diabetes strategic plan - diabetes north carolina north carolina diabetes strategic plan identifies...

North Carolina

Diabetes Strategic Plan2 0 1 1 – 2 0 1 5

Draft Version Date: October 8, 2010

North Carolina Department of Health & Human Services is an equal opportunity provider and employer.

08/2011

North Carolina Department of Health and Human Services

N.C. Diabetes Prevention and Control

www.ncdiabetes.org

Mailing Address

1915 Mail Service Center

Raleigh, NC 27699-1915

Physical Address

5505 Six Forks Road

Raleigh, NC 27609

NC Diabetes Strategic Plan 2011-2015 - i - NC DHHS / N.C. Diabetes Prevention and Control

Greetings,

I am pleased to share North Carolina’s plan for diabetes prevention and management for 2011 to 2015. This plan reflects the most current thinking on how to prevent and manage diabetes at a population level. Although the plan strategies address implementation from a sState level, many partners are necessary to make a difference. Some of the strategies address policy change, several focus on change at the healthcare system and community levels. All seek to improve the quality of life for people with diabetes and favor prevention where possible.

The authors of this plan conducted an environmental scan and SWOT analysis (Strengths, Weaknesses, Opportunities and Threats), researched best practices in other states, and relied on the best science available from CDC and other sources to discern the strategies that would make the most impact in diabetes prevention and management. Tom Frieden, Director of the U.S.Centers for Disease Control and Prevention, designed the plan framework. Dr. Frieden believes that the focus on public health should shift from traditional health promotion events to long term environmental and policy changes. He advocates for strategies that reach the most people by making long lasting protective changes and making the default decisions the healthy decisions. This plan incorporates these ideas through diverse strategies such as advocating for increased graduation rates, developing culturally appropriate self-management curriculum materials, and helping people with identified pre-diabetes return to a normal blood glucose level through increased physical activity.

This plan can only be successful if it transitions from words on a page to action and intervention. I challenge every person who reads this plan to find a strategy that resonates and join the cause. While Type 1 diabetes is not preventable, recent research points to environmental initiators. This plan allows efforts to determine those causes and eliminate them. Type 2 diabetes can be prevented and complications such as kidney failure, amputation and blindness are not inevitable. Through this plan, we hope to reverse the diabetes trends in North Carolina. We want to lower the rate at which people develop diabetes and increase the number of healthy years for people with diabetes. This plan is an important first step taking us down this new road.

Finally, I would like to thank the authors of this plan. Their names are listed in the Appendix. Special thanks to David Napp who facilitated the meetings and drafted the plan and to Diabetes Advisory Council members Bruce Forker, Betty Lamb, and Jan Nicollerat who provided leadership throughout the process. I would like to dedicate this plan to Myrna Miller who served as the Diabetes Advisory Council Vice Chair and unexpectedly passed away in February 2010. I also want to acknowledge Janet Reaves who served as the DPCP Coordinator from 2000-2004 and who passed away in February 2008.

With highest regards,

Joe Konen, MD, MSPHChair, N.C. Diabetes Advisory Council

NC Diabetes Strategic Plan 2011-2015 - ii - NC DHHS / N.C. Diabetes Prevention and Control

Executive Summary

Diabetes is a major public health problem in North Carolina. The diabetes prevalence rate has more than doubled over the last decade, with North Carolina ranked 13th highest nationally for the number of adults with diabetes in 2009. The burden of diabetes and its complications disproportionately affect North Carolina’s minority populations, including African-Americans, Native Americans, and Hispanics, as well as the elderly and people with lower levels of income and education.

The North Carolina Diabetes Strategic Plan identifies statewide strategies for the prevention and management of diabetes to be implemented during the years 2011–2015 through the joint efforts of the North Carolina Diabetes Advisory Council (DAC) and the Diabetes Prevention and Control Branch (DPCB) of the North Carolina Department of Health and Human Services, along with numerous public and private collaborative partners.

The process to develop this plan included a two-day strategic planning meeting with a diverse group of stakeholders who reviewed epidemiological data on the burden of diabetes; discussed evidence and best practices in diabetes prevention and management; conducted an environmental scan to identify strengths and needs; and decided priority strategies. A second meeting was convened to review and finalize the strategic plan. David Napp, an independent consultant under contact with the DPCB, facilitated the planning process and helped develop the strategic plan.

The strategies in this plan were developed in accordance with the Health Impact Pyramid, a framework for developing public health strategies endorsed by the Centers for Disease Control and Prevention (CDC). This framework underscores the importance of interventions at multiple levels to achieve greatest public health impact. Seven types of strategies are described in this plan: 1) addressing socioeconomic factors, such as reducing poverty and increasing educational attainment; 2) changing the context to make default decisions healthy, such as increasing the availability of healthy foods; 3) offering long-lasting protective interventions, such as smoking cessation; 4) providing clinical interventions, such as screening and early intervention; 5) making available counseling and education interventions, such as support groups and social marketing campaigns; 6) supporting development of local strategies; and 7) addressing surveillance and data needs.

At the beginning of each year covered by this plan, the DAC, the DPCB, and their collaborative partners will develop a joint action plan specifying how priority strategies will be implemented for that year. Monitoring and evaluation procedures have been established to track implementation strategies and to assess progress on achieving diabetes prevention and management outcomes. Eight outcome indicators have been specified and baseline measures established.

NC Diabetes Strategic Plan 2011-2015 - 1 - NC DHHS / N.C. Diabetes Prevention and Control

Table of Contents

Chapter 1: The Burden of Diabetes Overview ..................................................................................................................................4

Diabetes Disparities ..................................................................................................................5

Children and Diabetes in North Carolina .................................................................................5

Diabetes Mortality ....................................................................................................................8

Diabetes Risk Factors ................................................................................................................9

Diabetes Complications ............................................................................................................9

Preventive Care Practices .........................................................................................................11

Diabetes Cost..........................................................................................................................12

Chapter 2: Diabetes Prevention and Management Efforts in North CarolinaLeadership and Partnerships ....................................................................................................11

Progress on 2005–2010 North Carolina Diabetes Strategic Plan .............................................13

Chapter 3: Diabetes Prevention and Management StrategiesDeveloping the Plan ................................................................................................................15

Evidence and Best Practices .....................................................................................................15

Strategy Framework ................................................................................................................16

Strategic Priorities ...................................................................................................................18

Chapter 4: Evaluation Logic Model............................................................................................................................23

Process Evaluation ...................................................................................................................24

Outcome Monitoring .............................................................................................................24

Chapter 5: Planning to Action: Building on Past SuccessLogic Model............................................................................................................................23

Process Evaluation ...................................................................................................................24

AttachmentsOutcome Monitoring Indicators .............................................................................................23

Diabetes Strategic Planning Meeting Participants, March 18–19, 2010 ..................................26


Chapter 1: The Burden of Diabetes

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Overview

Diabetes affects all socio-demographic population groups (and is reaching epidemic proportions) in North Carolina. Both the number of prevalent cases (existing cases) and the number of incident cases (new cases) of diabetes are increasing. In North Carolina, the diabetes prevalence rate has more than doubled over the last decade, from 4.4 percent in 1995 to 9.6 percent in 2009 (Behavioral Risk Factor Surveillance System (BRFSS) 2009 data1, the most recent available data from CDC2). The age-adjusted incidence rate of diabetes per 1000 population has

increased from 5.7 percent in 1995–1997 to 10.1 percent in 2005–2007 (CDC). Nationally, North Carolina ranked 13th highest for adult diabetes prevalence in 2009.

In North Carolina in 2009, an estimated 674,000 adults had diagnosed diabetes (BRFSS). Another 147,000 were estimated to have undiagnosed diabetes (NHANES). Nearly 451,000 adults had pre-diabetes (BRFSS). Altogether, an estimated 1.27 million adults had some form of hyperglycemia (high blood sugar levels). The number of diagnosed new cases of diabetes in the state doubled from 29,000 in 1995–1997 to 59,000 in 2005–2007 (CDC).

Prevalence of Diagnosed Diabetes in North Carolina, 1995-2009

1The Behavioral Risk Factor Surveillance System (BRFSS) is an annual random telephone survey of adults (aged 18 and older, civilian, non-institutionalized by state, coordinated by the Center for Disease Control and Prevention (CDC). Most of the data in this document came from the BRFSS survey. NC BRFSS survey is conducted by the State Center for Health Statistics, DHHS.2For comprehensive diabetes information, please visit The North Carolina Diabetes Prevention and Control Program website at www.ncdiabetes.org.

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Diabetes Disparities

The burden of diabetes and its complications disproportionately affect certain demographic groups, including African-Americans and Native Americans, the elderly, and people with lower levels of income and education (Table1). In 2009, North Carolina’s African-American population had the highest diabetes prevalence rate (15.6 %) followed by Native Americans (11.7 %). African-Americans had almost twice (15.6 %) the diabetes prevalence as whites. Diabetes prevalence increases as people age. One in five North Carolinians aged 55 and older had diagnosed diabetes in 2009. Women were shown to have higher diabetes prevalence than men. Adults with less than a high school education had a higher diabetes rate than college graduates (15.3 % vs. 5.5 %). North Carolina adults with annual household incomes of less than $15,000 had a significantly higher rate of diabetes as compared with people with incomes of $75,000 or higher (14.6% vs. 4.9%).

Children and Diabetes in North Carolina

Type 1 or Juvenile diabetes, an autoimmune disease where the pancreas does not produce insulin, is the most frequently occurring type of diabetes in children, although it can present itself at any age. Because the pancreas can no longer produce insulin, people with this type of diabetes are required to take insulin daily. A combination of genetic and environmental factors puts some people at increased risk for type 1 diabetes.

Type 1 diabetes accounts for 5 to 10 percent of all diagnosed cases of diabetes, but it is the most common type of diabetes in children of all ages. In

Table 1. Demographic Characteristics of adults with diagnosed diabetes, North Carolina, 2009

Demographic Characteristic

Prevalence Rate (%)

Total 9.6

Gender

Male 9.2

Female 10.0

Age

18-44 2.9

45-64 13.6

75+ 21.4

Race

White 8.4

African American 15.6

Native American 11.7

Hispanic 4.9

Education

Less than H.S. 15.3

H.S. or G.E.D. 11.7

Some post-H.S. 9.0

College Graduate 5.5

Household Income

< $15,000 14.6

$15,000-24,999 11.5

$25,000-34,999 10.0

$35,000-49,999 9.8

$50,000-74,999 8.7

$75,000+ 4.9

Source: BRFSS 2009


children less than 10 years old, type 1 accounts for almost all diabetes (CDC). Based on 2002–2003 data, the SEARCH for Diabetes in Youth study3 shows that 15,000 youth under 20 years of age are diagnosed annually with type 1 diabetes in the United States. The incidence of type 1 diabetes (new cases) is highest among white children, especially in the 10–14 years age group (Table 2).

In North Carolina, more than 3,400 schoolchildren were known to have type 1 diabetes in the 2008–2009 school year. Children and youth with type 1 diabetes are at substantial risk for long-term complications, including cardiovascular disease (CVD), compromised oral heath, and diseases and complications of the kidneys, eyes, nerves, blood vessels, and skin. Children with type 1 diabetes need to keep blood sugar levels under control to prevent complications by following a good diabetes management plan, including checking blood glucose levels regularly, healthy meal planning, and participating in regular physical activity.

Table 2. Estimated incidence (new cases) of type 1 diabetes among non-Hispanic white children and youth in the U.S., 2002-2005

Age groupIncidence of type 1

diabetes

0-4 19 per 100,000

5-9 28 per 100,000

10-14 33 per 100,000

15-19 15 per 100,000

Source: SEARCH Study

Type 2 diabetes in children was rare prior to 1980, accounting for only 1 to 2 percent of diabetic cases in children in the United States. Now, as more children and adolescents are becoming overweight/obese and inactive, type 2 diabetes is occurring more often in young people. Overweight and obese children are at increased risk for developing type 2 diabetes during childhood, adolescence, and even later in life.

Based on 2002–2003 data, the SEARCH study shows that 3,700 children each year are newly diagnosed (incident cases) with type 2 diabetes in the U.S. Type 2 diabetes is becoming increasingly common, especially in minority youth 10 years and older. This form of diabetes represents 57.8 percent of newly diagnosed cases of diabetes in African-American youth, 86.2 percent in Native American youth, 46.1 percent in Hispanic youth, 69.7 percent in Asian/Pacific Islanders, and 14.9 percent in white youth.

Like children with type 1 diabetes, many youth with type 2 diabetes have multiple cardiovascular disease (CVD) risk factors, and need to follow a healthy lifestyle to manage their weight, blood lipids (cholesterol levels), and blood pressure to help prevent or delay the development of CVD and other complications. One out of every three children born in the year 2000 will have diabetes sometime during his or her lifetime. It will be worse for African American and Hispanic children, as almost 50 percent of them are likely to develop diabetes (CDC).

3SEARCH is a multi-center study funded by the CDC (Center for Disease Control and Prevention) and NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases). The study focuses on children and youth in the U.S. who have diabetes


Because there are no published studies of diabetes prevalence in children in North Carolina, two different sources of information were compared to estimate the number of children with diabetes in the state: the Annual School Health Services Report for Public Schools and the Child Health Monitoring and Assessment Program (CHAMP) Survey.

North Carolina Annual School Health Services Report for Public Schools is an annual report made by public school nurses across the state that documents the number of school children with diabetes in elementary, middle, and high school (Table 3). In 2008-2009, 4,584 public school students had diabetes (type 1 and type 2). The report also stated that 3,548 school children monitored blood glucose at school; 2,101 received insulin injections at school; 1,544 managed insulin pumps; and 2,527 were known to self-carry their medication.

Table 3. The number of schoolchildren in North Carolina who had diabetes in 2008–2009 school year

Type of Diabetes

Elementary Middle High Total

Type 1 diabetes

1,155 904 1,348 3,407

Type 2 diabetes

289 366 522 1,177

Source: North Carolina Annual School Health Services Report for Public Schools, 2008-2009.

Table 4. Demographic characteristics of children with diabetes in CHAMP survey, North Carolina, 2009

The Child Health and Monitoring Program (CHAMP) survey in North Carolina shows that the mean prevalence rate for diabetes was 6 cases per 1,000 children in 2009 (Table 4). Girls are shown to have higher diabetes prevalence than boys. Youth ages 14 through 17 had the highest prevalence among youth age groups.

Demographic Characteristic

Diabetes Prevalence Rate (%)

C.I. (95%)

Total 0.6 0.3-1.1

Gender

Male 0.3 0.1-0.9

Female 0.9 0.4-2.0

Race

White 0.6 0.3-1.3African American

0.2 0.0-1.7

Other Minorities

1.2 0.4-4.0

Hispanic

Yes 2.3 0.8-6.5

No 0.4 0.2-0.7

Age groups

Under 5 0.3 0.1-1.5

5 through 10 0.6 0.2-1.5

11 through 13 0.7 0.1-5.1

14 through 17 0.8 0.3-2.3

NOTE: 2,366 parents completed CHAMP survey of which 13 reported that their child had diabetes or high blood sugar. Sample is extremely small.


Diabetes Mortality

Nationally, North Carolina ranked 21st in diabetes mortality in 2007 (latest available mortality ranking data, CDC). In 20084 in North Carolina, diabetes ranked as the seventh leading cause of death, accounting for 2,164 deaths where diabetes was considered the primary cause of death, representing a 24 percent increase over 1995 data (2008 NC Death

Table 5. Number of deaths and age-adjusted death rates (diabetes deaths per 100,000 population) with diabetes listed as the primary cause of death by race and sex, North Carolina, 2008

Skilled and intermediate nursing care, $1,224, 30%

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services, $1,192, 29%

Hospital services, $868, 21%

Outpatient clinic services,

$326, 8%

Prescription drugs, $235, 6%

Home health care, $152, 4%Other, $101, 2%

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Trends in Diabetes Mortality by Race North Carolina, 1996-2008

Total White Black

Number Rate Number Rate Number Rate

Total 2,164 22.8 1,375 17.9 747 46.4

Male 1,068 26.5 718 21.9 329 51.3

Female 1,096 19.9 657 14.8 418 42.7

Certificates data). Diabetes was a contributing factor for an additional 6,532 deaths in 2008 in North Carolina. Diabetes was the fourth leading cause of death among African-Americans. Black males had the highest diabetes death rate in 2008, and were 2.3 times more likely to die from diabetes than white males (51.3 vs. 21.9 per 100,000 population) (Table 5).

Source: 2008 NC resident death certificates data, North Carolina State Center for Health Statistics, DHHS

4NC Vital Statistics Volume 2: Leading Causes of Death-2008, State Center for Health Statistics, DHHS

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Diabetes Risk Factors

Physical activity, weight management, healthy diet and portion control, and smoking cessation reduce the risk and improve outcomes of people with type 2 diabetes. These lifestyle changes also prevent or delay pre-diabetes and gestational diabetes, which are risk factors for type 2 diabetes.

Physical activity: Physical activity helps control not only blood sugar but also weight and blood pressure, and it may improve cholesterol levels. Physical activity also reduces the risk of common diabetes complications, such as heart disease and nerve damage. Only 31.2 percent of North Carolina residents with diabetes reported moderate physical activity in 2009 (BRFSS).

Obesity: Obesity is a major contributor to Type 2 diabetes. More than half (51.9%) of North Carolina adults with diabetes were obese in 2009 (BRFSS). Big portion sizes, calorie-dense snacks and sugary drinks are all significant contributors to overweight and obesity. People with diabetes need to follow a healthy diet that includes fruits and vegetables, whole grains, lean protein, low-fat dairy products, and moderate amounts of healthier fats with optimal portion sizes. In North Carolina, 81.3 percent of adults with diabetes did not consume five or more servings of fruits and vegetables in 2009 (BRFSS).

Smoking: Smoking has devastating effects on people with diabetes. Smoking raises blood glucose (sugar) and reduces the body’s ability to use insulin, making controlling one’s diabetes difficult. Smokers with diabetes are eleven times more likely to have a

heart attack or stroke than people without diabetes and who do not smoke. In North Carolina, 15.3% of adults with diabetes smoked in 2009 (BRFSS 2009).

Pre-diabetes: Pre-diabetes is a condition in which individuals have blood glucose (blood sugar) levels higher than normal but not high enough to be diagnosed as diabetes. People with pre-diabetes have an increased risk of developing type 2 diabetes and heart disease. More than 7 percent of adults in North Carolina were diagnosed with pre-diabetes in 2009 (BRFSS 2009).

Gestational Diabetes: Gestational Diabetes (GD) occurs in some pregnant women who have no history of diabetes but have high glucose levels during pregnancy. GD is a major risk factor for type 2 diabetes. Although GD goes away after pregnancy in a majority of cases, 5-10 percent of women develop type 2 diabetes immediately after birth, and an additional 20-50 percent develops diabetes within the next 5-10 years. In the U.S., an estimated 135,000 cases of GD occur each year. The North Carolina PRAMS5 survey shows that 10.8 percent of women had GD in 2008. Treating GD is important as it poses risks to both the mother and the child. Lifestyle changes such as losing weight, exercising, and making healthy food choices may help prevent diabetes among women who have had gestational diabetes.

5Pregnancy Risk Monitoring System, The State Center for Health Statistics, DHHS


Diabetes Complications

Cardiovascular Disease (CVD): Diabetes is a major risk factor for heart attacks, strokes and other heart problems. In North Carolina, people with diabetes are 3.7 times more likely to have heart attack, angina, coronary heart disease, or stroke compared to people without diabetes. (25.6% vs. 7.0%) in 2009. Among adults with diabetes, 69.4 percent had high blood pressure, and 66.4 percent had high blood cholesterol in 2009 in the state. According to national data, improved control of LDL (bad) cholesterol levels alone can reduce cardiovascular complications by 20 to 50 percent (National Diabetes Statistics 2007, National Institutes of Health).

Kidney Disease and End-Stage Renal disease (ESRD): People with diabetes are the fastest growing group with kidney disease. In North Carolina, 14 percent of adults with diabetes had kidney disease compared to 1.9 percent of general adult population in 2009. Diabetes is the leading cause of end-stage renal disease (ESRD), which is kidney failure requiring dialysis or transplant. The incidence and prevalence of ESRD have increased greatly in North Carolina over the last decade. ESRD is a major diabetes health problem because of the high cost of renal replacement therapy, the associated high mortality, and the effect on the patient’s quality of life. The number of people with diabetes who initiated treatment for ESRD (incidence) increased by more than 80 percent from 840 in 1995 to 1523 in 2007 in the state (United States Renal Data System). ESRD prevalence due to diabetes (existing cases) has increased by 136 percent from 2,717 in 1995 to 6,427 in 2007.

Visual Impairment and Diabetic Retinopathy: In North Carolina, 45.2 percent of adults (age 40+) with diabetes reported some visual impairment in 2008 (BRFSS 2008, latest data available). Recent research shows that diabetic retinopathy is on the rise. Nearly 18 percent of North Carolina adults with diabetes reported diabetic retinopathy in 2009 (BRFSS 2009).

Neuropathy and Lower Extremity Amputations (LEA): An estimated 60 to 70 percent of people with diabetes have neuropathy, a disease of peripheral and autonomic nerves. Neuropathy disproportionately affects ethnic minority men such as African-Americans, American Indians, and Hispanics. The Diabetes Control and Complications Trial (DCCT) in 1993 found that tight blood sugar control cut the risk of neuropathy by 60 percent. Neuropathy, along with poor circulation, tends to target feet first, causing pain, burning, or loss of sensation that predisposes unrecognized injury, skin ulcerations, infection and amputation of the toe, foot or even the leg. African-Americans with diabetes are 2.7 times more likely to have an above-the-knee amputation than whites. African-American males consistently have the highest amputation rates. In North Carolina, out of the total 4,079 lower limb amputations in 2007, 2,608 (64%) occurred among people with diabetes (NC Hospital Discharge data 2007).


Preventive Care Practices

Preventive care practices, such as dilated eye exams and comprehensive foot exams, as well as daily self-monitoring of blood glucose, are effective in reducing both the incidence and progression of diabetes-related complications. Although preventive care practices are increasing, many North Carolinians with diabetes do not receive these services or do not fully engage in self-care practices. Preventive care practices should be emphasized in clinical and community settings to increase the percentage of adults with diabetes who receive them. North Carolina BRFSS data show that North

Table 6. Preventive Care Practices among adults with diabetes, North Carolina, 2009

Preventive Care Practices % Achieved HP 2010 Goal

Annual Doctor Visit for Diabetes 87% --

Annual Foot Exam 76% 75%

Twice Annual HbA1c Test 75% 50%

Annual Dilated Eye Exam 68% 75%

Daily Self-Exam of Feet 73% --

Daily Self-Monitoring of Blood Glucose 63% 60%

Annual Influenza Vaccine 63% 60%

Attended Diabetes Self-Mgmt Classes 54% 60%

Ever Had Pneumococcal Vaccine 55% 60%

Selected Healthy People 2010 goals. Data Source: BRFSS 2009, North Carolina State Center for Health Statistics, DHHS

Carolina has surpassed four of the seven selected Healthy People 2010 goals: two or more A1c tests in previous year, annual foot exam, daily blood glucose self-monitoring, and annual influenza vaccine. Despite the known benefits, however, the prevalence of some preventive care practices is suboptimal and data indicate room for improvement.


Diabetes Costs

Diabetes and pre-diabetes costs in the United States were $218 billion in 2007, including $153 billion for direct medical costs and $65 billion in lost productivity.6 Nationally, almost one-in-four hospital dollars go to treat people with or at high risk for diabetes.7 In 2008 in the United States, an estimated 7.8 percent of people had diagnosed diabetes and their total hospitalization costs were $83 billion, accounting for 23 percent of total hospital spending. The average hospital cost for a person with diabetes is nearly $11,000, more than $2,000 higher than for someone without diabetes.

The American Diabetes Association (ADA) estimated that the cost of diabetes for people in



services, $1,192, 29%



$326, 8%



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North Carolina was $5.3 billion in 2006, including excess medical costs of $3.6 billion attributed to diabetes, and lost productivity valued at $1.7 billion. People with diagnosed diabetes have medical expenditures that are about 2.3 times higher than medical expenditures for people without diabetes.8 In fiscal year 2007, the North Carolina state Medicaid program spent $525 million for diabetes-related medical care and prescription drugs for adults, with an average expenditure of $4,098 per adult with diabetes.9 The figure below illustrates that the largest categories of Medicaid expenditures for diabetes patients were skilled and intermediate nursing care (30%), and physician and other medical services (29%), followed by hospital services and outpatient clinics (21%).

Source: Medical Care Costs for Diabetes Associated with Health Disparities Among Adults Enrolled in Medicaid in North Carolina., State Center for Health Statistics, SCHS Study No. 160, August 2009.

Medicaid Expenditures for Diabetes by Category of Service: North Carolina, July 2007 through July 2008, age 18 and older

6Timothy M. Dall1,*, Yiduo Zhang, et al, The Economic burden of diabetes, Health Affairs, Published online Jan 14, 2010.7 Fraze, T., H.J. Jiang and J. Burgess. Hospital stays for patients with diabetes, 2008. Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality Statistical Brief #93.8 Chronic Disease Calculator, version 1, November 2008, CDC, www.cdc.gov/nccdpphp/resources/calculator.htm9 Paul A. Buescher, Tim Whitmire, and Barbara Pullen-Smith, Medical Care Costs for Diabetes Associated with Health Disparities Among Adults Enrolled in Medicaid in North Carolina. SCHS Study No. 160, August 2009.


Chapter 2: Diabetes Prevention and Management Efforts in North Carolina

Leadership and Partnerships

North Carolina Diabetes Advisory Council: The North Carolina Diabetes Advisory Council (DAC) was created in 1994 to build capacity, leverage resources, and advocate for diabetes prevention and control efforts in the state. This 32-member body, appointed by the State Health Director, is comprised of stakeholder organizations, professionals, and consumers representing diverse cultures and regions. Since 1994, the DAC has secured major funding for diabetes prevention and control from the Kate B. Reynolds Charitable Trust and the Blue Cross and Blue Shield of North Carolina Foundation; initiated the first statewide diabetes strategic plan; and developed and produced quality improvement tools, including state guidelines for diabetes care and an education curriculum for the care of diabetes. The DAC initiated a biannual diabetes advocacy day at the North Carolina General Assembly and developed a legislative action plan. DAC members and others successfully advocated for the passage of three significant bills that guarantee insurance coverage of diabetes testing supplies and education; protections and other provisions for school children with diabetes, and mandatory school reporting related to school children with diabetes.

North Carolina Diabetes Prevention and Control Program: The North Carolina Diabetes Prevention and Control Program (DPCP) is responsible for helping North Carolina citizens prevent diabetes, reduce the impact of the disease on people with diabetes, and work to eliminate diabetes-related health disparities. The DPCP accomplishes these goals through leadership, education, surveillance, communication, community involvement and capacity building, advocacy and policy development. The DPCP has established partnerships with various national, state and local government agencies, nonprofit organizations, and educational institutions to increase awareness of diabetes prevention and control strategies. Additional information can be found at www.ncdiabetes.org. The DPCP is primarily funded by the Centers for Disease Control and Prevention.

ADA Education Recognition Program: The N.C. Diabetes Prevention and Control Program (NC DPCP) is an “umbrella” program recognized by the American Diabetes Association (commonly referred to as ADA Recognition) to provide diabetes self-management education. The DPCP partners with local health departments as “multi-sites” under this umbrella recognition. The purpose of the DPCP is to increase access to diabetes self-management education in all areas of the state, provide reimbursement to local health departments for providing this education to address health disparities, and encourage linkages with statewide and community partners. The North Carolina Diabetes Education Recognition Program (DERP) is the largest in the United States and, as of 2010, included 40 local health department sites. Program evaluation data show that people who participate in the DERP lower their A1c’s by about 1 point, increase their self foot exams, and lower their blood pressure.


Diabetes Self-Management Education Curriculum: North Carolina is one of a few states that has developed its own diabetes self-management curriculum. The curriculum meets the National Standards for Diabetes Self-Management Education and is available to health professionals who are providing diabetes self-management education. This Tool Kit contains 10 modules outlining diabetes self-management topics and an array of teaching tools. The curriculum is available for download at www.ncdiabetes.org.

Diabetes Today: Diabetes Today is an DPCP training initiative program that looks at diabetes from a public health perspective rather than exclusively as a medical problem. The curriculum is a guide to engage and mobilize community members, health professionals and community institutions in understanding and responding to the burden of diabetes and its prevention. Diabetes Today began in 1994 in North Carolina. Through Diabetes Today and the lessons learned through the Project DIRECT Academy, local health department grantees have been able to implement interventions aimed at increasing physical activity, which in turn has resulted in the creation of more walking trails across the state. They have created at least five miles of walking trails in Harnett, Hoke, and Robeson Counties. In addition, Surry County has installed a wellness center that serves multiple counties in the faith-based communities. Hertford County has leveraged $12,000 to purchase exercise equipment for students and staff in elementary schools.

Policy/Advocacy: The Diabetes Advisory Council (DAC) advocates for environmental and policy changes that enhance the lives of people with diabetes and those at risk. DAC members have

been instrumental in passing three laws that focus on North Carolinians with diabetes. One requires that diabetes supplies and education be covered by insurance (S.L. 1997-225). Another addresses school children with diabetes (S.L. 2002-103). North Carolina was among the first states to enact this legislation. In 2009, The N.C. General Assembly passed additional legislation which required that Charter schools be subject to the previous law regarding school children with diabetes and that all schools report annually about diabetes (S.L. 2009-563). In 2006, the DAC, in collaboration with the American Diabetes Association, introduced a Diabetes Advocacy Day at the N. C. General Assembly. The purpose of this day is to educate legislators on the burden of diabetes and showcase the work of diabetes partnerships throughout the State. Diabetes Advocacy Day is held on the even year General Assembly sessions and corresponds to national efforts to raise awareness about the importance of early detection.

Social Marketing and Health Communications: The DPCP emphasizes primary and secondary prevention of diabetes in much of its social marketing and communication campaigns. The program annually sponsors audience-specific messages, highlighting physical activity and good nutrition as key to avoiding diabetes and/or reducing the complications associated with the disease. Many of the media tools are nationally developed and tested for efficacy prior to adaptation for North Carolina. Recent campaigns highlighted the benefits of managing the ABC’s (Alc, Blood Pressure, and Cholesterol). Through a partnership with the Durham Herald-Sun, the DPCP encourages prevention through health communication messages and reports on statewide diabetes initiatives. In 2010, the DPCP will launch a YouTube project that will highlight people


with diabetes in North Carolina. The goal of the campaign is to raise awareness of diabetes prevention and the prevention of complications in people with diabetes. Social media is a fledgling field that offers a new way to connect with people with and at risk for chronic conditions. It allows for instant feedback and adjustments in the approach.

Community Engagement Activities to Eliminate Health Disparities: In 2009, the Kate B. Reynolds Charitable Trust awarded the North Carolina (NC) Public Health Foundation a one-year grant to plan a healthy living program in Lenoir and Pamlico Counties. This planning phase of Living Healthy for Men by Men (LHMM) sought to learn what African-American men believed about healthy living, and about preventing and controlling diabetes and other chronic diseases (including heart disease, high blood pressure, lung disease, stroke, etc.). To guide the design and implementation of the program, an Advisory Committee, representative of various community networks and formal and informal leadership structures, was established. The Committee and several male residents (via focus groups) identified barriers to healthy living for African-American men and strategies to remove these barriers.

In Pamlico County, the Advisory Committee started a health education and weight control program. Also, Committee members and their wives completed a four-day training on Chronic Disease Self-Management. In Lenoir County, the Advisory Committee seeks to make policy changes. They have presented findings on barriers to healthy living for African-American men to Lenoir County officials.

In 2009, lessons learned from this project were applied in Hyde County, where diabetes morbidity and mortality rates are among the state’s highest.

The Hyde County project, titled Project DIRECT (Diabetes Interventions Reaching & Educating Communities Together) Legacy for Men, promotes healthy living for African-American men. Educational workshops, presentations and home visits are led by trained community members, largely African-American men. The project is funded through a grant from the Medical University of South Carolina, College of Nursing, South Eastern African American Center of Excellence to Eliminate Disparities (SEA-CEED). This project represents a partnership of state, regional, and local groups ranging from the state health agencies to faith communities to Hyde County’s own Toy Truckers Club, a group of truck owners who volunteer for community programs.

The program’s focus is on providing a “Legacy for Men” by relying on everyday people from the community to train other area residents. Hyde County’s success story will serve as a model for communities throughout the state.

Progress on 2005–2010 North Carolina Diabetes Strategic Plan

Progress has been made in addressing diabetes in North Carolina. The Diabetes Strategic Plan for 2005–2010 identified 58 strategies across seven priority areas. Most (85%) of these strategies have been fully or partially implemented. The Strategic Plan also identified 13 outcome indicators, and 2010 targets, based both on CDC expectations for state diabetes prevention and control programs and state-specific goals.

State BRFSS data from 2009 indicate improvement from baseline for several indicators, including increasing the percentage of people with diabetes in North Carolina who obtained influenza and


pneumococcal vaccines, received at least two hemoglobin A1c tests annually, met CDC physical activity recommendations, and took daily aspirin if they also had cardiovascular conditions. A favorable decrease from baseline occurred in the percentage of people with diabetes who smoke. An improvement from baseline was also seen in the gap in diabetes mortality rates among whites versus minority populations.

Outcomes Identified in the NC Diabetes Strategic Plan, 2005–2010

2003Baseline

2009BRFSS

2010Target

Increase the percentage of persons with diabetes who:Receive annual foot exam 76.4% 75.7% 80.2%Receive annual dilated eye exam 75.5% 68.4% 79.3%Receive annual influenza vaccine 58.0% 62.9% 63.8%Receive pneumococcal vaccine 52.0% 55.0% 57.2%Receive two hemoglobin A1c tests annually 73.8% 74.8% 77.5%Receive a blood test for diabetes 61.9% 61.4% 68.1%Receive health care provider advice about weight to control either diabetes or pre-diabetes

43.8% N/A 54.7%

Meet the CDC physical activity recommendations 29.0% 31.2% 37.7%Have cardiovascular conditions and take daily aspirin 57.3% 58.2% 63.0%Have a blood pressure <130/80 and an LDL cholesterol <100 mg/dl 10 N/A

BP - 58%LDL-C - 50%

BP - 70%LDL-C - 70%

Decrease the percentage of persons with diabetes who:Smoke 18.6% 15.3% 16.7%Are hospitalized or visit the Emergency Department for hypoglycemia or other diabetes complications

N/A 6.7% 5.7%

Decrease gap or disparity in diabetes mortality rates among whites versus minority populations.

29.1% 28.5% 27.6%

BRFSS data for 2010 are not yet available, making it difficult to assess final progress on identified indictors. While indictors may improve further toward 2010 targets, it also is possible that some targets may be unrealistic for what can be achieved within five years. For example, the 2010 target for the percentage of people with diabetes who meet CDC physical activity recommendations represents a 30 percent improvement over baseline (from 29.0% to 37.7%). It is unlikely that this indicator will increase further by 6.5 percent (from 31.2% to 37.7%) in the remaining year, as this represents a 21 percent increase from 2009 levels. Nonetheless, these indicators will continue to be monitored to track progress over time.

10Source: IPIP (Nov 2009)


Chapter 3: Diabetes Prevention and Management Strategies

This chapter of the North Carolina Diabetes Strategic Plan identifies statewide strategies for the prevention and management of diabetes to be implemented during the years 2011–2015 through the joint efforts of the North Carolina Diabetes Advisory Council, Diabetes Prevention and Control Branch of the North Carolina Department of Health and Human Services, and their collaborative partners. The following sections 1) describe the process for developing the plan,2) summarize evidence and best practices for addressing diabetes, 3) present the framework used to develop strategies, and 4) identify a comprehensive set of priority strategies.

Developing the Plan

A two-day strategic planning meeting with a diverse group of stakeholders was convened in March 2010 (see appendix for participants) to review epidemiological data on the burden of diabetes, discuss evidence and best practices in diabetes prevention and management, conduct an environmental scan to identify strengths and needs, and develop priority strategies. The planning process was highly participatory and included a series of facilitated small group discussions to develop strategies, followed by a nominal group process to determine overall strategic priorities. Evaluation of the planning meeting indicated a high degree of participant satisfaction with the planning process and it products.

To cultivate buy-in and ownership of the planning process, a core working group of DAC leadership helped design the meeting, facilitate small group discussions during the meeting, and review early drafts of the strategic plan as it was developed afterwards. The full DAC then met in July 2010 to review and finalize the strategic plan. David Napp, an independent consultant under contact with the DPCB, collaborated with the DAC to facilitate the strategic planning process and write the strategic plan.

Evidence and Best Practices

The strategies in this plan are grounded in evidence and best practices for the prevention and management of diabetes. While no single best source of evidence and best practices exists, the Centers for Disease Control and Prevention (CDC), and the American Diabetes Association (ADA) have conducted systematic reviews of the literature and gathered expert opinion to produce recommendations for diabetes prevention and management. The CDC’s Guide to Community Preventive Services for Diabetes recommends strategies for diabetes case management, diabetes self-management education, and disease management as an organized, proactive, multi-component approach to healthcare delivery for people with diabetes.11 Recommendations from CDC’s Division of Diabetes Translation include health system strategies for integrated disease management, continuous quality improvement, copayment reduction, and enhanced basic coverage rates, as well as policy strategies for food and menu labeling, and for physical activity and nutrition in schools. 12 Lastly, the ADA’s recently updated Standards of Medical Care in Diabetes includes recommendations for screening, diagnostic, and therapeutic actions to favorably affect health outcomes of patients with diabetes.13

11www.thecommunityguide.org12 Framework and Update on Best Practices for Prevention and Control of Diabetes, Edward Gregg, CDC, Division of Diabetes Translation, 5/12/1013 ADA Clinical Guidelines, 2010, www.diabetes.org


Some important sources of evidence and best practices also come from the national Institute of Medicine (IOM) and the North Carolina Institute of Medicine (NCIOM), both of which have conducted systematic reviews and developed recommendations that, while not specific to diabetes, have important implications for diabetes prevention and management. The IOM developed recommendations to reduce sodium intake in the United States that encourage public health agencies and their private and public partners to support reduction of sodium levels in the food supply and to engage in activities that support consumers in reducing their sodium intake. 14 The NCIOM’s 2010 Prevention Action Plan for North Carolina includes recommendations on a broad array of public health issues, some of which affect diabetes risk and health outcomes. For example, the Prevention Action Plan recommends increasing taxes on all tobacco products, expanding smoke-free policies, and improving access to cessation services. It also recommends menu labeling, school nutrition and physical activity policies, and improved community access to opportunities for physical activity. 15

There is a growing body of literature on the role of social determinates of health and the important role of public health agencies in policy and environmental change strategies to address underlying causes of chronic disease, such as poverty, food insecurity, and societal stress, as well as more proximal contributors like tobacco use, physical inactivity, and poor nutritional intake. 16 17 Policy and environmental change are considered relatively low-cost, high-reach strategies to address chronic diseases; they operate by influencing access, incentives, and social norms and help create

supportive environments for subsequent targeted interventions. 18

While most literature identified discusses the role of social determinates of health in general, or chronic diseases more specifically, some have described a direct link between social determinants and the incidence and management of diabetes. 19 This research indicates that stresses associated with poverty and material deprivations of healthy food and adequate housing accumulate over the lifespan, which in turn can increase the likelihood of diabetes. For example, poverty is associated with low birth weight, which has been shown to increase the risk of diabetes in adulthood. Poverty is similarly associated with obesity and physical inactivity, which further increase susceptibility to diabetes. Furthermore, psychological stress, also associated with poverty, has direct effects that increase the likelihood of diabetes via neuro-endocrine pathways as well as indirect effects leading to adoption of unhealthy behaviors as an adaptive response to environmental conditions. Lifestyle changes related to diet and physical activity necessary for diabetes self-management may be particularly difficult for low-income individuals.

Strategy Framework

The strategies in this plan were developed in accordance with the Health Impact Pyramid, a framework for developing public health strategies endorsed by the Centers for Disease Control and Prevention (CDC). The Health Impact Pyramid provides a useful framework for developing diabetes prevention and management strategies and underscores the importance of interventions at multiple levels to achieve greatest public health

14 Institute of Medicine. 2010. Strategies to Reduce Sodium Intake in the Unites States. Washington, DC: The National Academies Press.15 North Carolina Institute of Medicine, Prevention for the Health of North Carolina: Prevention Action Plan, 200616 Baker, E., Metzler, M., and Galea, S. Addressing Social Determinants of Health Inequities: Learning from Doing. Am J Public Health. 2005; 95:4, 553-55517 Schmid, T. L., Pratt, M., and Howze, E. Policy as Intervention: Environmental and Policy Approaches to the Prevention of Cardiovascular Disease18 Am J Public Health. 1995; 85:1207-1211. Brownson RC, Haire-Joshu D, Luke DA. (2006). Shaping the context of health: a review of environmental and policy approaches in the prevention of chronic diseases. Annu Rev Public Health: 27:341-70.19 Raphael, D, et al. The social determinants of the incidence and management of type 2 diabetes mellitus: are we prepared to rethink our questions and redirect our research activities? Leadership in Health Services. 2003;16(3):10-20.)


impact. This framework describes five levels of intervention addressing socioeconomic factors, such as reducing poverty and increasing educational attainment; changing the context to make default decisions healthy, such as increasing the availability of healthy foods; offering long-lasting protective interventions, such as smoking cessation; providing clinical interventions, such as screening and early intervention; and making available counseling and education interventions, such as support groups and social marketing campaigns.

Interventions at the lower levels of the pyramid generally have greater public health impact because they reach broader segments of society and are less dependent on individual-level behavior change. Interventions at

higher levels of the pyramid tend to require ongoing programmatic or clinical efforts, reach fewer people, and are more dependent on patient adherence and behavior modification. Strategies that include multiple interventions at many levels of the Health Impact Pyramid are more likely to have public health impact than strategies that omit intervention levels.

This framework has several important implications for diabetes prevention and management strategies. While counseling and education, and clinical interventions, are important and familiar approaches

to addressing diabetes, this framework indicates the need to also incorporate robust environment and policy change strategies that address risk and protective factors for interrelated chronic diseases. Strategies at the lower levels of the pyramid present some unique challenges in that they involve policy changes, require collaboration among stakeholders frequently funded to address specific chronic diseases and their risk factors, and broaden the focus to include social determinants of health that fall outside of a more traditional public health scope.

The Health Impact Pyramid



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Strategic Priorities

Socioeconomic Factors

Strategies to address socioeconomic factors, also sometimes referred to as social determinants of health, will focus primarily on poverty and educational attainment since the burden of diabetes and its complications disproportionately affect people with lower levels of income and education. Poverty and education also impacts access to health care and other health innovations as well as food security, and nutritional and physical fitness. Addressing these issues will necessitate non-traditional partnerships with those working outside the scope of diabetes prevention and management strategies and require collaboration with state and local education and economic development efforts. Building partnerships among traditional and non-traditional stakeholder groups within and outside of public health will be an essential feature of strategies to address social determinants.

• PartnerwiththeStateDepartmentofPublicInstruction and those working on Coordinated School Health to emphasize the relationship between health and educational attainment.

• Collaboratewithagenciesandorganizationsengaged in economic development efforts to highlight the relationship between poverty, diabetes, and other chronic diseases.

• Workwithenvironmentalhealthagenciestoidentify and reduce environmental triggers that can contribute to onset of type 1 diabetes.

• Developandwidelydisseminateawhite

paper on the relationship between poverty, educational attainment, and diabetes and other chronic diseases.

Changing the Context

These strategies focus on changing the environmental context within which people make choices that affect risk for diabetes and effective management of disease. The overarching goal of these strategies is to make healthy choices the easiest ones This may be accomplished through strategies that increase the availability of healthy foods, improve food security, expand opportunities for physical activity, reduce financial barriers to health care, and create disincentives for tobacco use and incentives for healthy behaviors, such as:• Developajointpolicyplatformtoaddressinterrelated chronic diseases across the Diabetes Prevention and Control Branch, Heart Disease and Stroke Prevention Branch, Physical Activity and Nutrition Branch, and Tobacco Cessation Branch within the North Carolina Department of Health and Human Services.

• WorkwithNorthCarolinabasedfoodretailers to increase the availability of healthy foods; for example, with limited sodium and increased fiber.

• Sponsorapilotprojecttoalterfoodplacement in grocery stores to favor healthy options.

• Collaboratewithstateandlocalstakeholdersto alter the physical environment to enhance opportunities for physical activity; for example, encourage development of walkable communities


and other characteristics of urban planning that support physical activity.

• Supportimplementationofphysicalactivity and nutrition requirements for elementary and middle schools, encourage expansion of these requirements to high schools, and strengthen requirements for all grades.

• Encouragehealthinsurerstoaddfinancialincentives for diabetes prevention and management, such as member wellness benefits; lowering premiums for participating in diabetes prevention counseling, chronic disease education, and diabetes self-management classes; and increasing Medicaid and Medicare reimbursement for diabetes prevention and management.

• Expandtobacco-freepoliciestoallworkplaces, and support efforts to strengthen the tobacco tax and other financial disincentives to tobacco use.

• Increasetheroleofcommunityadvocatesin health care planning and policy advisory groups to ensure the consumer voice is well represented on decision-making bodies.

• Expandthenumberofworksitewellnessprograms statewide.

Long-Lasting Protective Interventions

These strategies emphasize short-term interventions with long-term protective effects. Although they focus on reaching individuals, these interventions require relatively brief interaction with the public

health and health care system and, therefore, may be more cost-effective and less dependent on long-term patient adherence than clinical, counseling, and education interventions.• Improveaccessforpeoplewithdiabetestodiabetes prevention and management services by expanding local health department participation in the Diabetes Self Management Program (DSME) and encouraging community members who complete DSME to also participate in the Chronic Disease Self Management Program.

• Increaseparticipationinsmokingcessation programs by increasing their availability, strengthening referral linkages from health care providers, and decreasing barriers to enrollment.

• Promotepneumococcalvaccineandinfluenza vaccine for people with diabetes.

Clinical Interventions

Clinical interventions focus on screening, referral, and provision of health care, as well as strategies that improve the quality of care and the organization of the health care system. Clinical interventions typically focus on individuals, require ongoing long-term interaction between the patient and the health care system, and are dependent on patient adherence. It should be noted that access to care issues related to insurance coverage are likely to be addressed by strategies described above under Changing the Context, and that strategies to address Socioeconomic Factors recognize the role of poverty and lack of education as barriers to health care access.• Buildcollaborativeprovidersystemsatthe local level to ensure continuity in care, with emphasis on outcomes and quality of life; for


example, development of medical homes, creation of accountable care organizations, and use of the Planned Care Model.

• Improvescreeningandmanagementofdiabetes by encouraging healthcare providers to follow ADA guidelines, and include oral health and auditory screening as part of baseline assessments for people with diabetes.

• Requireallclinicallaboratoriestoautomatically compute and report eGFR values for all creatine determinations, and require that providers discuss results with patients.

• Improveearlyinterventionbyencouraginghospitals to link patients identified with, or at risk for, diabetes to case management and referral services upon discharge.

• Supportnationalcertificationforschoolnurses consistent with recognized guidelines in patient education, and increase school nurse ratio to recommended 1:750.

• Increasetheuseoflayambassadorsandcertified diabetes educators within the health care system to help screen for diabetes risk, and to educate patients about healthy lifestyles and disease prevention.

• Supportdiabetesqualityimprovementinitiatives by establishing an A1c registry, using electronic health records data, and GIS mapping of 250.xx diabetes reimbursement code.

• Encouragegeneralprovidersandendocrinologists to test for sleep apnea and hearing

loss in people with diabetes, recognizing sleep apnea as a potentially fatal co-morbidity and that hearing loss may be the root cause of depression in some people with diabetes.

Counseling and Education

These strategies include counseling and education strategies to be provided in clinical and community settings. The goal of these strategies in generally to raise awareness of diabetes, and to provide information to encourage behavior change. These strategies may target populations, for example through social marketing campaigns, or they may target individuals, as with support groups.

• Enlistthesupportofcivic,faith-based,andother community groups to raise awareness about diabetes, including risk factors, prevention, and management.

• Improveconsumeraccesstoinformationabout healthy food choices by developing guidelines for nutrition labeling in restaurants and grocery stores.

• Createculturallycompetentandlanguageappropriate diabetes self-management education tools and curricula.

• Raiseawarenessaboutlesswell-knowndiabetes co-morbidities such as hearing loss and sleep apnea.

• Conductandevaluatesocialmarketingcampaigns about diabetes prevention and management tailored to specific audiences


experiencing a disproportionate burden of diabetes in the state.

• Developpeer-ledsupportgroupsincollaboration with health professionals for diabetes management patients, and build referral networks from local healthcare systems to these groups.

• Expandaccesstoeducationalinterventionsby establishing a mechanism to facilitate referral for community members participating in the WISEWOMAN program to local health department Diabetes Self Management Programs and Chronic Disease Self Management Programs.

Supporting Development of Local Strategies

Supporting development of regional and county-level action on diabetes prevention and management is an important cross-cutting statewide strategy, aligning with all levels of the Health Impact Pyramid described above. The purpose of these strategies is to partner with existing stakeholder groups, such as Healthy Carolinians, Diabetes Today, and the North Carolina Northeast Partnership for Public Health, as well as non-traditional groups outside the public health and health care systems, such as the Department of Corrections, to guide development of evidence-based strategies that address diabetes and related chronic diseases at multiple levels.In 2010, the CDC’s Division of Diabetes Translation released a matrix showing impactful strategies to prevent and control diabetes that address system and community-level changes. The Diabetes Prevention and Control Branch will use this matrix to engage community partnerships to focus efforts on strategies that can make the greatest impact,

including advocating for a medical home for people with diabetes; encouraging providers to use the planned care model to assure quality care of people with diabetes; advocating for reimbursement of lifestyle interventions; and lowering of insurance rates for those who receive diabetes self-management education, worksite wellness initiatives, and community based social marketing campaigns.

A key component of successful implementation of local strategies is using evidence as a base, and then translating evidence into local strategies. These types of community-based participatory approaches are valuable because they rely on the community to assess the issue, plan the action, implement the strategies, and evaluate the results. There is a much higher degree of sustainability when strategies come directly from the people who will benefit from them. Project DIRECT was a multi-year CDC demonstration project that showed that communities can effectively work to reduce the burden of diabetes. Some strategies that were particularly effective for Project DIRECT that can translate to other communities are:

• Developinglayleadersforwalkingprograms.

• Workingwithfaithcommunitykitchencommittees to learn to prepare healthy options for congregational celebrations.

• Makingwalkingtrailsmoreuser-friendlythrough signage and lighting.


Surveillance and Data Needs

Surveillance and data strategies will supplement existing epidemiological and other data sets to help better understand the burden of diabetes in the state and inform the development of new diabetes prevention and management strategies. As such, these strategies apply to all levels of the Health Impact Pyramid. A Surveillance and Data Task Force of the Diabetes Advisory Council will be established to assist in the implementation of these strategies.

• Establishadatabasetomonitorsocialdeterminants of health indicators recommended by the National Association of Chronic Disease Director’s Diabetes Council, such as poverty rate, cigarette tax, percent of local budget spent on public health, and expenditures on natural resources, parks, and recreation.

• EstablishingnewN.C.YouthRiskBehaviorSurvey (YRBS) measures of diabetes knowledge and prevalence for high school students with diabetes.• Conductfocusgroupswithpeoplelivingwith diabetes to better understand their perspective on barriers and facilitators to diabetes prevention and management.

• Developsurveillancestrategiesforinstitutionalized populations often not represented in BRFSS data, such as those with developmental disabilities, substance abusers, and individuals within the mental health system, as these populations represent a significant portion of those with diabetes.


Chapter 4: Evaluation

This section describes strategies for evaluation of the strategic plan, including the logic model, process and outcome monitoring, outcome indicators, baseline measures, and data sources.

Logic Model

The logic model below depicts the inputs, strategies, outcomes, and impacts that form the foundation of this strategic plan. Strategies in the model reflect the five levels of the Health Impact Pyramid as

well as proposed efforts to support development of locally derived evidence-based approaches to address diabetes, and to address surveillance and data needs Outcomes are stratified in three levels – shorter, intermediate, and longer – to represent intended proximal and distal results and the manner in which they interact to yield impacts for the prevention of diabetes, reduction of complications from diabetes, and decrease in diabetes health disparities.

Draft Version Date: October 8, 2010 24

Counseling & Education

Clinical

Interventions

Long-lasting Protective

Interventions

Changing the Context to Encourage

Healthy Decisions

Socioeconomic

Factors

Supporting Development

of Local Strategies

Surveillance

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Increase opportunities for

healthy eating and physical activity

Increase provider compliance with

clinical guidelines

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recommendations

Inputs

DAC and Task Forces

Diabetes Prevention and Control Branch

Internal and External Partners

Federal, State, and Local Funding

North Carolina Diabetes Prevention and Control Logic Model, 2011–2015

Prevent diabetes

Reduce

complications from diabetes

Decrease

diabetes health disparities

Individual and community awareness, attitudes towards, and knowledge of diabetes

Evidence-based integrated health care

Policies and environments

responsive to diabetes risk and protective

factors

Partnerships with stakeholders to address social determinants of

diabetes risk

Intermediate Longer

Decrease diabetes risk

factors

Improve quality of life and health

for those with diabetes

Locally derived evidence-based

strategies

Improved disease monitoring


Process Evaluation

Process evaluation will focus on monitoring the extent to which the strategies specified in this plan are implemented. The intent is to ensure accountability in implementation, track successes, identify challenges, and prompt development of additional strategies in response to emergent conditions. At the beginning of each year covered by this plan, the DAC, DPCB, and their collaborative partners will develop a joint action plan specifying how priority strategies will be implemented for that year. The action plan will include implementation targets for each priority strategy, and those targets will be monitored during the course of the year. For example, if development of a joint policy platform is selected as a priority strategy for a given year (see Changing the Context strategies), then process evaluation data may include a listing of parties that collaborated to develop the policy platform, the language of the policy platform itself, and documentation of subsequent actions to enact the policy. At the end of each year covered by this plan, a progress report based on specified implementation targets will be provided to the DAC, DPCB, and their collaborative partners as a prelude to action planning for the subsequent year.

Outcome Monitoring

Outcome monitoring for this plan emphasizes the use of secondary data to assess population-level changes in diabetes risk and management. Selection of outcome indictors requires careful consideration of available secondary data sources, identification of domains for which measurable change is likely to occur within the time frame addressed by this plan, and responsiveness to national and state-level goals for Healthy People 2020. Measuring population-level impacts such as decreasing diabetes incidence, reducing diabetes complications, and eliminating disparities is not feasible within the scope of this evaluation and is complicated by numerous

confounding variables that make it difficult to attribute such distal impacts to the strategies specified in this plan. For that reason, outcome indicators have been selected that are aligned with the longer-term outcomes represented in the logic model. However, a strong theoretical basis supports the assumption that achieving the specified longer-term outcomes will substantially contribute to impact level changes. The following indicators will be used to monitor outcomes of this strategic plan. Additional information about indicators is provided in Attachment: Outcome Monitoring Indicators, including current baseline levels, data sources, and rationale.

• Increasethepercentageofpeoplewithdiabetes who demonstrate good Glycemic control via A1c < 7.

• Increasethepercentageofpeoplewithdiabetes who have seen a health professional to have their blood pressure evaluated.

• Decreasethepercentageofpeoplewithdiabetes who have been told by a health professional that they have high blood cholesterol.

• Increasethepercentageofpersonswithdiabetes who receive pneumococcal vaccine. • Increasethepercentageofpersonswithdiabetes who receive annual influenza vaccine.

• Reducetherateoflowerextremityamputations in persons with diabetes.

• Reducethepercentageofpeoplewithdiagnosed diabetes who smoke.

• Increasethepercentageofpeoplewithpre-diabetes or multiple diabetes risk factors who are engaged in diabetes prevention activities (e.g., physical activity and healthy nutrition).


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Diabetes Strategic Planning Meeting Participants, March 18–19, 2010

Diabetes Advisory Council MembersDolly Daniel InnovexNelson Dollar NC House of RepresentativesBeverly R. Goble Person Living with DiabetesJoe Konen Physician, PfizerBetty Lamb ConsumerSue Liverman Rural Health GroupJanet Nicollerat Adult Diabetes at Duke UniversitySharon Pearce NC Association of Nurse AnesthetistsJanet Southerland UNC School of DentistryMarti Wolf NC Community Health Center AssociationPeggy Yarborough Retired Pharmacist

Diabetes Advisory Council Task Force MembersBrandy Barnes Diabetes Sisters, Inc.Jennifer Cockerham Community Care of NCRonald DeVizia Piedmont Pharmaceutical Care Network

Invited GuestsAbhay Agarwal NC Department of Correction Division of PrisonsJeff Bachar Eastern Band of Cherokee IndiansDebra Carter NC Hospital AssociationKevin Cragwell Alexander Family YMCALaura Edwards NC Public Health FoundationKim Hanchette Diabetes Bus InitiativeDenise Hockaday National Kidney Foundation, Inc.Melvin Jackson Project DIRECT/Strengthening the Black FamilyJerri Mayberry Surry County Health and Nutrition CenterJackie McClelland NC Cooperative Extension NC State University Michael Moseley Living Healthy for Men by Men Lenoir CoBeth Oakley Prevent Blindness NC Theodore Parrish NC Central University Dept of Public Health EducationKaren Ramsey Nash County Health DeptBarbara Roole NC Health and Wellness Trust Fund


Invited Guests, continuedPaula Smith NC Department of Correction Division of PrisonsJennifer Talbot Prevent Blindness NC Greg Walters Piedmont Health Coalition, IncNeil Williams Clinical Pharmacist Coordinator, Community Care of NCAnne Wrenn Brunswick County Health Department

State Liaisons to the Diabetes Advisory CouncilElizabeth MacLachlan NC Public Health FoundationAmy Quesinberry Winston-Salem Regional Office, Women, Children and Health

Section, NC Div of Public HealthJeremy Moseley Heart Disease and Stroke PreventionJoyce Swetlick Tobacco

North Carolina Department of Health and Human ServicesBrenda Brogden Diabetes Prevention and Control BranchDelmonte Jefferson WISEWOMANCindy Haynes-Morgan Diabetes Prevention and Control BranchChristine Ogden Chronic Disease and Injury Prevention SectionJoyce Page Diabetes Prevention and Control BranchRuth Petersen Chronic Disease and Injury Prevention SectionParvati Potru Diabetes Prevention and Control BranchApril Reese Diabetes Prevention and Control BranchJoanne Rinker Diabetes Prevention and Control BranchDe Vernon Diabetes Prevention and Control Branch

North CarolinaDiabetes Strategic Plan

2011–2015

North Carolina Department of Health and Human Services

N.C. Diabetes Prevention and Control

www.ncdiabetes.org

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