Frank Schwartz, M.D., associate professor of endocrinology and director
                                                               of the Appalachian Rural Health Institute Diabetes/Endocrine Center, and
                                                              Leonard Kohn, M.D., professor of biomedical sciences and J.O. Watson,
                                                              D.O., Endowed Research Chair, are leaders in the college's research and
                                                              clinical efforts to better treat the diabetic population of Southeastern Ohio.

This article originally appeared in the September/October 2003 issue of Rounds

Center takes aim at diabetes

by William Gillis

As they say in baseball, the statistics don’t lie. And the statistics showing the dramatic increase in diabetes prevalence in the United States paint a grim picture. In Appalachian Ohio, the diabetes crisis is even more acute. In 1999, OU-COM’s Center for Appalachian and Rural Health Research conducted a study that suggested that 16 percent of area residents have diabetes—more than twice the national rate of 7.3 percent. What’s more, the region also has one of the highest incidences of diabetes-related heart disease in the country.

While no one has conducted a study precisely documenting diabetes incidence in Southeast Ohio and West Virginia, there’s little doubt among doctors and researchers that the area is a diabetes hotbed.

“It’s unclear what the exact incidence of diabetes in this area is,” says Chris Simpson, D.O., OU-COM associate professor of family medicine and co-director of the Appalachian Rural Health Institute. ARHI is a university-wide initiative that succeeded the Center for Appalachian and Rural Health Research to bring research, rural health information and health-care services to the region.

“But it’s my experience as a clinician—and if you talk to other clinicians that practice in this area, they’ll say the same—that the diabetes incidence in this area is quite high,” says Simpson.

To help combat diabetes in this region, Ohio University has founded the ARHI Diabetes/Endocrine Center, which will offer clinical care and education to area residents, pursue diabetes research, and train medical residents and medical, nursing and dietician students. ARHI is funded by a $500,000 federal appropriation and also will benefit from a $1.5 million gift from the Columbus-based Osteopathic Heritage Foundations to fund the J.O. Watson, D.O., Endowed Research Chair. The research chair is dedicated to diabetes and cardiovascular disease research.

“The ARHI Diabetes/Endocrine Center will create new programs in Southeastern Ohio that provide patient care, training for medical professionals and research in diabetes,” says OU-COM Dean Jack Brose, D.O.

“It will examine the disease from the genetic and biochemical levels all the way through clinical treatment and patient education. Partnering with the College of Health and Human Services, OU-COM will obtain funding for these programs through private, state and federal sources. This is one of the most exciting initiatives ever undertaken at our medical school.” Brose adds that he participates frequently in continuing medical education programs that help physicians prevent and manage the complications of diabetes.

One of the center’s major components is a diabetes clinic located in OU-COM’s Parks Hall. The clinic, which opened its door on July 14, operates as part of University Medical Associates (formerly University Osteopathic Medical Center), a private entity. The outreach, education and training programs conducted by the center are spearheaded by ARHI.

Leading the research efforts of the ARHI Diabetes/Endocrine Center is Leonard Kohn, M.D., a professor of biomedical sciences and distinguished senior research scientist in the Edison Biotechnology Institute. Kohn arrived at the University in January 2001 after spending 30 years with the National Institutes of Health in Bethesda, Md. Kohn has continued the diabetes research he began at NIH at Edison.

In spring 2003, Kohn was appointed J.O. Watson, D.O., Endowed Research Chair. His appointment and the OHF grant provided the opportunity to establish the diabetes center and attract an expert endocrinologist to lead the center’s clinical operation.

“When the Watson D.O. Chair opportunity came up, the interest was to have a researcher doing diabetes,” Kohn says. “I fit that description, and I accepted the appointment on the presumption that monies to support it would be used to attract Frank Schwartz, an endocrinologist with extensive diabetes treatment experience, and that we would create a diabetes center. And that’s what happened.”

Frank Schwartz, M.D., joined OU-COM’s Department of Specialty Medicine as an associate professor of endocrinology July 1. For the last 20 years, Schwartz has been in private practice in Parkersburg, W.Va. There, he established five American Diabetes Association-recognized diabetes education programs at local hospitals and within his own practice. Schwartz says the opportunity to come to OU-COM and set up a diabetes center was the “main reason” he left his private practice. “I took the opportunity to come here and be able to do something really exciting,” Schwartz says. “We will transform how diabetes care is delivered to the region’s citizens.”

Along with Brose, Kohn was instrumental in bringing Schwartz to OU-COM. Kohn says that while there has been important diabetes research taking place at OU for years, the University has lacked a clinical component—until now. “One of the first things I heard about Type 2 diabetes here was that it had two or three times greater incidence than the rest of the country,” Kohn says. “So a clinical component is a clear-cut need in the community. We can’t depend on a purely scattered group of local family and primary-care physicians to handle the diabetes problem.”

Improved diabetes care will have a major impact on the region’s diabetes sufferers and those at risk of developing diabetes. Statistics show that diabetes treatment can add 15 years of lifespan per person and virtually eliminates chances of blindness and end-stage renal failure. And the regional economic impact of improved diabetes care is often dramatic as well. Diabetes care can result in a $1,000 savings in health-care costs per year for each person who completes a comprehensive diabetes education program; a $30,000 lifetime savings for each person who achieves intensive glucose control; and a 70 percent reduction in hospital readmissions.

One of the cornerstones of the center’s efforts is outreach to clinics in Coolville, McArthur and Nelsonville along with other locations to be determined in the coming months. The goals of these diabetes-related clinics are to increase dialogue, networking and support among patients, their families and the Diabetes Center staff, and to organize patient support groups. In addition, education programs will be held regularly in area clinics and hospitals.

Since its opening, the diabetes clinic has hired a diabetes educator, a dietician and a nurse practitioner. Schwartz explains that these hires are part of the effort to build a comprehensive, state-of-the-art diabetes clinic for the community. Of course, meeting these goals requires money. Kohn and Schwartz are working together to obtain funding from a number of sources. They plan to start an endowment with the Osteopathic Heritage Foundation and secure ongoing grants to fund the center. (See “Voinovich announces $75,000 ARC grant to diabetes center” on pg. xx.)

Increased funding, they hope, will provide a financial source for local patients who lack health insurance coverage but want to be treated at the clinic. “There is a problem of access to health care in this region,” Schwartz says. “So we’re going to have to work on alternative funding for them.”

M. Brooke Hallowell, Ph.D., co-director of AHRI and an associate dean and associate professor at the College of Health and Human Services, says that AHRI’s education and outreach programs can help people improve their diets and lifestyles so diabetes complications never set in. “The treatment of diabetes isn’t necessarily medical,” she says. “There are a lot of things that people can do to prevent it and control it that don’t necessarily require a primary physician’s care. And there would be a lot less people needing expensive primary care if they had the prevention and education services early on. It becomes expensive care when you let diabetes go unchecked and then seek out a physician’s care.”

For Schwartz, one of the educational services key to combating diabetes in Appalachia is informing the population of the dangers of a high-fat, high-carbohydrate diet. Obesity is assumed to be a major factor in developing type 2 diabetes, and Appalachian Ohio has a high rate of obesity, heart disease and diabetes. “When you assume the industrialized lifestyle — with less physical activity, exercise, or high-density, high-fat foods, high-carbohydrate foods — obesity results, and that’s when type 2 diabetes can develop,” he says.

Schwartz believes that one reason that poor regions have high rates of obesity is that large portions of the population rely on government food programs. “A lot of the problems develop from government subsidies and how they provide food stamps,” he says. “All the government-surplus food that has been given out for 35 years has been high-fat, high-density food. And if you look at health-care insurance, prevention isn’t paid for, so we end up paying 30 to 40 times as much once people develop the complications. If we can change health-care to a preventive mode instead of just taking care of complications, we can save billions and billions of dollars and prevent all the pain and suffering. I think we can become major advocates and a thorn in the side of politicians and health-care financiers who run these health insurance companies for profit only.”

Another primary goal for the ARHI Diabetes/Endocrine Center is to create a diabetes patient database of information and samples from clinic patients. Kohn and Schwartz hope that such a database will shed light on diabetes causes and prevalence. The findings will not only help shape diabetes treatment as a whole, but the treatment of individual patients as well. “By taking blood samples, DNA and RNA and storing it, we can see if patients have specific genetic markers or serum markers for disease and disease progression,” Kohn explains. “So we can then go back to the patient and give them a serum yearly for the rest of their life.”

Kohn and Schwartz also hope that creating and examining such a database will provide insight into the extraordinary rate of diabetes in the Appalachian region. While many theories exist to explain the area’s high incidence, none have been proven, Kohn says. “It’s unknown,” he says. “Type 2 diabetes is not presumed to be genetic. Is it environmental then? Is it socioeconomics? Does obesity contribute to diabetes? And these all may be true, but we don’t know per se.”

An additional potential benefit of the diabetes patient database is that it eventually might generate money that could be invested back into the center. “We can create such a database, wherein the database itself generates income,” Kohn says. “If Eli Lilly wanted to use our database, they would pay for it. And that money would be used to provide care to the patients who are contributing to the database and to anyone else. It becomes a cyclical thing.”

The diabetes center has been established to deliver tangible health-care benefits to the Appalachian region. ARHI’s co-director Simpson hopes the center also will serve as a model and inspiration to start up other centers like it. “Maybe we can start an obesity center, a cardiovascular center or a hypertension center,” he says. While that’s a hope for the future, in the meantime the diabetes center will work toward improved diabetes treatment and care for the people of Ohio and West Virginia.

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