What required insulin injections, individuals diagnosed with T2D

What is

Diabetes is a
chronic condition that occurred when the pancreas does not produce enough
insulin or the body is unable to effectively use the insulin it does produce or
a combination of both.12 Insulin is the hormone that regulates blood
sugar, metabolizes fats, and produces energy for the body to function
effectively. Normally, the body breaks down sugars and carbohydrates from a consumed
meal and processed the meal into glucose. Afterwards, the pancreas releases
insulin into the bloodstream. Insulin is the signal for cells to take in the
glucose in order to harvest their energy. There are two types of diabetes:
type-1 diabetes (T1D) and type-2 diabetes mellitus (T2D).

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Individuals diagnosed
with T1D have an autoimmune condition that causes the insulin-producing cells to
destroy their immune system. Therefore, individuals diagnosed with T1D may have
a genetic disposition that prevent them from producing insulin. The most common
form if diabetes is T2D. Individuals diagnosed with T2D are unable to produce
enough insulin which makes the insulin ineffective in signaling the glucose to
the cells. While treatment for individuals diagnosed with T1D required insulin
injections, individuals diagnosed with T2D regulate their blood glucose levels
through oral medications or insulin injections in addition to behavioral
changes (i.e., exercise and eating healthy).13

In order for individuals
to manage their T2D effectively, they must consistently monitor their glucose
levels, take their prescribed medications, and take care of their overall
health. The challenge in the diagnosis of T2D, is that individuals can be
asymptomatic for several years before they are diagnosed with the disease. Uncontrolled
T2D can have a domino effect on major organs systems in the body including the cardiovascular
system, urinary system, and nervous system. Type-2 diabetes can cause an
increased risk of heart attacks, stroke, vision problems, necrosis, and
irreversible end-stage kidney disease. These complications can eventually be
life threatening.14

Prevalence of
Type-2 Diabetes in the U.S.

According to
World Health Organization, 422 million people were diagnosed with T2D15
and is the seventh leading cause of death in the United States.16 It
is predicted that T2D will affect 522 million people by the year 2030. The
prevalence rate of Americans is 9.4 percent.16 Each year, an
alarmingly number of Americans are diagnosed with T2D (e.g., 1.4 million).16
The following conditions associated with T2D are high blood pressure, high
cholesterol, mobility limitations, limitations in instrumental activities of
daily living, severe vision impairment or blindness, and coronary heart disease.1
The rates of cardiovascular disease and hypoglycemia exceeded those of the
state of Texas (46.4% and 9.9%, respectively).1Even worse, over one
out of four individuals (i.e., 29 million) can be diagnosed with prediabetes.
Individuals who fall within this category do not know they have the condition
and are not properly managing the condition.17

Prevalence of
Type-2 Diabetes in the Texas

Texas ranks 17th
out of the 50 states with adults being diagnosed with T2D (11.4%) .18
In 2013, there was an estimated 11% of adults diagnosed with diabetes and 8.1% with
prediabetes. The total number deaths in the state of Texas caused by diabetes
was 5,262.19 Approximately
XXX individuals in the city of Bryan-College Station was diagnosed with T2D in
2015. The gender divide is almost split equally among recent diagnosed
residents in the Bryan-College Station (i.e., 45.9% of males and 54.1% of
females). Residents in Bryan-College Station diagnosed T2D were
diagnosed with the following complications due to T2D such as, cardiovascular
disease (56.1%), hypoglycemia (17.2%), nephropathy (34.8%), neuropathy (26.9%),
and peripheral artery disease (15%).

Burden of Care or Cost of Type-2

Diabetes is
more than just an emotional and physical burden, it is also an economic burden.
Annually, the United States contributes an estimated total of $245 billion
dollars to diabetes related T2D programs and treatments. Of that $245 billion,
$176 billion dollars is directly associated with the medical cost of diabetes
and $69 billion of the is related to the reduced productivity associated with
diabetes.52 In the state of Texas, the total cost of diabetes is
approximately $67 million dollars, with approximately $27 million in direct
medical costs and approximately $40 million in indirect costs (i.e., inability
to work, work absenteeism, presentism, household productivity loss and
mortality).53 Interestingly, the United States spends the most on
health care compared to other high-income nations yet still has some of the
worst health outcomes. On average, the U.S. spends $9,086 dollars per person
annually on health care and the life expectancy is 78.8 years whereas Japan
spends $3,713 per person annually and has the highest life expectancy of 83.4.54


Three Main
Factors Associated with T2D

environmental, and health risk factors are the three main influencing
characteristics associations with diabetes. The T2D prevalence rates among
African Americans has quadrupled in the past 30 years. African Americans are
1.7 times more likely to develop T2D and develop greater co-morbidities from
diabetes-related complications compared to their white counterparts.20
The relationship between hyperinsulinemia, hypertension, dyslipidemia, and
coronary artery disease is known as metabolic syndrome. In order to be
diagnosed with metabolic syndrome an individual must be have abdominal obesity,
hypertriglyceridemia, hypertension, high fasting glucose and/or low levels of
high density lipoprotein. When an individual has 3 or more of these conditions,
they are diagnosed with metabolic syndrome. Among African American men, the
prevalence rate for developing metabolic syndrome is 16% compared to white men
who prevalence rate is 25%. However, African American women have the highest
prevalence rate  (i.e., 26%) of
developing metabolic syndrome compared to  white women prevalence rate is 23%.21
Consequently, African Americans with T2D have a higher rate of developing
retinopathy, end stage renal disease, lower extremity amputation, and mortality
compared to non-Hispanic whites.21 This could be in part because African
Americans (41.4%) has the highest prevalence rate of obesity while Hispanics
(39.2) have the second highest prevalence and non-Hispanic whites (27.9%) with
the lowest prevalence rate of obesity. Obesity is a significant risk factor for
developing T2D.1 In Texas, 9.6% of African Americans was diagnosed
with prediabetes and 12.9% of African Americans were diagnosed with diabetes
compared to 8.5% of non-Hispanic whites being diagnosed with prediabetes and
9.9% being diagnosed with diabetes.19

found that the genetic risks associated with T2D were genes involved in glucose
metabolism.22  The researchers
found that the participants of African descent had deregulation in blood
glucose levels. Schisler and colleagues suggested that because of the
environmental genetic lineage, African Americans were not suited the new
environments.22 However, other genetic studies found that fat mass
and obesity associated factor (FTO) and the transcription factor 7-Like 2
(TCF712) to assess the genetic risk for obesity and T2D in African Americans. CITE LITERATURE Recent studies
analyzed the effect of FTO as a risk factor for developing T2D. Another gene
that played a role in obesity is the melanocortin 4 receptor (MC4R). The MC4R is
associated to effect energy balance, monogenic obesity, body mass index,
height, increased appetite, and higher circulating insulin levels. CITE LITERATURE
Unfortunately, there are inconsistencies within the African American
populations due to the lack of genetic material collected. In individuals of
European descent with the risk allele of TCF712, the risk of developing T2D is
21% compared to those without the risk allele. CITE LITERATURE In a recent
study, African Americans with the risk allele had a higher risk of developing T2D
and had abnormal metabolic profiles (i.e., obesity and low levels of HDL

In addition, socioeconomic
status and neighborhood environments are additional environmental risk factors
associated with T2D among African Americans. The Jackson Heart Study, longitudinal
study among African Americans, demonstrated that African Americans diagnosed with
T2D tended to be female, older, less educated, physically inactive, lower socioeconomic
status, a family history of T2D and compared to African Americans without T2D
at baseline. 24  African
Americans in the study tended to live in neighborhoods with lower social
cohesion and violence, unfavorable food stores and physical activity resources.24

Risk Factors
for T2D

There are
several risk factors associated with type 2 diabetes.25 The risk
factors associated with T2D are age, gender, race, family history, obesity, and
diet behaviors.25


Type 2 diabetes
(T2D) is more prevalent among adults, especially individuals 45 years of age
and older.26 Approximately, 11.8 million Americans aged 65 years and
older are diagnosed with T2D.16 In Texas, the rate per 100 people in
the age group of 65 to 74 years of age is 24.6 while individuals 75 years of
age and older it is 25.4.27 Although T2D was known as an adult-onset
diabetes (i.e., more common in adults), as of 2009 it was estimated that 3,700 children
were diagnosed with T2D.28 By 2030, more than fifty percent of adolescents
will be at risk for diagnosed with type 2 diabetes.29 The increased
amounts of cases are associated with youth aged between 10 to 19 years of age in
minority population compared to non-Hispanic whites.30 Childhood
obesity has more than doubled in children and quadrupled in adolescents in the
past 30 years, with more than one-third of children and adolescents are either overweight
or obese.31


Gender is
another risk factor for T2D. As of 2014, the age-adjusted rate of diagnosed
diabetes per 100 individuals in the United States for males it is 6.6 whereas
for females it is 5.9.33 In Texas, the rate of prevalence of self-reported
diagnosed diabetes in adults is 11.8 among males and 10.0 among females.27
However, it is important to note that T2D affects men and women differently.
Women are at higher risk of being diagnosed with heart disease, and have a lower
survival rates and poorer quality of life after a heart attack. Women are also
at higher risk for blindness and depression.34


Type 2 diabetes
is more common among Native Americans, African Americans, and Hispanics.  Native Americans has the highest prevalence (15.9%)
of being diagnosed with T2D, followed by African Americans (13.2%), Hispanics (12.8%),  and  Asian
Americans (9%) and  of non-Hispanic
whites (7.6% ). Among Hispanics the rate of T2D varies among national and origin.
The prevalence rate for Puerto Ricans is 14.8%, Mexican Americans (13.9%), Cubans
(9.3%) and Central and South Americans (8.5%). Among Asian Americans the prevalence
rates among subgroups are as follows: 13% for Asian Indians, 11.3% for
Filipinos, and 4.4% for Chinese, and 8.8% for other Asian Americans.16

Family History

Family history
is another risk factor that contributes to prevalence rate of T2D. Individuals
with Type 2 diabetes who were diagnosed before the age of 50 have children
whose risk of getting diabetes is 1 in 7 and if they were diagnosed after the
age of 50 their children have a risk of 1 in 13. If both the parents have Type
2 Diabetes, the child’s risk is 1 in 2. Although, this is largely due to
genetics, lifestyle has a huge influence. Poor eating habits, obesity and
physical inactivity runs in families contributing to their risk of developing
Type 2 Diabetes.35  


The single
predictor for T2D is being overweight or obese. Approximately 90% of individuals
diagnosed with T2D are either overweight or obese.36 The prevalence rate
of developing T2D is 3 to 7 times higher in individuals who are obese compared
to individuals at a normal weight. Individuals with a body mass index greater
than 35 kg/m2 are 20 times more likely to develop T2D. Individuals
who carry most of the excess weight around their waist have a higher incidence
of developing T2D than those who carry it on their thighs and hips.37
African Americans have the highest prevalence rate of obesity (38.1%) followed
by Hispanics (31.9%) and non-Hispanic whites (27.6%).38 In Texas,
the current adult obesity rate is 32.4. percent, with 11.4 per cent adult
diabetes, having the 15th highest adult obesity rate in the United

Dietary Behaviors

behaviors highly influence individuals’ health outcomes and are directly
related to the food selection process and food consumption.  In a study,
98 patients, with a mean age of 51.98 years of age whose average duration of
diabetes was 9.76 years, were surveyed about the most important factors when
selecting food. The highest mean response was taste followed by cost. Majority
of the participants agreed that barriers to healthy eating included the cost of
healthy food, temptation to eating unhealthy food and stress-related
inappropriate eating.43 Unhealthy diets, those with high content in
fats, free sugars, and salt along with physical inactivity lead to
cardiovascular diseases, T2D, stroke, gastrointestinal cancer and obesity.

Other dietary
factors that influence the risk of T2Ds include the type of food an individual
consumes. Whole grains can help decrease the risk of developing T2D. Whole
grains consisted of bran and fiber, which makes it difficult for digestive
enzymes to break down the starches into glucose. This means that those starches
are slowly being broken down and slowly raising blood glucose levels and in
turn, insulin lowers the glycemic index. Individuals who ate 2 to 3 servings of
whole grains per day were 30 per cent less likely to develop T2D. Simply
substituting refined grains with whole grains may help lower the risk of T2D by
36 per cent. 44 Another dietary behavior that may lead to T2D is
drinking sugary drinks. Drinking one or more sugar-sweetened beverages per day
increases the risk of T2D by 83 percent. 44 Sugary drinks increase
weight, contribute to chronic inflammation, increase levels of triglycerides,
decrease HDL cholesterol levels, and increase insulin resistance. 44 Limiting
red meat and avoiding processed meat can help decrease the risk of T2D. Eating
just one daily 3-ounce serving of red increases the risk of T2D by 20 percent
while eating just smaller amounts of processed red meat each day increases the
risk of T2D by 51 per cent. 44 However, substituting that protein
with nuts, low-fat dairy, poultry, or fish can decrease the risk of T2D by up
to 35 per cent. Moderate alcohol consumption increases the effective of insulin
within the cells and may decrease the risk of being diagnosed with T2D.44
Smokers, especially heavy smokers, are 50 per cent more likely to develop T2D than
nonsmokers. 44

is an additional risk factor associated with T2D. In the United States, 89
million Americans are living with prediabetes.45 Prediabetes occurs when
blood glucose levels are higher than normal (100 mg/dl to 125 mg/dl), but not
high enough to be diagnosed with diabetes (126 mg/dl or higher).46 The
risk factors for prediabetes are similar to T2D, which  include age, racial and ethnicity, physical
inactivity, being overweight or obese, having a family history of T2D, and history
of gestational diabetes Cite. The recommendation to help prevent or delay the
start of T2D is to lose five to seven percent  of your body weight and to be physically
active for at least 150 minutes each week.47


One of Healthy
People 2020 primary goals is to enhanced the understanding between the  relationship of how diverse population groups navigate
their physical environment and the impact the environment has on health.48
One way to improve health outcomes of individuals diagnosed with T2D is social
support and self-management behaviors. This study aims to identify key aspects
of social support and self-management behaviors among African-Americans diagnosed
with T2D. Dietary
behaviors, physical activity, and weight management are all modifiable risk
factors that increase the risk of an individual developing T2D. The secondary
aim  is to explore the  neighborhood characteristics among African
Americans and the impact the neighborhood has on dietary behaviors and physical


There are two
factors that influence the health outcomes of individuals–social support and
environment. It is estimated that 7.6 million older adults in America feel the
need for more emotional support.49 Higher levels of social support
are associated with better glycemic control, increased knowledge, enhanced
treatment adherence, and improved quality of life. Lack of social support has
been associated with increased mortality and complications.50 Lack
of social support in older adults tends to lead to longer hospital or nursing
home stays.49

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of sentences based on the articles attached.

Latinos, Rotberg and colleagues, found that patients with low levels of
perceived social support had a higher A1C (9.8%) than those who had reported
moderate to high levels of support (8.9%).51 IH1 Similarly, researchers found that as participants experienced greater trust
and cooperationIH2 , their risk for T2D decreased
Cite. Social support aids individuals diagnosed with T2D in
helping them facilitate their self-care activities. Individuals with greater
social support increased their levels of physical activity and had healthier
eating patterns than those with lower levels of social support Cite. Other
programs IH3 whose purpose is to provide support to patients have seen that
their patients have improved foot care, blood glucose and weight monitoring
along with a higher frequency of physician visits, medication adherence and
cholesterol and blood pressure control.

Physical Environment

There are
several factors in an environment that affect individuals’ health outcomes. These
factors include infrastructures, transportation systems, restaurants, access to
medical care and availability of parks Cite. The environment is a huge aspect
in achieving a better quality of life. Neighborhood characteristics indicate
that there is an association between high levels of physical active (PA) and
less driving with higher levels of cardiorespiratory fitness (CRF) and a lower
BMI. Overall, the effects were modified by age.55 Neighborhood
factors are socio-environmental factors that also impact health outcomes Cite.
Poor neighborhood qualities, such as violence, lack of quality resources, lack
of social support and reduced access to healthy foods have been shown to be
barriers to performing self-care behaviors and attaining better health outcomes.
Researchers from the Jackson Heart Study investigated the connection between neighborhood-,  social-, 
and physical environments  with the
prevalence and incidence rates of  T2D among
African Americans.24 The study found that neighborhoods with high
social cohesion had 22% lower incidence of T2D compared to neighborhoods with
low social cohesion.24 In addition, neighborhoods with higher
density of unfavorable food stores (i.e. convenience stores, bakeries, candy
shops, ice cream stores, liquor stores, alcoholic drinking places, and fast
food stores) had a 34% higher incidence of T2D.24 In contrast,
research conducted the California Healthy Cities and Communities found that participants
engaged in school gardening programs with
nutrition and physical activity education helped increase the number of
physical activity sessions they had by 6% and increased their consumption of
fruit and vegetables by 10%.57 Social support and neighborhood
characteristics can have an impactful influence on individuals’ health
outcomes. This study aims to research how both, social support and neighborhood
characteristics are essential in self-management behaviors among African


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