Type 2 Diabetes Screening Type 2 Diabetes Screening & Education Program& Education Program

Margaret Lynn Yonekura, MD, Margaret Lynn Yonekura, MD, Heather Kun, PhD, Luis Dimen, MD, Heather Kun, PhD, Luis Dimen, MD,

Mariola Ficinski, MDMariola Ficinski, MD

BackgroundBackground

6/24/08 News Bulletin from CDC6/24/08 News Bulletin from CDC 24 million Americans (8%) now have diagnosed 24 million Americans (8%) now have diagnosed

diabetes, an increase of 3 million in the past 2 yearsdiabetes, an increase of 3 million in the past 2 years Another 57 million have prediabetesAnother 57 million have prediabetes Striking racial/ethnic disparities among those with Striking racial/ethnic disparities among those with

diagnosed diabetes:diagnosed diabetes: 16.5% of Native Americans/Native Alaskans16.5% of Native Americans/Native Alaskans 11.8% of African Americans11.8% of African Americans 10.4% of Hispanics10.4% of Hispanics 7.4% of Asian Americans7.4% of Asian Americans 6.6% of Whites6.6% of Whites

BackgroundBackground

Steady rise of diabetes in Los Angeles Steady rise of diabetes in Los Angeles County among adults County among adults >> 18 yr from 6.6% in 18 yr from 6.6% in 1997 to 8.6% in 20051997 to 8.6% in 2005

Those with the least access to preventive Those with the least access to preventive health care at highest risk:health care at highest risk:Rates for Latinos and AA double that of Rates for Latinos and AA double that of

whites and Asian/PIwhites and Asian/PIRates increased most rapidly among poor Rates increased most rapidly among poor

(14% of 0-99% FPL vs 6.5% of >200%FPL) (14% of 0-99% FPL vs 6.5% of >200%FPL) and non-HS graduatesand non-HS graduates

ObjectivesObjectives

1.1. Increase early identification of those at high-Increase early identification of those at high-risk for developing diabetes and provide risk for developing diabetes and provide education and promote behavioral changes to education and promote behavioral changes to prevent its developmentprevent its development

2.2. Increase early diagnosis of those with diabetes Increase early diagnosis of those with diabetes and provide education and support to help and provide education and support to help them manage their diseasethem manage their disease

3.3. Educate providers to promote quality diabetes Educate providers to promote quality diabetes care in the communitycare in the community

Chronic Disease Management Chronic Disease Management ConsortiumConsortium

Participating hospitalsParticipating hospitals California Hospital Medical CenterCalifornia Hospital Medical Center Huntington Memorial HospitalHuntington Memorial Hospital Good Samaritan HospitalGood Samaritan Hospital

No pediatricsNo pediatrics Childrens Hospital Los AngelesChildrens Hospital Los Angeles

Only pediatricsOnly pediatrics

National Health FoundationNational Health Foundation Functions for Consortium: grant writer, facilitator, Functions for Consortium: grant writer, facilitator,

design and management of web-based data system, design and management of web-based data system, and evaluator. and evaluator.

MethodsMethods

All services provided in English and All services provided in English and Spanish free of chargeSpanish free of chargeFunded by a 3-year grant from the Good Funded by a 3-year grant from the Good

Hope Medical FoundationHope Medical FoundationOutreach education about type 2 diabetes Outreach education about type 2 diabetes

and screening using the ADA Risk Test at and screening using the ADA Risk Test at a variety of community sitesa variety of community sites

ADA Risk TestADA Risk Test

1. My weight is equal to or above that listed in the 1. My weight is equal to or above that listed in the chart. (BMI chart)chart. (BMI chart)

YesYes 55

2. I am under 65 years of age 2. I am under 65 years of age andand I get little or no I get little or no exercise during a usual day.exercise during a usual day.

YesYes 55

3. I am between 45 and 64 years of age.3. I am between 45 and 64 years of age. YesYes 55

4. I am 65 years old or older.4. I am 65 years old or older. YesYes 99

5. I am a woman who has had a baby weighing more 5. I am a woman who has had a baby weighing more than 9 pounds at birth.than 9 pounds at birth.

YesYes 11

6. I have a sister or brother with diabetes.6. I have a sister or brother with diabetes. YesYes 11

7. I have a parent with diabetes.7. I have a parent with diabetes. YesYes 11

Scoring 3-9 points: probably low risk for diabetes now Scoring 3-9 points: probably low risk for diabetes now but don’t forget about it.but don’t forget about it.

Scoring 10 or more points: greater risk for diabetes. Get Scoring 10 or more points: greater risk for diabetes. Get tested by your health care provider.tested by your health care provider.

Program CurriculaProgram Curricula

Developed by dieticians from three collaborating Developed by dieticians from three collaborating hospitals based on current recommendationshospitals based on current recommendations

Each 2 hour workshop is Each 2 hour workshop is highly interactivehighly interactive so so that program participants are able to that program participants are able to both learn both learn and applyand apply the facts, principles, and concepts the facts, principles, and concepts being taught.being taught.

Action planning at end of each workshopAction planning at end of each workshop Olympic Food Guide is a tool developed to help Olympic Food Guide is a tool developed to help

participants make healthier food choices.participants make healthier food choices.

StandardizationStandardization

Same training for Health EducatorsSame training for Health EducatorsCHW/CHW/promotoraspromotorasMPH/RDMPH/RD

Same “take aways” from workshopsSame “take aways” from workshopsConsistent number and sequence of Consistent number and sequence of

workshopsworkshopsSame clinical and self-reported outcomesSame clinical and self-reported outcomes

MethodsMethods

Food, Fitness, and Diabetes PreventionFood, Fitness, and Diabetes Prevention Intake process: health screen, activity & Intake process: health screen, activity &

nutrition assessmentnutrition assessment4 weekly 2-hour sessions conducted by either 4 weekly 2-hour sessions conducted by either

CHW/CHW/promotoraspromotoras or professional staff (MPH or professional staff (MPH or RD)or RD)

3-6 month follow-up: repeat health screen, 3-6 month follow-up: repeat health screen, activity & nutrition reassessmentsactivity & nutrition reassessments

Telephone education and support groups as Telephone education and support groups as neededneeded

Food, Fitness & Diabetes Food, Fitness & Diabetes Prevention: Prevention: ModulesModules

1.1. Diabetes prevention, good nutrition, and Diabetes prevention, good nutrition, and our healthour health

2.2. Healthy meals & healthy movementHealthy meals & healthy movement

3.3. Reading food labelsReading food labels

4.4. Heart health & disease preventionHeart health & disease prevention

The Gap!(It is Widening!)

American Culture

Healthy Lifestyles

MethodsMethods

Living with DiabetesLiving with Diabetes Intake process: health screen, diabetes knowledge Intake process: health screen, diabetes knowledge

and self-efficacy assessment, activity & nutrition and self-efficacy assessment, activity & nutrition assessmentassessment

4 weekly 2-hour sessions4 weekly 2-hour sessions 3-6 month follow-up: repeat health screen, diabetes 3-6 month follow-up: repeat health screen, diabetes

knowledge and self-efficacy reassessment, activity & knowledge and self-efficacy reassessment, activity & nutrition reassessments nutrition reassessments

Telephone education and support groups as neededTelephone education and support groups as needed

Chronic Disease Self-Management ProgramChronic Disease Self-Management Program 6 weekly 2-hour sessions conducted by certified lay 6 weekly 2-hour sessions conducted by certified lay

leaders, at least one of whom has a chronic conditionleaders, at least one of whom has a chronic condition

Living with Diabetes: Living with Diabetes: ModulesModules

1.1. About diabetes and monitoring your bodyAbout diabetes and monitoring your bodyTake Charge! with Take Charge! with Diabetes Health RecordDiabetes Health Record

www.caldiabetes.orgwww.caldiabetes.org

2.2. Nutrition, part 1Nutrition, part 1Carbohydrates and sugar, protein & fatCarbohydrates and sugar, protein & fatPlate method & carbohydrate countingPlate method & carbohydrate counting

3.3. Nutrition, part 2Nutrition, part 2Reading food labels, healthy kitchen, Reading food labels, healthy kitchen,

recipes recipes & physical activity& physical activity4.4. Preventing complications and medicationsPreventing complications and medications

ResultsResults

Outreach & ScreeningOutreach & Screening

Between October 2005 and August 2008Between October 2005 and August 2008286 outreach events286 outreach events5418 ADA Risk Tests administered5418 ADA Risk Tests administered

13% Low/No risk (0-2 pt)13% Low/No risk (0-2 pt)36% Intermediate risk (3-9 pt)36% Intermediate risk (3-9 pt)52% High risk (> 9 pt)52% High risk (> 9 pt)

2095 high risk clients referred to provider for 2095 high risk clients referred to provider for testingtesting

Type 2 Diabetes Prevention Type 2 Diabetes Prevention ProgramProgram

Between October 2005 and August 2008Between October 2005 and August 2008852 participants852 participants

67% Hispanic,17% Caucasian, 7% African 67% Hispanic,17% Caucasian, 7% African American, 7% AsianAmerican, 7% Asian

88% female88% female32% overweight, 41% obese32% overweight, 41% obese66% waist circumference above the cutoff66% waist circumference above the cutoff

498 workshops conducted, 53% in English & 498 workshops conducted, 53% in English & 47% in Spanish47% in Spanish

Retention rate 80%Retention rate 80%

Type 2 Diabetes Prevention Type 2 Diabetes Prevention ProgramProgram

27% lost weight (27% lost weight (>> 4 lb) and 9% lost more 4 lb) and 9% lost more than 5% of their weightthan 5% of their weight

46% increased their knowledge about 46% increased their knowledge about healthy eating behaviorshealthy eating behaviors36% eating 36% eating >> 5 servings of fruits & 5 servings of fruits &

vegetables/dvegetables/d76% drinking 76% drinking >> 4 cups of water/d 4 cups of water/d72% eating breakfast daily72% eating breakfast daily76% eating fast food 0-1 days in last week76% eating fast food 0-1 days in last week

Type 2 Diabetes Prevention Type 2 Diabetes Prevention ProgramProgram

At beginning of program 63% knew how At beginning of program 63% knew how much PA is recommendedmuch PA is recommended

21% increased their knowledge about PA21% increased their knowledge about PA62% increased duration of physical activity 62% increased duration of physical activity

to to >> 30 minutes each time 30 minutes each time49% increased the distance walked/d49% increased the distance walked/d35% increased frequency of being 35% increased frequency of being

physically active to physically active to >> 4 times/week 4 times/week

Living with Diabetes ProgramLiving with Diabetes Program Between October 2005 and August 2008Between October 2005 and August 2008

496 participants496 participants 58% Hispanic, 20% African American, 14% Caucasian, 5% 58% Hispanic, 20% African American, 14% Caucasian, 5%

AsianAsian 68% female68% female 29% overweight and 56% obese29% overweight and 56% obese 77% waist circumference above the cutoff77% waist circumference above the cutoff 91% previously diagnosed & 7% newly diagnosed91% previously diagnosed & 7% newly diagnosed Prior morbidity from diabetes: 32% diabetic neuropathy, 16% Prior morbidity from diabetes: 32% diabetic neuropathy, 16%

diabetic retinopathy, 15% gastroparesis, 10% myocardial diabetic retinopathy, 15% gastroparesis, 10% myocardial infarction, 9% stroke, 7% nephropathy, & 2% amputationinfarction, 9% stroke, 7% nephropathy, & 2% amputation

62% Hgb A1c 62% Hgb A1c >> 7 7 61% had hypertension & 38% had elevated cholesterol61% had hypertension & 38% had elevated cholesterol

424 workshops, 59% in English & 40% in Spanish424 workshops, 59% in English & 40% in Spanish 75% retention rate75% retention rate

Living with Diabetes ProgramLiving with Diabetes Program

35% lost weight (35% lost weight (>> 4 lb) and 14% lost 4 lb) and 14% lost more than 5% of their weightmore than 5% of their weight6% decreased waist circumference below 6% decreased waist circumference below

cutoff; total 27%cutoff; total 27%2% decreased body fat to normal range; total 2% decreased body fat to normal range; total

9%9%12% decreased their Hgb A1c below 7; 12% decreased their Hgb A1c below 7;

total of 53% had Hgb A1c < 7total of 53% had Hgb A1c < 7

Living with Diabetes ProgramLiving with Diabetes Program

51% reported increased confidence in improving 51% reported increased confidence in improving their eating habitstheir eating habits 37% eating 37% eating >> 5 servings of fruits & vegetables/d 5 servings of fruits & vegetables/d 79% drinking 79% drinking >> 4 cups of water/d 4 cups of water/d 82% eating breakfast daily82% eating breakfast daily 75% eating fast food 0-1 days in last week75% eating fast food 0-1 days in last week

Living with Diabetes ProgramLiving with Diabetes Program

51% reported increased confidence in improving 51% reported increased confidence in improving their exercise habitstheir exercise habits 12% started being physically active12% started being physically active 37% physically active 37% physically active >> 4 times/wk; 62% total 4 times/wk; 62% total 37% increased frequency37% increased frequency 56% physically active 56% physically active >> 30 minutes each time; 79% 30 minutes each time; 79%

totaltotal 39% increased duration of PA39% increased duration of PA 51% increased distance walked51% increased distance walked

42% increased their emotional wellbeing42% increased their emotional wellbeing

Living with Diabetes ProgramLiving with Diabetes Program 65% reported increased confidence in managing 65% reported increased confidence in managing

their diabetestheir diabetes 20% began asking questions about their diabetes & 20% began asking questions about their diabetes &

treatmenttreatment 14% increase in discussing their personal problems 14% increase in discussing their personal problems

related to diabetes with doctorrelated to diabetes with doctor 46% learned what the Hgb A1c target was46% learned what the Hgb A1c target was 79% checked BS daily79% checked BS daily 87% checked feet daily for sores87% checked feet daily for sores 71% had dilated eye exam in past year71% had dilated eye exam in past year 5% quit smoking5% quit smoking 23% requested pneumonia vaccine23% requested pneumonia vaccine 40% requested flu shot40% requested flu shot

www.patient education.stanford.eduwww.patient education.stanford.edu

Chronic Disease Self Management Chronic Disease Self Management ProgramProgram

54 workshops, 48% in English & 52% in 54 workshops, 48% in English & 52% in SpanishSpanish

252 participants and 282 guests = 538252 participants and 282 guests = 538Retention rate 72%Retention rate 72%

BarriersBarriers

Implementation delayed due to difficulties finding Implementation delayed due to difficulties finding a culturally appropriate curriculuma culturally appropriate curriculum Living with Diabetes/Viviendo Con DiabetesLiving with Diabetes/Viviendo Con Diabetes from from

National Alliance for Hispanic HealthNational Alliance for Hispanic Health California’s California’s Guidelines for CareGuidelines for Care Consortium’s Consortium’s Healthy Eating Lifestyle ProgramHealthy Eating Lifestyle Program

curriculumcurriculum Community distrust of some hospitals as Community distrust of some hospitals as

legitimate source of health informationlegitimate source of health information ““The hospital is here for your health.”The hospital is here for your health.” Collaboration with community clinicsCollaboration with community clinics

BarriersBarriers

Difficulty recruiting participants for the Difficulty recruiting participants for the Prevention ProgramPrevention Program ““reality doesn’t hit them (community reality doesn’t hit them (community

members) until they get diabetes.”members) until they get diabetes.”Began marketing the prevention workshops Began marketing the prevention workshops

as “healthy living” classesas “healthy living” classes

Public Health ImplicationsPublic Health Implications

Benefits of Chronic Disease Management Benefits of Chronic Disease Management ConsortiumConsortium Community hears consistent messageCommunity hears consistent message More efficient and cost effectiveMore efficient and cost effective Able to secure grant fundingAble to secure grant funding

Centralized web-based data collection and Centralized web-based data collection and reporting systemreporting system Provides real-time information on effectiveness of Provides real-time information on effectiveness of

program and progress toward outcomesprogram and progress toward outcomes Data for reports to superiors and current/future Data for reports to superiors and current/future

fundersfunders

Public Health ImplicationsPublic Health Implications

The model of non-profit hospitals working closely The model of non-profit hospitals working closely with local community clinics to address the with local community clinics to address the diabetes epidemic is an important and replicable diabetes epidemic is an important and replicable modelmodel. . Hospital staff provide outreach education & screening Hospital staff provide outreach education & screening

for type 2 diabetes and refer high risk individuals to for type 2 diabetes and refer high risk individuals to clinics for diagnostic testing and on-going care.clinics for diagnostic testing and on-going care.

Individuals at risk for diabetes participate in Individuals at risk for diabetes participate in prevention workshops while those with diabetes learn prevention workshops while those with diabetes learn critical self-management skills in workshops focused critical self-management skills in workshops focused on on Living with DiabetesLiving with Diabetes..

Public Health ImplicationsPublic Health Implications

Patients benefit from improved understanding Patients benefit from improved understanding of what they can do to prevent diabetes of what they can do to prevent diabetes and/or optimize their health and delay/prevent and/or optimize their health and delay/prevent the onset of complications.the onset of complications.

Clinics benefit because of increased patient Clinics benefit because of increased patient compliance with regular preventive care and compliance with regular preventive care and self management.self management.

Hospitals benefit from decreased ER visits Hospitals benefit from decreased ER visits and hospitalizations for glucose control.and hospitalizations for glucose control.

RememberRemember

Take all these lessons one step at a time. Take all these lessons one step at a time.

Learn to live with diabetes and you will enjoy a Learn to live with diabetes and you will enjoy a full, healthy, and rewarding life.full, healthy, and rewarding life.

QUESTIONSQUESTIONS

Thank you !Thank you !