Health on the Map: The Dynamics of Diabetes with Endocrine Specialist Chris Yedinak

Mount Marty University President, Marc Long, recently joined Chris Yedinak for Health on the Map, a podcast that explores rural health care in the United States. She is a noted researcher and board certified nurse practitioner with a background in endocrine conditions. Yedinak has authored nearly 40 peer-reviewed journal articles and 16 book chapters during her career and has co-edited the only endocrinology textbook for advanced practice nursing. She co-founded the Federation of International Nurses in Endocrinology and served as president of both that organization and the Endocrine Nurses Society in the United States. Yedinak earned her doctorate in nursing practice from Oregon Health and Science University and currently serves as the endocrinology program director at Mount Marty University. 

This conversation has been taken from the original podcast and edited for length and clarity.

President Marc Long: Can you describe what diabetes is and the difference between type 1 and type 2 diabetes?

Dr. Chris Yedinak: Diabetes is a complex disease, but it's really the result of the pancreas not doing its job properly. The pancreas’ job is to produce insulin. Insulin is really a hormone that is produced once we eat and particularly when we eat foods with sugar, a specific sugar called glucose. The insulin actually then picks up that glucose, and it transports it into all the body cells. That really powers the cells, and it gives the cells energy. But when there's not enough insulin, the glucose just builds up in the blood and is not being used by the cells.  But when there's not enough insulin, that glucose just builds up in the blood. And so it's not being used by the cells. So then the kidneys have to work kind of hard because they've got to get rid of all that extra glucose. And so the person with diabetes actually urinates a lot and hence how it got its name: diabetes mellitus. The word diabetes is derived from the Greek and it means siphon or to pass through which is what happens with a lot of the glucose.

Type 1 diabetes is really more often a disease where the pancreas genetically doesn't do its job; it can't do its job. So often that it’s diagnosed really early in life, in childhood, but there's actually now diagnosis of that type of diabetes later in life as well. 

Type 2 is most common. 90% to 95% of diabetes is type 2. Type 2 is really an issue of the pancreas not making enough insulin, or the body is kind of resistant to that insulin, so it's not allowing it to do its job very well.

I know according to the CDC that in 1980 about 6 million Americans has diabetes. That number has now grown to more than 38 million. So a six-fold increase in the last 45 years or so. Right now apparently more than 50% of American adults either have diabetes or pre-diabetes. Why do you think that prevalence has grown so much during that time?

I think there's a number of reasons. And that figure may actually be a lot higher than that because those are the people that we know. For those people that are undiagnosed, that figure may be more in the 40 million range. But when talking about type 2 in particular, lifestyle is kind of a big issue.

Since around the 1950s, we became more sedentary, and tv is more prominent, and computers have kind of taken charge of our lives, video games for kids, and a lot of people are working desk jobs. I think another issue is we're all running busy lives, and so fast food has become a choice and very available in most places. Then in the supermarkets, we have a lot of over-processed foods. Those foods both have a propensity for people to gain weight. Also, we're exposed to more environmental toxins, and particularly things like endocrine disruptors [which] are in plastics, the food we eat and the stuff that we use for cooking, et cetera. 

We also have better diagnostic tools so we can recognize diabetes earlier now. And the other factor really is we're living longer and because we're living longer, there's a higher likelihood that we're going to develop diabetes in the long run.

We at Mount Marty University focus a lot on rural health, and there's some research that shows that residents in rural areas are more likely to die from diabetes than those in suburban and even urban areas. Why do you think that is? 

I think it's very true. A lot of the data that I've been seeing is expressing similar concerns. There's about a 17% higher risk of diabetes if you live in a rural area. In urban areas, we actually see a decrease in diabetes, but not so in rural areas. We know that there's a higher poverty rate in rural areas. We also know that access is very limited in rural areas to health care and to good [healthy] food. There's an increased chance of being overweight in a rural area versus an urban area, higher blood pressure, higher cholesterol levels. Physical inactivity is actually higher in rural areas, which I thought was very interesting, but there's some studies that have shown very clearly that there's less activity in people in rural areas than in urban areas.

Interesting. You know, I grew up on a farm, so I see rural areas as being a lot of farms and ranches that have people out working and being active. ­­But, I guess that's not always the case. You think of small towns and people who have acreages, and maybe they have riding lawnmowers and things like that. They're just not as active as perhaps they used to be. 

And I think the other thing is there's some good data now in terms of exposure to pesticides, and those people that are in rural areas are more likely because of spraying or the use of pest controls in crops. They're more likely to be exposed and that actually can increase that propensity for diabetes. And then of course, access to care and evaluation. We should be evaluating people more in rural areas and yet it's very difficult to get people to specialty care or even to access to primary care just because of transportation issues, again, and poverty, et cetera.

Interesting, and we'll talk about the program that you run at Mount Marty University, which is hopefully helping us in that area with providers. But you mentioned food, and so I want to double back to your comment about processed food. Let's talk a little bit about food deserts. Can you maybe describe what they are and why they have a significant impact on rural health in general and diabetes in particular? 

By definition, it's an area that lacks affordable or adequate supply of things like fresh fruits, vegetables, grains and milk, etc. Very nutritious types of food. I think it can also be related to individuals and families. So some families live in very food insecure environments both because of economics, but also there's a sparse population in rural regions. And so, for a lot of retail stores, it's just uneconomic to have a store that's at least accessible to the majority of people that are living in rural areas. So, if people have to travel a long way to get to a store and they're low income, they're less likely to do it. They may go to like the local gas station or buy fast food because fast food seems to be much more available even in rural areas. So I think that's a big issue, sadly. 

So the good news is that diabetes can usually be managed. The bad news is that there aren't a lot of providers out there who have a depth of knowledge about diabetes. We talk about endocrinologists, which are the physicians who manage endocrine disorders including diabetes most often, and there aren't a lot of them out there. You've spent so much of your career focused on the treatment of endocrine disorders from an advanced nursing practice perspective. Can you talk about the role of nurse practitioners in working with patients and other providers and managing all sorts of endocrine disorders including diabetes?

It’s very true, unfortunately, that people aren't going into endocrinology as frequently as they used to. Recently, the stats show that there's about one physician endocrinologist to about 37,000 people in the U.S. Now that is including urban areas, and so that figure is going to be significantly higher in the rural areas because there's a gravitation towards that practice within an urban area.

As a nurse practitioner, I think a lot of us will go into this profession, and it really is the fastest growing profession. We're more likely to work in a rural area, and I think there's a bunch of different reasons for that. In a lot of states now there's full practice authority, so that means that a nurse practitioner working in a rural area is autonomous. So, they often want to practice where they live.

Nurse practitioners generally focus on prevention. I think it's really important as we start to work with families and educate them, which is typically what nurse practitioners do: they focus on the family. They focus on the patient and their environment. And so, teaching a family how to effectively develop a good dietary regime is important because then you can start to prevent obesity and the food desert issues within that family. We look at lifestyle interventions that prioritize a healthy lifestyle and educate around that. 

Let's pivot to our new endocrinology program at Mount Marty University. Can you discuss the certificate that we have, the knowledge that you hope nurse practitioners who complete the program will obtain and the impact they will have on care?

I think it's very exciting.

It was really developed out of a need in the rural area but also an increasing need in primary care for endocrine knowledge because, as we talked about before, there's this shrinking population of endocrinologists. And so, a lot of that care has been absorbed by primary care providers and nurse practitioners train as primary care providers. It's an extremely important move, I think, when we look at basic training in terms of nurse practitioners and certificates. And so this is a gap that Mount Marty is filling with a sub specialty in terms of endocrinology for the primary provider so that they can be more effective in treating these patients and feeling like they can actually address their needs. 

Yeah, it's exciting. And we've gotten a lot of good feedback from the health care community in the upper Midwest and elsewhere. And I know the first cohort of these practicing nurse practitioners who have already been in practice, several of them for years, have decided to go back to school in this online program. What have you learned from those six as you have started this new certificate program?

It’s seeing them rediscover the joy of learning because when you think about going back [to school] as an older adult it's a little daunting. And so trying to juggle a practice, because all of these students are working full time, and trying to juggle that with a clinical component as well as a didactic component… But they are so motivated and so determined to fill that gap for the needs of their patients that they're willing to make those sacrifices. Every week we discover something new as they're bringing cases to discuss and asking questions. It's been a very exciting development, and I'm looking forward to this continuing. We're only in the end of the first semester so we have a lot more to share together. It looks like it has an exciting future. 

You have spent years on the staff of the Pituitary Center at Oregon Health and Sciences University working on other endocrine conditions. It's sort of fascinating. I mean, if people know anything at all about the pituitary gland, they know it's in your head. But many people don't know what it is or what it does. Can you talk a little bit about your rewarding work in that area? 

Certainly. The pituitary is really the master gland of the body. It directs a lot of the end organ functions throughout a body. So if there's an issue with the pituitary gland, then there's some significant health issues down the line. I think it's more prevalent again than what we realize. We know that a number of people have pituitary tumors and most of them actually are not a problem. But we also know that people experience traumas through wars and head injuries that can also develop pituitary diseases, and some medications now affect pituitary function—particularly some medications for cancers. Being able to address these and help the patient get back to a stable quality of life is very rewarding. 

Yeah, that's great. Wonderful. Thank you for that work. And I just realized how rewarding maybe being in this endocrine environment is because unlike orthopedic surgery where you're replacing a hip and then moving on, you do get a chance to develop a relationship with patients on these chronic diseases. 

Indeed. Diabetes is very dynamic, and it changes from day to day. It changes from life transitions through childhood, adulthood, marriage and pregnancy. So it's rewarding to be able to work with patients to meet the barriers, meet the hurdles, jump the hurdles and then be able to [have the patients] be able to manage their health journey themselves. 

That's great. Dr. Chris Yedinak, anything else I should have asked?

I think it's important to continue to screen, and if people are concerned that they have diabetes, I think they need to seek that screening. And then whether it's a lifestyle or potentially a genetic issue, we can treat it.

For sure. Thank you so much, Dr. Yedinak, for joining me today.

Health on the Map is a production of Mount Marty University Nursing and is available for streaming on Spotify, Apple Podcasts, and YouTube. To learn more about Mount Marty, South Dakota's Catholic University, visit mountmarty.edu/nursing.

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Founded in 1936 by the Benedictine Sisters of Sacred Heart Monastery, Mount Marty University is South Dakota's only Catholic institution of higher education. Located along the bluffs of the Missouri River in Yankton, with additional locations in Watertown and Sioux Falls, Mount Marty offers undergraduate and graduate degrees focusing on student and alumni success in high-demand fields such as health sciences, education, criminal justice, business, accounting, and more. A community of learners in the Benedictine tradition, Mount Marty emphasizes academic excellence and develops well-rounded students with intellectual competence, professional and personal skills and moral, spiritual and social values. To learn more, visit mountmarty.edu.