Transcript A Successful, Cost-effective Program for the Prevention

Type 2 Diabetes Screening
& Education Program
Margaret Lynn Yonekura, MD,
Heather Kun, PhD, Luis Dimen, MD,
Mariola Ficinski, MD
Background

6/24/08 News Bulletin from CDC



24 million Americans (8%) now have diagnosed
diabetes, an increase of 3 million in the past 2 years
Another 57 million have prediabetes
Striking racial/ethnic disparities among those with
diagnosed diabetes:





16.5% of Native Americans/Native Alaskans
11.8% of African Americans
10.4% of Hispanics
7.4% of Asian Americans
6.6% of Whites
Background
Steady rise of diabetes in Los Angeles
County among adults > 18 yr from 6.6% in
1997 to 8.6% in 2005
 Those with the least access to preventive
health care at highest risk:

Rates for Latinos and AA double that of whites
and Asian/PI
 Rates increased most rapidly among poor
(14% of 0-99% FPL vs 6.5% of >200%FPL)
and non-HS graduates

Objectives
1.
2.
3.
Increase early identification of those at highrisk for developing diabetes and provide
education and promote behavioral changes to
prevent its development
Increase early diagnosis of those with diabetes
and provide education and support to help
them manage their disease
Educate providers to promote quality diabetes
care in the community
Chronic Disease Management
Consortium

Participating hospitals



California Hospital Medical Center
Huntington Memorial Hospital
Good Samaritan Hospital


Childrens Hospital Los Angeles


No pediatrics
Only pediatrics
National Health Foundation

Functions for Consortium: grant writer, facilitator,
design and management of web-based data system,
and evaluator.
Methods

All services provided in English and
Spanish free of charge


Funded by a 3-year grant from the Good
Hope Medical Foundation
Outreach education about type 2 diabetes
and screening using the ADA Risk Test at
a variety of community sites
ADA Risk Test
1. My weight is equal to or above that listed in the
chart. (BMI chart)
Yes
5
2. I am under 65 years of age and I get little or no
exercise during a usual day.
Yes
5
3. I am between 45 and 64 years of age.
Yes
5
4. I am 65 years old or older.
Yes
9
5. I am a woman who has had a baby weighing more
than 9 pounds at birth.
Yes
1
6. I have a sister or brother with diabetes.
Yes
1
7. I have a parent with diabetes.
Yes
1


Scoring 3-9 points: probably low risk for diabetes now
but don’t forget about it.
Scoring 10 or more points: greater risk for diabetes. Get
tested by your health care provider.
Program Curricula




Developed by dieticians from three collaborating
hospitals based on current recommendations
Each 2 hour workshop is highly interactive so
that program participants are able to both learn
and apply the facts, principles, and concepts
being taught.
Action planning at end of each workshop
Olympic Food Guide is a tool developed to help
participants make healthier food choices.
Standardization

Same training for Health Educators
CHW/promotoras
 MPH/RD

Same “take aways” from workshops
 Consistent number and sequence of
workshops
 Same clinical and self-reported outcomes

Methods

Food, Fitness, and Diabetes Prevention
Intake process: health screen, activity &
nutrition assessment
 4 weekly 2-hour sessions conducted by either
CHW/promotoras or professional staff (MPH
or RD)
 3-6 month follow-up: repeat health screen,
activity & nutrition reassessments
 Telephone education and support groups as
needed

Food, Fitness & Diabetes
Prevention: Modules
1.
2.
3.
4.
Diabetes prevention, good nutrition, and
our health
Healthy meals & healthy movement
Reading food labels
Heart health & disease prevention
Healthy
Lifestyles
American
Culture
The Gap!
(It is Widening!)
Methods

Living with Diabetes





Intake process: health screen, diabetes knowledge
and self-efficacy assessment, activity & nutrition
assessment
4 weekly 2-hour sessions
3-6 month follow-up: repeat health screen, diabetes
knowledge and self-efficacy reassessment, activity &
nutrition reassessments
Telephone education and support groups as needed
Chronic Disease Self-Management Program

6 weekly 2-hour sessions conducted by certified lay
leaders, at least one of whom has a chronic condition
Living with Diabetes: Modules
1.
About diabetes and monitoring your body
Take Charge! with Diabetes Health Record
www.caldiabetes.org
Nutrition, part 1
Carbohydrates and sugar, protein & fat
Plate method & carbohydrate counting
3. Nutrition, part 2
Reading food labels, healthy kitchen, recipes
& physical activity
4. Preventing complications and medications
2.
Results
Outreach & Screening

Between October 2005 and August 2008
286 outreach events
 5418 ADA Risk Tests administered

 13%
Low/No risk (0-2 pt)
 36% Intermediate risk (3-9 pt)
 52% High risk (> 9 pt)

2095 high risk clients referred to provider for
testing
Type 2 Diabetes Prevention
Program

Between October 2005 and August 2008

852 participants
 67%
Hispanic,17% Caucasian, 7% African
American, 7% Asian
 88% female
 32% overweight, 41% obese
 66% waist circumference above the cutoff
498 workshops conducted, 53% in English &
47% in Spanish
 Retention rate 80%

Type 2 Diabetes Prevention
Program
27% lost weight (> 4 lb) and 9% lost more
than 5% of their weight
 46% increased their knowledge about
healthy eating behaviors

36% eating > 5 servings of fruits &
vegetables/d
 76% drinking > 4 cups of water/d
 72% eating breakfast daily
 76% eating fast food 0-1 days in last week

Type 2 Diabetes Prevention
Program
At beginning of program 63% knew how
much PA is recommended
 21% increased their knowledge about PA
 62% increased duration of physical activity
to > 30 minutes each time
 49% increased the distance walked/d
 35% increased frequency of being
physically active to > 4 times/week

Living with Diabetes Program

Between October 2005 and August 2008

496 participants










58% Hispanic, 20% African American, 14% Caucasian, 5%
Asian
68% female
29% overweight and 56% obese
77% waist circumference above the cutoff
91% previously diagnosed & 7% newly diagnosed
Prior morbidity from diabetes: 32% diabetic neuropathy, 16%
diabetic retinopathy, 15% gastroparesis, 10% myocardial
infarction, 9% stroke, 7% nephropathy, & 2% amputation
62% Hgb A1c > 7
61% had hypertension & 38% had elevated cholesterol
424 workshops, 59% in English & 40% in Spanish
75% retention rate
Living with Diabetes Program

35% lost weight (> 4 lb) and 14% lost
more than 5% of their weight
6% decreased waist circumference below
cutoff; total 27%
 2% decreased body fat to normal range; total
9%


12% decreased their Hgb A1c below 7;
total of 53% had Hgb A1c < 7
Living with Diabetes Program

51% reported increased confidence in improving
their eating habits




37% eating > 5 servings of fruits & vegetables/d
79% drinking > 4 cups of water/d
82% eating breakfast daily
75% eating fast food 0-1 days in last week
Living with Diabetes Program

51% reported increased confidence in improving
their exercise habits







12% started being physically active
37% physically active > 4 times/wk; 62% total
37% increased frequency
56% physically active > 30 minutes each time; 79%
total
39% increased duration of PA
51% increased distance walked
42% increased their emotional wellbeing
Living with Diabetes Program

65% reported increased confidence in managing
their diabetes









20% began asking questions about their diabetes &
treatment
14% increase in discussing their personal problems
related to diabetes with doctor
46% learned what the Hgb A1c target was
79% checked BS daily
87% checked feet daily for sores
71% had dilated eye exam in past year
5% quit smoking
23% requested pneumonia vaccine
40% requested flu shot
Chronic Disease Self Management
Program
54 workshops, 48% in English & 52% in
Spanish
 252 participants and 282 guests = 538
 Retention rate 72%

www.patient education.stanford.edu
Barriers

Implementation delayed due to difficulties finding
a culturally appropriate curriculum




Living with Diabetes/Viviendo Con Diabetes from
National Alliance for Hispanic Health
California’s Guidelines for Care
Consortium’s Healthy Eating Lifestyle Program
curriculum
Community distrust of some hospitals as
legitimate source of health information


“The hospital is here for your health.”
Collaboration with community clinics
Barriers

Difficulty recruiting participants for the
Prevention Program
“reality doesn’t hit them (community
members) until they get diabetes.”
 Began marketing the prevention workshops
as “healthy living” classes

Public Health Implications

Benefits of Chronic Disease Management
Consortium




Community hears consistent message
More efficient and cost effective
Able to secure grant funding
Centralized web-based data collection and
reporting system


Provides real-time information on effectiveness of
program and progress toward outcomes
Data for reports to superiors and current/future
funders
Public Health Implications

The model of non-profit hospitals working
closely with local community clinics to address
the diabetes epidemic is an important and
replicable model.


Hospital staff provide outreach education & screening
for type 2 diabetes and refer high risk individuals to
clinics for diagnostic testing and on-going care.
Individuals at risk for diabetes participate in
prevention workshops while those with diabetes learn
critical self-management skills in workshops focused
on Living with Diabetes.
Public Health Implications
Patients benefit from improved understanding
of what they can do to prevent diabetes
and/or optimize their health and delay/prevent
the onset of complications.
 Clinics benefit because of increased patient
compliance with regular preventive care and
self management.
 Hospitals benefit from decreased ER visits
and hospitalizations for glucose control.

Remember
Take all these lessons one step at a time.
Learn to live with diabetes and you will enjoy a full, healthy, and
rewarding life.
QUESTIONS
Thank you !