Type 2 Diabetes Screening & Education Program

1. Type 2 Diabetes Screening & Education Program Margaret Lynn Yonekura, MD, Heather Kun, PhD, Luis Dimen, MD, Mariola Ficinski, MD

2. Background • 6/24/08 News Bulletin from CDC • 24 million Americans (8%) now have diagnosed diabetes, an increase of 3 million in the past 2 years • Another 57 million have prediabetes • Striking racial/ethnic disparities among those with diagnosed diabetes: • 16.5% of Native Americans/Native Alaskans • 11.8% of African Americans • 10.4% of Hispanics • 7.4% of Asian Americans • 6.6% of Whites

3. Background • Steady rise of diabetes in Los Angeles County among adults > 18 yr from 6.6% in 1997 to 8.6% in 2005 • Those with the least access to preventive health care at highest risk: • Rates for Latinos and AA double that of whites and Asian/PI • Rates increased most rapidly among poor (14% of 0-99% FPL vs 6.5% of >200%FPL) and non-HS graduates

4. Objectives • Increase early identification of those at high-risk for developing diabetes and provide education and promote behavioral changes to prevent its development • Increase early diagnosis of those with diabetes and provide education and support to help them manage their disease • Educate providers to promote quality diabetes care in the community

5. Chronic Disease Management Consortium • Participating hospitals • California Hospital Medical Center • Huntington Memorial Hospital • Good Samaritan Hospital • No pediatrics • Childrens Hospital Los Angeles • Only pediatrics • National Health Foundation • Functions for Consortium: grant writer, facilitator, design and management of web-based data system, and evaluator.

6. Methods • All services provided in English and Spanish free of charge • Funded by a 3-year grant from the Good Hope Medical Foundation • Outreach education about type 2 diabetes and screening using the ADA Risk Test at a variety of community sites

7. ADA Risk Test • Scoring 3-9 points: probably low risk for diabetes now but don’t forget about it. • Scoring 10 or more points: greater risk for diabetes. Get tested by your health care provider.

8. Program Curricula • Developed by dieticians from three collaborating hospitals based on current recommendations • Each 2 hour workshop is highly interactive so that program participants are able to both learn and apply the facts, principles, and concepts being taught. • Action planning at end of each workshop • Olympic Food Guide is a tool developed to help participants make healthier food choices.

9. Standardization • Same training for Health Educators • CHW/promotoras • MPH/RD • Same “take aways” from workshops • Consistent number and sequence of workshops • Same clinical and self-reported outcomes

10. Methods • Food, Fitness, and Diabetes Prevention • Intake process: health screen, activity & nutrition assessment • 4 weekly 2-hour sessions conducted by either CHW/promotoras or professional staff (MPH or RD) • 3-6 month follow-up: repeat health screen, activity & nutrition reassessments • Telephone education and support groups as needed

11. Healthy Lifestyles American Culture The Gap! (It is Widening!) Food, Fitness & Diabetes Prevention: Modules • Diabetes prevention, good nutrition, and our health • Healthy meals & healthy movement • Reading food labels • Heart health & disease prevention

12. Methods • Living with Diabetes • Intake process: health screen, diabetes knowledge and self-efficacy assessment, activity & nutrition assessment • 4 weekly 2-hour sessions • 3-6 month follow-up: repeat health screen, diabetes knowledge and self-efficacy reassessment, activity & nutrition reassessments • Telephone education and support groups as needed • Chronic Disease Self-Management Program • 6 weekly 2-hour sessions conducted by certified lay leaders, at least one of whom has a chronic condition

13. Living with Diabetes: Modules • About diabetes and monitoring your body Take Charge! with Diabetes Health Record www.caldiabetes.org • Nutrition, part 1 Carbohydrates and sugar, protein & fat Plate method & carbohydrate counting 3. Nutrition, part 2 Reading food labels, healthy kitchen, recipes & physical activity 4. Preventing complications and medications

14. Results

15. Outreach & Screening • Between October 2005 and August 2008 • 286 outreach events • 5418 ADA Risk Tests administered • 13% Low/No risk (0-2 pt) • 36% Intermediate risk (3-9 pt) • 52% High risk (> 9 pt) • 2095 high risk clients referred to provider for testing

16. Type 2 Diabetes Prevention Program • Between October 2005 and August 2008 • 852 participants • 67% Hispanic,17% Caucasian, 7% African American, 7% Asian • 88% female • 32% overweight, 41% obese • 66% waist circumference above the cutoff • 498 workshops conducted, 53% in English & 47% in Spanish • Retention rate 80%

17. Type 2 Diabetes Prevention Program • 27% lost weight (> 4 lb) and 9% lost more than 5% of their weight • 46% increased their knowledge about healthy eating behaviors • 36% eating > 5 servings of fruits & vegetables/d • 76% drinking > 4 cups of water/d • 72% eating breakfast daily • 76% eating fast food 0-1 days in last week

18. Type 2 Diabetes Prevention Program • At beginning of program 63% knew how much PA is recommended • 21% increased their knowledge about PA • 62% increased duration of physical activity to > 30 minutes each time • 49% increased the distance walked/d • 35% increased frequency of being physically active to > 4 times/week

19. Living with Diabetes Program • Between October 2005 and August 2008 • 496 participants • 58% Hispanic, 20% African American, 14% Caucasian, 5% Asian • 68% female • 29% overweight and 56% obese • 77% waist circumference above the cutoff • 91% previously diagnosed & 7% newly diagnosed • Prior morbidity from diabetes: 32% diabetic neuropathy, 16% diabetic retinopathy, 15% gastroparesis, 10% myocardial infarction, 9% stroke, 7% nephropathy, & 2% amputation • 62% Hgb A1c > 7 • 61% had hypertension & 38% had elevated cholesterol • 424 workshops, 59% in English & 40% in Spanish • 75% retention rate

20. Living with Diabetes Program • 35% lost weight (> 4 lb) and 14% lost more than 5% of their weight • 6% decreased waist circumference below cutoff; total 27% • 2% decreased body fat to normal range; total 9% • 12% decreased their Hgb A1c below 7; total of 53% had Hgb A1c < 7

21. Living with Diabetes Program • 51% reported increased confidence in improving their eating habits • 37% eating > 5 servings of fruits & vegetables/d • 79% drinking > 4 cups of water/d • 82% eating breakfast daily • 75% eating fast food 0-1 days in last week

22. Living with Diabetes Program • 51% reported increased confidence in improving their exercise habits • 12% started being physically active • 37% physically active > 4 times/wk; 62% total • 37% increased frequency • 56% physically active > 30 minutes each time; 79% total • 39% increased duration of PA • 51% increased distance walked • 42% increased their emotional wellbeing

23. Living with Diabetes Program • 65% reported increased confidence in managing their diabetes • 20% began asking questions about their diabetes & treatment • 14% increase in discussing their personal problems related to diabetes with doctor • 46% learned what the Hgb A1c target was • 79% checked BS daily • 87% checked feet daily for sores • 71% had dilated eye exam in past year • 5% quit smoking • 23% requested pneumonia vaccine • 40% requested flu shot

24. Chronic Disease Self Management Program • 54 workshops, 48% in English & 52% in Spanish • 252 participants and 282 guests = 538 • Retention rate 72% www.patient education.stanford.edu

25. Barriers • Implementation delayed due to difficulties finding a culturally appropriate curriculum • Living with Diabetes/Viviendo Con Diabetes from National Alliance for Hispanic Health • California’s Guidelines for Care • Consortium’s Healthy Eating Lifestyle Program curriculum • Community distrust of some hospitals as legitimate source of health information • “The hospital is here for your health.” • Collaboration with community clinics

26. Barriers • Difficulty recruiting participants for the Prevention Program • “reality doesn’t hit them (community members) until they get diabetes.” • Began marketing the prevention workshops as “healthy living” classes

27. Public Health Implications • Benefits of Chronic Disease Management Consortium • Community hears consistent message • More efficient and cost effective • Able to secure grant funding • Centralized web-based data collection and reporting system • Provides real-time information on effectiveness of program and progress toward outcomes • Data for reports to superiors and current/future funders

28. Public Health Implications • The model of non-profit hospitals working closely with local community clinics to address the diabetes epidemic is an important and replicable model. • Hospital staff provide outreach education & screening for type 2 diabetes and refer high risk individuals to clinics for diagnostic testing and on-going care. • Individuals at risk for diabetes participate in prevention workshops while those with diabetes learn critical self-management skills in workshops focused on Living with Diabetes.

29. Public Health Implications • Patients benefit from improved understanding of what they can do to prevent diabetes and/or optimize their health and delay/prevent the onset of complications. • Clinics benefit because of increased patient compliance with regular preventive care and self management. • Hospitals benefit from decreased ER visits and hospitalizations for glucose control.

30. Remember Take all these lessons one step at a time. Learn to live with diabetes and you will enjoy a full, healthy, and rewarding life.

31. QUESTIONS Thank you !