetable intake.  It has been well established that poor diet directly correlates with chronic health conditions, such as diabetes and cardiovascular disease.  A disproportionate amount of individuals who are obese or have diabetes and other chronic health conditions are of lower socioeconomic status. Thus, financial constraints coupled with the availability of healthy food options in certain communities play a major role in determining a person’s diet.  In combating what many have termed “the obesity epidemic” and the skyrocketing rates of diabetes (which is estimated to double or triple in the next 40 years), we must cater food policies towards at-risk populations.  Specifically, it will be important to look at food policies geared towards programs which have a significant impact on these populations, such as food stamps, food pantries, and school lunch programs. 

Recently, while sitting in a food pantry, I overheard several women talking about their strategies for getting food.  The women were complaining about the insufficient amount of money they received on food stamps and discussed strategies for stretching food stamps to bring home the most amount of food.  One woman expressed her preference for purchasing hotdogs over healthier options, exclaiming that she makes her decisions based on the maximum quantity of filling foods for the lowest possible cost.

It turns out that individuals like the women I overheard talking in the food pantry are making logical decisions about feeding themselves and their families.  Better to eat unhealthy foods than eat healthy and suffer the consequences of hunger.  Studies have shown that individuals who receive assistance from food pantries, meals on wheels, food stamps, or other forms of food assistance are more likely to face “food insufficiency” (not having enough food to eat because of financial constraints) than other populations.  This can have a serious impact on the health and well-being of individuals with chronic health conditions, such as diabetes.  For example, one study that analyzed hospitalizations at a particular urban hospital found that about 30% of the hospitalizations for individuals with Type 1 diabetes that were due to low blood sugar levels occurred because the individual could not afford to eat.  Another study conducted in Georgia found that elderly individuals who receive or are on the wait list to receive meals delivered to their home are significantly less likely to properly manage medications, which can have a devastating effect on the management of chronic health conditions like diabetes.

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Watch out Produce Aisle, Here Comes Dad!

SarahBlennerBy Sarah Blenner, JD, MPH

Diabetes and obesity are serious health problems that are affecting an increasing number of Americans of all different ages.  The Center for Disease Control and Prevention (CDC) recently estimated that, based on existing trends, the prevalence of diabetes could increase from 1 in 10 adults to 1 in 3 adults within the next forty years.  This means that the CDC expects the number of people with diabetes to either double or triple by the year 2050.  While there is no single known cause for either type 1 or type 2 diabetes, there are a variety of widely accepted risk factors associated with both forms.  For example, type 2 diabetes risk factors include, but are not limited to: age, race/ethnicity, body mass index (BMI), activity levels, and family history.  Recent studies suggest that breast size, eyebrow color, and short stature might also be associated with an increased risk for diabetes. 

A recent study conducted on rats has even suggested that if a dad-to-be eats a lot of foods that are high in fat before his child is conceived, then he is more likely to pass the risk of diabetes and obesity on to his daughter.  This study might be the only one of its kind to report that a father can pass along a risk factor associated with diabetes that is not inherently genetic.  Although the study was conducted on rats, the researchers hypothesized that the conclusions of the study might be congruent in human populations, since obesity in men affects sperm function, sperm mobility, and the amount of DNA damaged in sperm.  If in fact the findings of this study are applicable to people, there may be some serious implications for future generations, as thirty-four percent of adults are considered obese, an additional thirty-four percent of adults are considered overweight and the rates of diabetes in the adult population are drastically rising. 

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Health Impact Assessments: A Policy Tool for Health Reform through Prevention and Planning

SarahBlennerBy Sarah Blenner, JD, MPH

Tamar is a sophomore in high school and plays on the school’s water polo team.  Her team practices in the swimming pool after classes are over for the day.  Following practice, when Tamar takes public transportation home, she has to transfer at two different bus stops before making it home.  Formerly, the trip lasted 45 minutes, but with recent reductions in bus service, the trip now lasts an hour and a half, leaving Tamar less time to complete her homework.  Tamar now has to wait longer on street corners at night, where she is increasingly exposed to a variety of negative elements such as extreme weather, cigarette smoke, gang violence, potential sexual assault, and the use of drugs by the people around her.  Longer exposure to these risks may increase her chance of engaging in behaviors that will negatively affect her health.  Had the policy implementing the bus cuts been subject to a formalized planning process that evaluated future impacts on the health and safety of those who use the public transit system, recommendations may have been implemented including maintaining frequent bus routes in critical neighborhoods or when students who participate in after-school activities are leaving school.

There are many factors that contribute to our health, such as individual behavior, societal influences, genetic predisposition, health care, and the physical environment.  In order to improve our health or the health of our communities, we must address these factors.  For one, environmental exposure can occur both through direct and indirect exposure.  Direct exposure occurs when an individual comes into contact with toxins, e.g. chemicals found in paint, the air, or even baby bottles.  Health can also be affected by indirect environmental factors, such as housing, urban development, land use, and transportation.  Tamar, the high school student who took the bus home from school, will be negatively affected by indirect environmental exposures.

The health of Americans is in need of improvement. According to the Center for Disease Control and Prevention (CDC), 34% of adults are considered obese, and another 34% overweight; 10% of adults in the U.S. have either diagnosed or undiagnosed diabetes; and 7.5% of adults in the U.S. have been diagnosed with asthma.  Former Interim President for Partnership for Prevention Corrine Hudson once said “[r]eal health reform must start with prevention.  Without a much stronger emphasis on prevention than now exists, we have little hope of controlling costs without sacrificing health.”  Health Impact Assessments do just this. Health Impact Assessments have been defined by both the World Health Organization (WHO) and the CDC as “a combination of procedures, methods, and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population.

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Illinois Care of Students with Diabetes Act

SarahBlennerBy Sarah Blenner, JD, MPH

One out of every 400-600 school aged children has type-1 diabetes.  Diabetes is a condition where individuals either cannot naturally produce or cannot properly use insulin.  While the medical complications and threats of low blood sugar levels are often more immediate and apparent then complications and threats of high blood sugar levels, both conditions must be treated immediately to ensure the overall safety and well being of a child with diabetes.  Keeping blood glucose levels as close to normal now will help a child live a longer, healthier life.  Since children spend a large amount of time in school, it is important for these children to control blood glucose levels during school hours.

Healthy People 2010, the U.S. Department of Health and Human Services’ National health objectives, sets a goal to increase the number of schools with a school nurse to student ratio of 1:750.   Healthy People 2010 and the National Association of School Nurses (NASN) also recognize that there are certain situations where more nurses are needed for a smaller student population, such as in situations where many of the students have healthcare needs that must be addressed during the school day. 

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Blood Glucose Monitors: A Sleek 21st Century Look With Nixon Era Accuracy

photo of Professor Ed Kraus GUEST BLOGGER Ed Kraus

It is essential that people with diabetes have accurate tools with which they can effectively manage their disease on a day-to-day basis.  And, despite all the recent technological and scientific advances in diabetes management, it appears that home blood glucose monitors—one of the most commonly used and critical tools for the management of glucose levels—are not keeping pace with the times.

In a July 2009 New York Times article, Gardiner Harris wrote that the Food and Drug Administration (FDA) is considering tightening its accuracy standards for home blood glucose monitors (BGMs).  The article highlights the fact that the FDA has long followed international standards set by the International Organization for Standardization (ISO) which allow for BGMs to be manufactured with an error rate of up to 20%.  While an error rate of 20% may have seemed acceptable or reasonable 10 years ago, given our present-day technology and our current understanding of the clear health benefits of tight control of glucose levels, it is simply indefensible.

To understand why this error rate is unacceptable, it is helpful to consider what a 20% error rate for a BGM actually means for an individual with diabetes.  Let’s take the example of an individual who checks her glucose level and gets a reading of 156 when, in fact, her blood glucose is only 130.  With a reading of 156, she might administer a correction dose of insulin to lower her glucose to a level within her target range.  However, had the BGM accurately displayed her glucose level as 130, she would not have taken any insulin.  This unnecessary dose of insulin could then cause her glucose levels to go too low — meaning below the low end of her target range — and cause her to suffer from hypoglycemia.  Alternatively, if her blood glucose level was actually 160 but the BGM gave a reading of 128, she might not administer any insulin — because she might falsely believe that her glucose level is within her target range.  Failing to administer insulin when it is needed could lead her to becoming hyperglycemic which, over time, can cause serious health complications.

As it turns out, in response to concerns from the American Association of Clinical Endocrinologists regarding BGMs’ accuracy, in June 2009, the FDA pressed the ISO to tighten its standards.  In addition, the FDA has indicated that if the ISO does not act, the FDA will take the initiative itself by requiring higher performance standards for BGMs sold in the United States.  However, as of September 2009, the FDA has yet to do so; rather, it appears that the FDA is still merely commenting on its plans to make changes in some way or another.

It is interesting to consider why there have not been any major improvements in the accuracy of BGMs in the past decade.  BGM manufacturers have improved the technology, aesthetics, and convenience of BGMs since their introduction in the 1970s, but manufacturers have not improved the accuracy of glucose level readings — arguably the single most important feature of a BGM.  As FDA Commissioner Margaret Hamburg has indicated, this is the result of manufacturers’ contentment with meeting the international standard set by the ISO.  But this response begs the question: Why have market forces led BGM manufacturers to improve certain aspects of their products, but not accuracy? After all, most people with diabetes purchase and use BGMs with the goal of closely managing and monitoring their glucose levels, which in turn enables them to minimize the risks of long-term, diabetes-related complications.  Perhaps BGM manufacturers have taken advantage of the fact that individuals easily notice the aesthetic difference between certain BGMs, but that most BGM users likely were never (or still aren’t) aware of the 20% error rate allowed by the FDA?

Whatever the reason for the market’s failure to promote the development of more accurate BGMs, the solution is clear.  Whether by pressuring the ISO or creating its own higher standards for domestic BGM approval, the FDA should act quickly and decisively to put an end to the current tolerance of a 20% error rate for BGMs.

Ed Kraus is an Associate Clinical Professor at Chicago-Kent College of Law.  Professor Kraus focuses part of his practice on representing and advocating for individuals with diabetes in education, employment and insurance matters.

“What if our perception of normal exposure is skewed?”: Analyzing the Science of BPA

SarahBlennerBy Sarah Blenner, JD, MPH

Bisphenol A (BPA) is an estrogen mimicking chemical commonly used to create both polycarbonate plastics and the resin lining of cans.  This chemical can be found in plastic food and beverage containers, cans, dental sealants, household products, cell phones, computers, and medical devices.  Hundreds of studies link the synthetic hormone, BPA, to a variety of adverse health conditions, including, breast cancer, prostate cancer, ADHD, autism, obesity, insulin resistance, type 2 diabetes, liver enzyme abnormalities, early onset of puberty, and cardiovascular disease.

In a study conducted by the CDC, scientists found that BPA was present in 93% of Americans tested, signifying the high prevalence of BPA exposure in the American population.  One participant of the “Is It In Us?” study, which measured the presence of toxic chemicals, such as BPA, in the blood and urine of participants, was relieved to know that her results were no different than the results of most of the other participants.  But then she thought: “what if our perception of normal exposure […] is skewed?

Last May, Chicago became the third jurisdiction in the United States to successfully pass legislation regarding Bisphenol A when it banned the sale of baby bottles and other empty food and liquid receptacles intended for the use by children under the age of three.  Prior to Chicago City Council’s passage of the BPA Free Kids Ordinance, the State of Minnesota and Suffolk County New York passed legislation regulating BPA.  In June, Connecticut became the fourth jurisdiction in the United States to address the health risks of BPA through legislation, when it passed an “Act Concerning Banning Bisphenol-A in Children’s Products and Food Products.”  According to the Public Act, beginning October 1, 2011, the sale of infant formula, baby food, and reusable food or beverage containers that contain the chemical Bisphenol A will be banned.

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Judge Sotomayor

JulieBergerBy Julie Burger

The headline of a recent Time Magazine story about President Obama’s U.S. Supreme Court nominee asked, Sotomayor’s Diabetes:  Will it Be a Handicap?

The authors seem to be asking whether Judge Sotomayor’s type 1 diabetes will be an impediment to her confirmation.  Although many news stories about Judge Sotomayor mention that she was diagnosed with the disease at age 8, most commentators and experts believe that the disease will not negatively impact her ability to be a justice on the Supreme Court.  The disease is serious, raising the risk of heart disease, blindness, amputation, and kidney problems.  And yet, if well-controlled, people with diabetes can live long and productive lives.  There is no reason Judge Sotomayor’s diabetes should prevent her from being qualified to sit on the Supreme Court.

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Wheels of Justice Grind Slowly for Havasupai Tribe

JulieBergerBy Julie Burger

In a remote section of the Grand Canyon about 450 members of the Havasupai Tribe live on tribal lands where they have lived for hundreds of years.  Another 200 members of the Tribe live away from Supai, the village area.  In March of 1990, researchers from Arizona State University (“ASU”) (Drs. Theresa Markow and John Martin) presented the Havasupai Tribal Council with a proposed diabetes study, saying that they would like to collect and use tribe members’ blood for diabetes studies.  The researchers met several times with the Tribal Council, but according to allegations, never revealed they intended to perform research other than diabetes research.  With the Council’s approval, blood samples were collected from members of the Tribe, including children and vulnerable people.  Researchers additionally took handprints from members.  English is not the tribal members’ primary language and many members do not even speak English as a second language.

The researchers did not stop at diabetes research.  They also performed additional research on the samples for schizophrenia, inbreeding, and population migration, and shared the samples with researchers at other institutions.  After discovering the additional research, the Havasupai filed state court complaints on behalf of individual Tribal members and on behalf of the Tribe against ASU and the researchers in 2004.  The Havasupai maintain that the schizophrenia and inbreeding research was stigmatizing and that they would not have consented to the migration research because it conflicts with their religious origin theory.  A member of the Tribe points out that “[the researchers] challenged our identity and our origins with our own blood and without telling us what they were doing.”

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