Handbook of Diabetes Management PDF

Handbook of Diabetes Management
Handbook of Diabetes Management
Edited by
Donna Zazworsky
Carondelet Health Network Diabetes Care and Community Outreach Centers
St. Elizabeth of Hungary Clinic
Case Manager Solutions, LLC
Tucson, Arizona
Jane Nelson Bolin

School of Rural Public Health
Texas A&M Health Sciences Center
College Station, Texas
Vicki B. Gaubeca
Mel and Enid Zuckerman College of Public Health
University of Arizona
Tucson, Arizona
Library of Congress Cataloging-in-Publication Data
Handbook of diabetes and diabetes management / edited by Donna Zazworsky, Jane Bolin,
Vicki B. Gaubeca.
p. ; cm.
Includes bibliographical references and indexes.
ISBN 0-387-23489-6 (Hardbound : alk. paper)
1. Diabetes—Handbooks, manuals, etc. I. Zazworsky, Donna. II. Bolin, Jane, RN.
III. Gaubeca, Vicki B.
[DNLM: 1. Diabetes Mellitus—epidemiology—United States. 2. Diabetes
Mellitus—therapy—United States. 3. Diabetes Mellitus—ethnology—United States.
WK 810 H2366 2005]
RC660.H356 2005
616.4 62—dc22
2004063189
Springer Science+Business Media, Inc.

New York, Boston, Dordrecht, London, Moscow
ISBN 10: 0-387-23489-6 (Hardbound) ISBN 13: 978-0387-23489-2
ISBN 0-387-23490-X (eBook)
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This book is dedicated to the memory of Carter Marshall, MD, MPH who passed away
this year. Dr. Marshall is remembered for his lifetime commitment and achievements
in improving the quality of our healthcare system. We deeply thank Dr. Marshall for
providing inspiration and professional guidance to many of the contributing authors.
About the Editors
Donna Zazworsky, MS, RN, CCM, FAAN, personal motivation for Donna, but case man-
is an internationally known expert in case agement and disease management systems
management and disease management with provide a primary focus for her work in under-
community populations. She is the manager standing and reducing barriers for people with
of the Diabetes Care and Community Out- diabetes.
reach Centers for Carondelet Health Network,
Jane Nelson Bolin, RN, JD, PhD, is a profes-
a three hospital healthcare organization and
sor and researcher in rural health and disease
a member of Ascension Health. The Centers
management at Texas A&M. On a personal
have provided the longest ADA-recognized
note, Jane has had gestational diabetes during
diabetes self-management programs to people
both of her pregnancies. Knowing that the in-
living in Southern Arizona’s Pima and Santa
cidence of getting type 2 diabetes at a later
Cruz counties. Ms. Zazworsky also works
age is very high, Jane practices a personal
with St. Elizabeth of Hungary Clinic as a vol-
prevention program that includes diet and
unteer consultant on diabetes disease man-
exercise.
agement issues and is the managing partner
for Case Manager Solutions, LLC. On a per- Vicki B. Gaubeca, MPH, is director of Public
sonal note, Donna’s mother and two maternal Affairs for the University of Arizona Mel and
aunts have experienced the devastating com- Enid Zuckerman College of Public Health.
plications of type 2 diabetes. Nine years ago, On a personal note, Vicki has had type 1 dia-
her mother suffered a stroke that has left her betes since she was a teenager. She knows the
with left-sided weakness. Both aunts died of day-to-day struggles of self management and
diabetes complications related to above the hopes that this handbook will lend insight to
knee bilateral amputations and end stage renal public health workers who help people with
disease. Not only is diabetes prevention a diabetes.
Contributors
Jorge A. Arzac, MD, FACOG, Methodist Karen D’Huyvetter, ND, MS, Mel and
Medical Center, Dallas, Texas Enid Zuckerman College of Public Health,
University of Arizona, Tucson, Arizona
Barbara J. Aung, DPM, Aung FootHealth
Clinics and Wound Management Center Betsy Dokken, NP, MSN, CDE,
Tucson, Arizona Department of Physiology, University of
Arizona, and University Physicians
Lourdes G. Barrera, Arizona International Healthcare, Tucson, Arizona
College, University of Arizona, Tucson,
Arizona Jean Donie, RN, MBA, CPHQ, Dell Webb
Hospital, Sun Health System, Sun City,
Judith Beck, MD, St. Elizabeth of Hungary Arizona
Clinic, Tucson, Arizona
James L. Dumbauld, DO, Department of
Jane Nelson Bolin PhD, JD, RN, Texas Family Medicine, St. Elizabeth of Hungary
A&M Health Sciences Center School of Clinic, and University of Arizona, Tucson,
Rural Public Health, College Station, Texas Arizona
Patrick J. Boyle, MD, Division of Scott Endsley, MD, MSc, Health Services
Endocrinology, Diabetes, and Metabolism, Advisory Group, Phoenix, Arizona
University of New Mexico Health Sciences Larry Gamm, PhD, Texas A&M Health
Center, Albuquerque, New Mexico Sciences Center School of Rural Public
Health, Department of Health Policy and
Lynda Juall Carpenito-Moyet, CRNP,
Management, College Station, Texas
MSN, LJC Consultants, Inc., Mickleton,
New Jersey, and ChesPenn Health Services, Brian L. Foster, MBA, Health Services
Chester, Pennsylvania Advisory Group, Phoenix, Arizona
Daniel Casto, MD, Department of Family Cindy Fraser, MS, Health Systems
and Community Medicine, College of Research Center, Carle Foundation, Urbana,
Medicine, University of Arizona, Tucson, Illinois
Arizona
Vicki B. Gaubeca, MPH, Mel and Enid
Larry Cooper, MA, Health Services Zuckerman College of Public Health,
Advisory Group, Phoenix, Arizona Tucson, Arizona
vii
viii CONTRIBUTORS
Terilene Glasses, Mel and Enid Zuckerman Nancy J. Metzger, RN, PhD, St. Elizabeth
College of Public Health, of Hungary Clinic, Tucson, Arizona
Tim Moore, MA, LISAC, Marana Health
Center, Marana, Arizona
Scott Going, PhD, Departments of
Nutritional Science & Physiology, Anita C. Murcko, MD, FACP, Healthcare
University of Arizona, Tucson, Arizona Group of Arizona/AHCCCS, Phoenix,
Arizona
Cecelia Hofberger, RN, Mountain Park
Health Center, Inc., Phoenix, Arizona Hirisaradaharally N. Nagaraja, MD,
Division of Endocrinology, Diabetes, and
Maia Ingram, MPH, Mel and Enid Metabolism, University of New Mexico
Zuckerman College of Public Health, Health Sciences Center, Albuquerque, New
University of Arizona, Tucson, Arizona Mexico
Linda Parker, BSN, RN, St. Elizabeth of
Bita Kash, MBA, FACHE, Texas
Hungary Clinic, Tucson, Arizona
A&M Health Sciences Center School
of Rural Public Health, College Station, B. Mitchell Peck, PhD, Texas A&M Health
Texas Sciences Center School of Rural Public
Health, College Station, Texas
Christine Kucera, BFA, Health Systems
Research Center, Carle Foundation, Urbana, Annette I. Peery, MSN, RN, CDE,
Illinois Department of Adult Health Nursing, School
of Nursing, East Carolina University,
Kathleen Lambert, BSN, RN, JD, Private Greenville, North Carolina
Practice Attorney at Law, Carondelet Juanita Peterman, RN, BSN, MAOM,
St. Joseph’s Hospital, Tucson, CPHQ, Clinica Adelante, Inc., Phoenix,
Arizona Arizona
James C. Leonard, MD, Carle Foundation, Michael Reis, MD, Department of Family &
Urbana, Illinois Community Medicine, Texas A&M
University System HSC College of
Isela Luna, PhD, RN, Healthcare Legal Medicine, Scott and White Memorial
Consultant, Tucson, Arizona Hospital, Temple, Texas
Catherine M. Robinson, MEd, RD, CDE.,
Carrie M. Maffeo, PharmD, BCPS, CDE, St. Elizabeth of Hungary Clinic, Tucson,
Health Education Center, Butler University, Arizona
College of Pharmacy and Health Sciences,
Indianapolis, Indiana Jennifer Ryan, MBA, PhD, Chiricahua
Community Health Centers, Inc., Elfrida,
Rose Marie Manchon, MN, APRN, Arizona
Carondelet Health Network, Tucson, Paul Shelton, EdD, Health Systems
Arizona Research Center, Carle Foundation, Urbana,
Illinois
Carter L. Marshall, MD, MPH, Clinical
Quality Assessment, Health Services Leslie Spry, MD, FACP, Lincoln
Advisory Group, Inc., Phoenix, Nephrology & Hypertension, Lincoln,
Arizona Nebraska
CONTRIBUTORS ix
John Stoll, MD, Primary Care and Pediatric Charmaine Trujillo, RN, Mountain
Sub-Specialties, General Internal Medicine, Park Health Center, Inc., Phoenix,
Carle Clinic Association, Urbana, Illinois Arizona
Barbalee Symm, RN, MS, Department of Donna Zazworsky, MS, RN, CCM, FAAN,
Family and Community Medicine, Texas Carondelet Diabetes Care and Community
A&M University System, HSC College of Outreach Centers; St. Elizabeth of Hungary
Medicine, Scott and White Memorial Clinic; and Case Manager Solutions, LLC,
Hospital, Temple, Texas Tucson, Arizona
Foreword
Diabetes—you read about it everywhere to- tell myself also that this was what aging was
day. It’s a hot topic in the news magazines, about.
on the talk shows, in professional journals, in Then came the diagnosis of diabetes and
the daily paper—even in the rags at the gro- I actually felt relief. Facing this reality made
cery counter. Should you be interested? Of me understand why my body had become a
course! If you do not have diabetes, you prob- stranger to me. I looked for all the informa-
ably know someone who does. You probably tion that I could get my hands on. And I found
know many people who are either diabetic or quite a bit of information in book stores and
prediabetic. I am interested in the topic be- on the Internet. But I really wanted a com-
cause I was diagnosed almost two years ago prehensive resource, something that would
with type 2 diabetes. give me both educational and practical in-
Many years ago, I was in the Miss formation about the diabetes epidemic that
America Pageant as Miss Arizona. I was a was facing the nation. I wanted to not only
letterwoman on the University of Arizona help myself but prepare my children so they
women’s swim team. I modeled for Mr. Black- would not have the same diagnosis in their
well of Hollywood, then I married my high future. I also wanted a manual to add to
school sweetheart and am now the mother my professional library that would be a re-
of four children and the grandmother of six source to me in both my nursing and law
(number seven is on the way.). I knew how careers.
important it was to stay in shape, but life and This handbook by expert professionals
time added pounds to my frame. I worked long covers every aspect of diabetic care. It is
hours, and pushed my limits. Even though I a sound, evidence-based, culturally informa-
had been a nurse for more than 30 years, I re- tive, practical approach to diabetes preven-
fused to see the initial symptoms of diabetes tion and disease management. It also pro-
and I rationalized the excessive thirst and fre- vides case studies which reflect the various
quent urination. I ignored how sleepy I felt at clinical settings in which diabetes care takes
times, especially after a big meal. I told my- place. There is information on the financial
self that I just wasn’t able to sleep through considerations of the population with diabetes
the night like I used to do. I had recurrent and methods for computing direct and indi-
yeast infections. All of these symptoms coin- rect costs of treatment. Special care issues of
cided with the thrills of menopause. I would the prediabetic and the gestational diabetic are
xi
xii FOREWORD
addressed. It includes sample diets, exercise health care professionals who appreciate the
programs, and tools for assessing depression. dramatic impact that the diagnosis of diabetes
This handbook is both interesting and fun. is having and will continue to have on the
As a comprehensive resource, it is a bonus to nation.
Kathleen Lambert, BSN, RN, JD

Attorney at Law
Administrative Supervisor
Carondelet St. Joseph’s Health
Tucson, Arizona
Preface
The focus of this book is on the problem create methods of managing this complex and
of diabetes and principles of effective dia- deceitfully subtle disease that manages to steal
betes population management. No one dis- productivity and health from such a large per-
putes that America is in the midst of an epi- centage of the American public.
demic of diabetes. Recent estimates from the The concerns that launched our efforts
Centers for Disease Control and Prevention to document methods of disease management
(CDC) on the percentage of the population were formed through daily exchanges with pa-
with diabetes is 6.3%, or 18.2 million people, tients and clinicians each attempting to bet-
with the percentage of Hispanics at 8.2% (2 ter understand this disease known as diabetes.
million) and Non-Hispanic blacks at 11.4% Concerns led to development of models of
(2.7 million) (CDC, 2004). Conservatively, clinical and community management which
diabetes affects over 17 million Americans in turn led to documentation that these meth-
with another 16 million diagnosed as pre- ods had resulted in reduced morbidity and ul-
diabetic, or at risk. In a recent study to be timately reduced mortality.
published in Obesity Research, researchers es- A recurring theme of every chapter, from
timated that in the U.S., obesity-attributable every contributor, is the vast complexity and
medical expenditures reached $75 billion in diversity of the population of persons with
2003 and that taxpayers financed about half of diabetes. While statistics are fairly straight-
these costs through Medicare and Medicaid. forward, they tell us that diabetes is a signif-
Obesity leads to a myriad of chronic health icant, national problem that will require the
conditions; most common among those con- efforts of all health professionals and their pa-
ditions is diabetes with all of its associated tients if it is to be addressed in a meaningful
morbidity. Clearly, we all have a vested inter- way.
est in finding solutions to this public health Fittingly, our book is divided into the fol-
crisis. lowing four sections:
Users of this book will notice that the Part 1: The Diabetes Framework. This
substance of each chapter is enhanced by the section addresses the picture of diabetes dis-
authors’ own personal and professional ex- ease management and population manage-
perience of dealing personally with the chal- ment. The challenging issues of the diabetes
lenges of diabetes. Collectively, each of our quality initiatives and the chronic care model
clinical and professional lives have been af- are thoughtfully explained to provide insight
fected by diabetes compelling us to create pre- for those beginning to step into this next
vention programs, investigate treatments, and level of care. The cultural competency and
xiii
xiv PREFACE
technology chapters offer a broader overview Other issues related to the uninsured,
of development and application. rural populations and border communities
Part 2: Caring for People with Diabetes. are also confronted in this section. Each of
This section covers evidence-based practice these issues present difficult challenges for
for the complex facets of diabetes care. The providers and the healthcare team. Helpful
chapters on the Origins of Diabetes and Med- tips are offered and are based on many years
ication Management cover the most up-to- of hands-on experience.
date research on these two topics. These chap- Finally, two other areas that are cov-
ters also offer the latest standards of practice ered in this section are Complimentary
in diabetes management. The Nutrition and Medicine and the emerging technology of
Glycemic Index chapter provides the readers Self–Management Systems and telehealth
with a plethora of information related to the care. This section offers a summary of other
glycemic index, diet recommendations, and uses of technology to support the patient in
how other highly promoted diets measure up their quest to be better self managers.
to the scientific rubric. Behavioral health and Part 4: Business Issues. Without ques-
self-management issues and interventions are tion, diabetes disease management cannot be
explained and practice applications are given. performed without addressing the business as-
Finally, sick day planning, travel, surgery and pects related to legal and regulatory issues,
foot care are covered, including specific tips to health policy initiatives, economic rationale,
give patients when facing any of these issues. funding sources and marketing components.
Part 3. Special Care Issues. This section This section provides the reader with valuable
addresses the complexities of caring for a di- knowledge to start and manage a successful
verse population. First there is the area of Pre- diabetes program.
diabetes. A relatively new term describing a Part 5: Case Studies. Finally, this sec-
stage of diabetes serves as a trigger for people tion provides case studies that have demon-
and providers to look at lifestyle issues more strated success with evidence-based practices
aggressively—with the intent to prevent the shaped for a variety of populations. These
onset of diabetes. case studies offer helpful tools and share their
Gestational diabetes must be addressed. lessons learned—following the motto: Share
Although usually a temporary condition trig- willingly and steal mercilessly.
gered by pregnancy, gestational diabetes has This handbook only begins to cover the
been a precursor to the onset of diabetes at a incredible work that is going on around the
later age. country. It is time to share our experiences so
Chronic kidney disease (CKD) has be- that other providers will glean those pieces
come more pronounced with the newly- that fit for their practices. In the long run, it
defined stages of CKD. Diabetes is one of the will be our communities that will benefit.
leading causes of renal disease leading to dial-
ysis and transplantation. A more aggressive Donna Zazworsky, Tucson, Arizona
effort is being made to promote early detec- Jane Bolin, College Station, Texas
tion of disease. Vicki B. Gaubeca, Tucson, Arizona
Contents
I. THE DIABETES FRAMEWORK
1 Essentials of Quality Improvement with Special Reference to Diabetes 3

Carter L. Marshall
2 The Chronic Care Model: Blueprint for Improving Total Diabetes Care 19
Anita C. Murcko, Jean Donie, Scott Endsley, and Larry Cooper
3 Promoting Cultural Competence through Community Partnerships 35

Isela Luna
3A Hispanic American Culture and Diabetes 41

Lourdes G. Barrera
3B Cultural Competency: Native Americans 45

Terilene Glasses
4 Preparing for the Technology Revolution in Health Care 49

Brian L. Foster
II. CARING FOR PEOPLE WITH DIABETES
5 Concepts on the Origin of Diabetes 61

Hirisadarahally N. Nagaraja and Patrick J. Boyle
6 Medication Management 69
Carrie M. Maffeo
7 Nutrition for Individuals with Diabetes 79

Catherine M. Robinson and Judith Beck
8 Diabetes and Exercise 125

Scott Going and Betsy Dokken
9 Living Well with Diabetes: An Approach to Behavioral Health Issues 143

Tim Moore
xv
xvi CONTENTS
10 Planning for Sick Days, Surgery, and Travel 151

Betsy Dokken
11 Self-Management 161
Donna Zazworksy and Lynda Juall Carpenito-Moyet
12 The Diabetic Foot 175

Barbara J. Aung
III. SPECIAL CARE ISSUES
13 Prediabetes: A Risky Prodrome to Diabetes 183

James L. Dumbauld
14 Gestational Diabetes 189

Jorge A. Arzac
15 Chronic Kidney Disease 199

Leslie Spry
16 Caring for the Uninsured and Diabetes 215

Daniel Casto
17 Disease Management in Rural Populations: Can It Be Done? 223

Jane Nelson Bolin, Larry Gamm, Bita Kash, and B. Mitchell Peck
18 Caring for the Border Communities 237

Maia Ingram
19 Utilizing Community Health Advisors in Diabetes Care Management 247

Nancy J. Metzger and Linda Parker
20 Complementary and Alternative Medicine in Diabetes 257

Karen D’Huyvetter
21 Leading Edge Technologies Related to Diabetes Care 273

Vicki B. Gaubeca and Donna Zazworsky
IV. BUSINESS ISSUES
22 Disease Management Research and Policy Initiatives 283

Larry Gamm, Jane Nelson Bolin, and Bita Kash
23 Legal and Regulatory Considerations of Diabetes Disease Management 301

Jane Nelson Bolin, Bita Kash, and Larry Gamm
24 Economics 311
Jennifer Ryan
25 Funding 317
Donna Zazworsky
CONTENTS xvii
26 Tools for Getting Your Message Out About Diabetes: Marketing/Public

Relations, Social Marketing and Media Advocacy 323
Vicki B. Gaubeca
V. CASE STUDIES
Case Study 1: Diabetes Disease Management Program 347

Donna Zazworsky and James Dumbauld
Case Study 2: Carle’s Diabetes Management Program 355

Christine Kucera, John Stoll, Cindy Fraser, James C. Leonard, and
Paul Shelton
Case Study 3: The Scott and White Experience: Chronic Disease Management
on a Shoe String 361
Barbalee Symm and Michael Reis
Case Study 4: Nutrition Survival Skills for Diabetes: A Personal Experience 367
Annette I. Peery
Case Study 5: Diabetes Continuing Care Clinic Group Visits for the
Uninsured: A Case Study of Three Community Health Centers 371
Donna Zazworsky, James Dumbauld, Charmaine Trujillo, Cecelia
Hofberger, and Juanita Peterman
Case Study 6: A Hospital Case Study in Diabetes Management: Carondelet

Health Network 387
Rose Marie Manchon
Index 395
I
The Diabetes Framework

1
Essentials of Quality Improvement with

Special Reference to Diabetes
Carter L. Marshall
Vice President, Clinical Quality Assessment, Health Services Advisory Group, Inc., Phoenix, Arizona
ORIGINS OF QUALITY virtually inevitable downhill course resulting

IMPROVEMENT IN DIABETES in death a few years after diagnosis. The dis-
covery of insulin by Banting and Best in 1921
Quality improvement (QI) in medicine revolutionized diabetes care and established
can be traced to Sir Thomas Percival (1740– insulin as the sine qua non of quality diabetes
1804) who, in 1803, advocated hospital prog- management. While it was immediately clear
rams to improve the quality of care provided that insulin prolonged the lives of patients
by physicians (www.whonamedit.com/doctor with diabetes, it was far less clear whether the
.cfm/2558.html, 2005). QI in the United strict control of diabetes led to fewer compli-
States began with Ernest Codman (1869– cations and still longer life. The answer to this
1940), a Boston surgeon who lost his appoint- question appeared with the publication of the
ment to the Harvard Medical School faculty famous Diabetes Control and Complications
because of his persistent call for study of sur- Trial (DCCT) in 1993. This study showed
gical outcomes. Codman’s ideas were even- for the first time that strict control in patients
tually incorporated into the newly established with type 1 diabetes greatly reduced compli-
American College of Surgery and he was in- cations of the disease. The equally important
strumental in the establishment of the Joint United Kingdom Prospective Diabetes Study
Commission on Accreditation of Health Care (UKPDS) provided similar evidence in favor
Organizations (JCAHO) (Murray, 2000). The of strict control in patients with type 2 diabetes
principles and methodology of QI owe much (Straaton et al., 2000). Subsequent studies of
to the process of continuous quality im- patients with type 2 diabetes produced similar
provement (CQI) pioneered by business guru results. DCCT made QI a reality in diabetes
Edward Deming (Aguayo, 1990). management by enabling the development of
The application of quality concepts to di- management standards that were both mea-
abetes was problematic as long as medicine surable and known to improve patient well-
was more or less powerless to restrain a being.
3
4 ESSENTIALS OF QUALITY IMPROVEMENT
WHY DO QUALITY patient managed by diet and exercise alone

IMPROVEMENT who has no microvascular, cardiovascular, or
neuropathic complications costs about $2,000
Obviously, QI is carried out to better the a year. The use of oral antidiabetic or antihy-
prognosis of individual patients with diabetes pertensive agents increases this cost by 10–
and other diseases, but there are other rea- 30% as does increased BMI and renal, cere-
sons as well. First, the quality of health care brovascular, or peripheral vascular disease.
needs improvement (Institute of Medicine Patients with heart disease, angina, or insulin
[IOM], 2001). As Robert Brook of the RAND therapy boost the cost by 60–90%, and the
Corporation once said of American health cost is increased 11-fold in patients with end-
care, “When it’s good, it’s very, very good, stage renal disease (Brandle et al., 2003). QI
but it’s not very good very often.” McGlynn is directed at improving provision of services
et al. examined 439 performance measures for and thereby reducing some of these costs. The
30 acute and chronic illnesses. Of these 439 managed care plans cited above reduced the
indicators, patients received 55% (McGlynn number of physician office visits by 13% and
et al., 2003). This level of care extends to di- doubled the number of services provided per
abetes as well. Of 2,865 diabetes patients in visit.
55 Midwestern community health centers, an- Out-of-pocket costs for patients have
nual rates for diabetes performance measures risen as well. Drug costs have been ris-
included 26% for dilated eye examination, ing at an annual rate of 13–14% (National
51% for foot care, 66% for dietary instruction, Health Statistics Group, 2003) and as in-
and 27% for two or more HbA1c tests (Chin termediaries such as managed care plans
et al., 2000). Mean HbA1c in this group was and employer-sponsored insurance shift costs
8.6%. to consumers, utilization of diabetes pre-
Second, the quality of care can be ventive services such as dilated eye exams
improved. In collaboration with Health and daily self-measurement of blood glu-
Services Advisory Group (HSAG), Arizona’s cose decline as the out-of-pocket costs of
Medicare Quality Improvement Organization these services rise (Karter et al., 2003).
(QIO), six Medicare managed care organi- Once baseline data are available for a
zations reduced mean HbA1c values from given condition, QI can document such
8.9% to 7.9% and increased the proportion changes and highlight the magnitude of unmet
of patients with HbA1c values below 8.0% needs.
from 40% to 62%. The proportion of 14 Finally, there is the question of value
performance measures provided to patients for money. Health care accounted for 15% of
rose from 35% to 55% (Marshall et al., the nation’s gross domestic in 2002. Although
2000). Americans spend twice as much on health care
Third, disparities in the level of care by as the Europeans or Japanese, life expectancy
race and income can be addressed through QI in the United States is 2–3 years lower than it
activities. Even when Medicare is paying the is in these areas (Mehring and Koretz, 2004).
bill, minorities receive care that is inferior to A significant part of this cost is the higher
whites (Skinner et al., 2003; Lavizzo-Mourey prevalence of obesity in this country and the
and Knickman, 2003). concomitant diabetes, heart disease, and can-
Fourth, quality improvement can con- cer to which it is related. In the absence of a
tribute to efforts to reduce the cost of medical way to prevent or cure obesity, diabetes, heart
care. Partly because of quality deficiencies, disease, and cancer, maximizing the quality
all illness and especially diabetes are very ex- of care is the most effective way to increase
pensive both to the society as a whole and to life expectancy, improve quality of life, and
the individual patient. Caring for a diabetes reduce costs.
ESSENTIALS OF QUALITY IMPROVEMENT 5
THE CENTERS FOR MEDICARE development of performance measures has

AND MEDICAID SERVICES become a business as QI gains acceptance.
The National Quality Foundation, JCAHO,
The Centers for Medicare and Medicaid CMS, and a number of private companies all
Services (CMS), an arm of the Social Secu- develop indicators. Indicators must be based
rity Administration, is the biggest purchaser on scientific evidence and reviewed frequen-
of medical care in the country if not the world. tly to assure that the evidence remains firm
Through Medicare directly and through Med- and that the measure itself has not been su-
icaid indirectly by way of several states, CMS perseded by a new technology or medication.
is in a unique position to change the quality of Quality improvement projects (QIPs)
medical care and is actively involved in doing compare what was to what is, i.e., baseline
so. It does this through centralized activities data to data collected after some interval of
such as Pay-for-Performance (see below) and, time, often monthly or quarterly. Projects al-
at the state level, though a network of quality ways produce periodic reports that sum up
improvement organizations (QIOs) that work the level of performance attained compared
with hospitals, nursing homes, home health to baseline data. QIPs thus require baseline
agencies, managed care plans, and, increas- data, remeasurement data, and some sort of in-
ingly, individual physicians to improve qual- tervention designed to bring about a positive
ity through improvement projects targeting change during the interval between the two.
specific diseases like pneumonia, heart fail- QIPs typically take place within institutions
ure, and acute myocardial infarction (AMI) either as an entirely internal activity or in col-
as well as adverse clinical events like surgical laboration with other providers and/or a QIO.
wound infections. The QIOs also accept and QIP reports have three main uses: (1) inform-
investigate complaints of beneficiaries regarding the provider of care so they can improve
ing providers. CMS maintains two websites: further; (2) providing a comparison among
www.cms.hhs.gov and www.medicare.gov. providers; and (3) informing the consumer to
Although anyone can access either site, the facilitate an informed choice of provider.
former is oriented to professionals and the lat- Quality improvement projects must be
ter to consumers. distinguished from quality assessments. Qual-
ity assessment is a measure of the quality of
care at a point in time—a cross-sectional snap-
MEASURING QUALITY shot. Assessments collect what is essentially
baseline data to see if a QIP is needed. As-
Quality improvement in diabetes and sessments are thus searches for opportunities
other diseases is a set of activities undertaken to improve care, and they often become the
to assure that patients receive the services baseline against which the remeasurement is
known to minimize complications and maxi- compared.
mize life expectancy. The essence of QI is the We also must distinguish between QI and
performance measure, used interchangeably the closely related area of patient safety, a
with the term “indicator.” Performance mea- term that incorporates medical errors. Patient
sures indicate how close to perfection (100%) safety burst upon the national consciousness
a provider comes in making a service avail- with the Institute of Medicine’s publication To
able to patients. Measures usually contain a Err is Human: Building a Safer Health Sys-
time component that specifies the frequency tem (IOM, 1999). QI and patient safety are
of the service, e.g., HbA1c determination ev- different sides of the same coin. The differ-
ery quarter. The results of performance mea- ence is that QI focuses on elevating the quality
sures are binary and expressed as the proof management of specific diseases like di-
portion of patients receiving the service. The abetes while patient safety looks across all
TABLE 1.1. The Structural Component of Quality Measurement

Component What the component addresses
Facility The physical environment. Is the building in which care occurs suitable for its use?
Organization/culture How efficient and how effectively is the care provided? Does the “culture” of the
organization support or hinder quality of care? What system changes might make care
better? If the facility treats substantial numbers of minority patients, is it “culturally
competent” to do so, e.g., in a facility treating Hispanics, is there an adequate cadre of
Spanish-speaking staff? Is there sufficient knowledge of the culture and life situation of
the patients to support quality care?
Finance Is the facility fiscally sound?
Utilization Who uses the facility, for what purpose, how often, and under what circumstances?
Manpower Is the staffing adequate to the task, e.g., are there enough nursing staff to adequately
provide for the number of patients served?
Societal General problems that impact the quality of health care by influencing consumer behavior,
but lie largely beyond the control of the provider, at least in the short run. Examples
include steep annual increases in the price of pharmaceuticals; the high prevalence of
Americans without health insurance; the decline in the number of people going into
nursing at a time when that segment of the population most in need of nursing care, the
elderly, is rapidly rising; and the unwitting or inappropriate use of alternative medicine
that harms the user either directly or by delaying the seeking of proper medical care
diseases seeking to prevent adverse events. qualities that promote innovation (Fisher and
One of several national hospital improvement Alford, 2000). Structure is often the basis of
projects now underway addresses the preven- overall evaluation of providers such as the hi-
tion of surgical wound infection, an adverse erarchy of “best” hospitals published annually
event that is not tied to a specific disease, by U.S. News and World Report.
condition, or procedure. A second difference Process and outcome measures are dis-
is that disease-oriented QI is primarily con- ease specific, and, besides obvious structural
cerned with acts of omission, e.g., was the problems like inadequate heating or very low
patient’s hypertension treated? Patient safety nurse to patient ratios, it is seldom clear ex-
usually addresses acts of commission, e.g., actly what role the structural elements play
was the hypertensive patient given the wrong as determinants of hands-on disease manage-
medicine or was he given the wrong dose. ment (DM).
These differences should not obscure their un- Outcome measures are intuitively ap-
derlying similarities. Both use the same pro- pealing. They deal with endpoints such as
cess: find errors, be they of commission or changes in heart disease mortality among
omission, quantify them, intervene to bring diabetes patients or lowered blood pressure
about improvement, and remeasure to quan- among hypertensives. Unfortunately, using
tify improvement. outcomes to measure quality, especially in
Quality improvement has three possible comparing one provider to another, is fraught
components: structure, process, and outcome. with difficulty. Different facilities have dif-
Two of these (process and outcome) are dy- ferent patients. Even when providers serve
namic and one (structure) is relatively static. the same population, the patients may and of-
Structure has to do with the environment in ten do differ significantly from one provider
which patient care takes place. Table 1.1 di- to another. The provider with the sicker pa-
vides “structure” into its component parts. tients will usually have the worse outcome.
Structural elements are often interdepen- Disparities in health, income, and education
dent. For example, high fiscal performance differ between entire population groups, and
in an organization is associated with cultural it is therefore difficult to compare outcomes
between providers who serve a largely poor, tient once his problem is known. Thus, as
uneducated, ethnic minority to one whose pa- shown in Table 1.2, blood pressure determi-
tients are preponderantly white, educated, and nation is the diagnostic measure, the ACE
relatively affluent. The use of outcomes re- inhibitor the patient receives if hypertensive
quires risk adjustment—a way of taking into is the intermediate measure, and the change
account differences in the patients served by in the incidence of the sequelae of hyper-
a given provider. Risk adjustment methodolo- tension, such as heart failure or stroke, is
gies are plentiful but there is no consensus as the outcome. Table 1.2 lists services that are
to which one is best, and it is inappropriate to commonly used as performance measures in
compare outcomes when different risk adjust- diabetes.
ments have been applied. The other problem It is usual for some subset of these mea-
with outcomes is that the combination of pa- sures, often as few as three or four, to be
tients changes over time even within the same used as the basis of diabetes QI. HbA1c is al-
provider. As a consequence, outcomes also ways included, and retinal examination, feet
will vary even though the quality of care pro- examination, and blood pressure usually ap-
vided remains unchanged. The ultimate out- pear along with HbA1c. Sets of measures of-
come, death, is not usually attributable to the ten differ as to frequency—annually, quar-
specific act of a given provider and may not, terly, monthly, every visit, etc.—and, unless
therefore, bear any relation whatever to the the frequency is known, providers should
quality of care provided. Finally, in many dis- not be compared even when they use the
eases and especially in diabetes, the patient same indicators. The major problem with pro-
plays a major role in determining his own cess indicators is that their application varies
outcome. This role is rarely, if ever, included by physician provider so results are affected
in quality measurement. For example, only when, for example, a large number of patients
about 75% of patients who receive prescrip- are cared for by a poor physician performer.
tions for β-blockers are taking this medica- CMS has been doing national process based
tion 6 months later (Butler et al., 2002). The QIPs for about 10 years. Between 1998 and
outcome for the remaining 25% may be ad- 2001, CMS projects that reported on improve-
versely affected by their lack of medication, ments in pneumonia, immunizations, and di-
but it would be most unusual for this factor to abetes among Medicare beneficiaries showed
be taken into account in assessing the quality improvement, albeit modest, in all three areas
of care offered by the providers who manage (Jencks et al., 2003).
these patients.
Process measures inherently incorporate
the limitations of medicine. The process of QUALITY IMPROVEMENT AND
care, when it includes every service known HEALTH SERVICES RESEARCH
to be beneficial, is all the health care system
has to offer. Every moviegoer is familiar with The purpose of health services research
the 19th century doctor’s classic line, usually is to uncover new knowledge about the deliv-
spoken to a grieving widow, “We have done ery of health services. The purpose of QI is
all that is humanly possible.” An unfortunate quite different. QI seeks to take information
outcome does not imply that more might have known from prior research and integrate it into
been done. the medical mainstream. It is the alchemy of
Process consists of both diagnostic and incorporating the content of articles from the
therapeutic actions. The latter are sometimes New England Journal of Medicine into usual
referred to as follow-up indicators or in- practice by all providers. QI deals with that
termediate outcomes. Intermediate outcomes which is known to benefit patients. Research
specify what should be done for the pa- is trying to find out what benefits patients. On
TABLE 1.2. Commonly Used Performance Measures (Indicators) in Diabetes

Management
Performance measures Comment
Process measures
Blood pressure quarterly Often required at every visit
HbA1c quarterly Sometimes required only once or twice annually
Foot examination twice a year Often required at every visit; sometimes required at intervals
greater than one year
Retinal examination yearly Almost always specified that this examination must be done
with eyes dilated and/or by an ophthalmologist
Lipid profile yearly Usually includes total cholesterol, HDL and LDL cholesterol,
triglycerides
Urine testing for protein yearly Usually testing uses Micral; sometimes testing begins with
dipstick and Micral is used if dipstick is negative
Serum creatinine
Daily aspirin
Immunization against influenza
Immunization against community acquired
pneumonia
Blood pressure at the ankle to test for Not commonly used but will probably become more common
peripheral vascular disease
Diabetes education
Nutrition instruction Most type 2 patients need to be placed on diets to lose weight
and all need to recognize the relationship between diet and
diabetes
Exercise Complements dieting and lowers blood sugar
Medication Necessary to avoid episodes of hypoglycemia and to
encourage proper use of medications, especially insulin
Use of home glucose meter Meters are accurate to within ±20% of readout. Meters whose
reading is based on whole blood give lower readouts than
those based on plasma.a Patients who switch from one type
to the other will find their disease suddenly getting much
better or much worse or lead to the conclusion that the
device does not work.
Follow-up (intermediate outcomes)
ACE-I if hypertensive ARBs are commonly substituted for ACE-Is
ACE-I if protein in urine ARBs are commonly substituted for ACE-Is
Treatment if hyperlipemic “Statin” drugs are increasingly used not only for hyperlipemia
but also to prevent AMIs and CVAs.
Ophthalmologic referral if abnormal retinal Not needed if examined by ophthalmologist
exam
a
All meter readings are based on whole blood. “Plasma” meters have a built in algorithm that converts whole blood reading to its
plasma equivalent. The “plasma” reading should be 12–15% higher than the whole blood reading. Plasma readings are popular
because they are closer to the value obtained when blood sugar is determined by a laboratory.
a practical level, the method of QI necessarily ried out among providers with no outside sup-
differs from that of research. Competent report. To conduct QI with the rigor of research
search always includes a control group. But would be prohibitively expensive without ac-
control groups are problematic in QI because cess to the kind of external support that is
it is unethical to withhold that which is known available to research. At the same time, QI
to be beneficial from some patients while pro- and research are mutually supporting in that
viding it to others. This is quite aside from QI often becomes the basis for research just
the practical reality that no provider wants to as research provides the knowledge applied
be a control group. Finally, QI is often car- by QI.
QUALITY IMPROVEMENT AND other outcome measures, patient satisfaction

PATIENT SATISFACTION must be risk adjusted to enable comparison
across providers. A risk adjustment scheme
A high level of patient satisfaction with for patient satisfaction might include age, sex,
the care they receive has long been consid- race, education, self-reported health status,
ered a hallmark of quality. Providers fre- and why the patient is under treatment. Pos-
quently play up patient satisfaction in their itive and negative experiences spread rapidly
advertising, and most health care institutions by word-of-mouth, and hospitals are very con-
regularly sample patients to obtain feedback. cerned about how its patients feel about them
While patient satisfaction and quality are seen and recognize the importance of pleased clien-
as complementary, it is usually unclear just tele to market share. CMS and the Agency for
how much satisfaction is needed to denote Health Research and Quality (AHRQ) have
quality. In a free market, a managed care jointly developed a standardized, risk adjusted
plan with patient satisfaction approval of less patient satisfaction instrument called the Hos-
than 85–90% or better is unusual for the sim- pital Consumer Assessment of Health Plans
ple reason that the dissatisfied simply disen- Survey (HCAHPS). It is modeled after a previ-
roll. Enrollment of Medicare beneficiaries in ously developed instrument designed for man-
managed care plans has been in free fall for aged care plans known as CAHPS, which is
about 5 years, a trend that began as plans ad- the same name without the “H.” Instruments
dressed rising costs, first by dropping liberal such as these can be used across providers and
prescription drug benefits and then by whole- yield valid results.
sale abandonment of patients and voluntarily Patient satisfaction and disease-specific
withdrawal from the market. Generous pro- quality assessment measure different aspects
visions for managed care in the newly en- of quality. For this reason, it is not sur-
acted Medicare Prescription Drug and Mod- prising that there is frequently no correla-
ernization Act of 2003 are intended to re- tion between patient satisfaction and clinical
verse both trends. Patient satisfaction played quality as measured by performance indica-
a key role in this downward spiral. As costs tors.
began to rise, stripping away the drug ben-
efit greatly reduced patient satisfaction and
reduced enrollment, leaving the plans with INTERVENTIONS
not only rising costs but declining income as
well. An intervention is any act that is taken
While this kind of patient satisfaction— to improve the quality of care provided to pa-
voting with one’s feet—has obvious ramifica- tients with a specified condition. An outpa-
tions where the patient has free choice, the role tient facility that provides continuing medical
of patient satisfaction and its relationship to education for its physicians is intervening to
quality of care in hospitals is often less clear. improve diabetes care. Some interventions be-
A patient with diabetes who is hospitalized come so standardized and well studied that
for an AMI is not likely to know if he was they themselves become quality measures
given an ACE inhibitor or β-blocker or even such as diabetes education for patients. The
whether he should have been given one or both success of interventions in bringing about pos-
of these drugs. On the other hand, he would itive change is far from certain. Interventions
know when pressing the call button brought no in one setting may seem to have no effect at all
assistance or how the food tasted or how well in, say, increasing the rate of lipid testing and
he was treated by the admitting staff. Patient yet work quite well in another setting. Inter-
satisfaction is a de facto outcome measure that ventions are influenced by the organizational
reflects both characteristics of the hospital and and cultural environment in which they oc-
the patients who experience the hospital. Like cur and the same intervention may be greeted
with enthusiasm by one provider and with dis- One can confidently expect to see major ef-
dain by another. Change in services provided forts to increase understanding of cultural in-
after an intervention may thus reflect influ- fluence so these can be harnessed in the cause
ence of the cultural climate rather than the of improved care.
intervention. Further, a QI may succeed pri-
marily because the provider knows that he is
being observed, thereby reflecting the well- TEN IMPORTANT
known “Hawthorne effect.” While the context CONSIDERATIONS IN
of this discussion is interventions as part of QI QUALITY IMPROVEMENT
projects, some interventions are quite differ-
ent. The Medicare program may be seen as (1) Weighted measures. Most diabetes
a huge intervention intended to improve care projects use several indicators similar to those
by removing financial barriers. The extensive in Table 1.2. It is not uncommon for those de-
QI activities of CMS throughout the United signing QIPs to make some indicators count
States, while not specifically geared to im- more than others. This is the application of
provement directly attributable to the Medi- weights to the measures used. Thus, indicator
care program, is intended to measure changes A might count as 1.0 but indicator B count as
in the quality of care received by beneficiaries. 2.0, making B twice as important in scoring
improvement than A. There are two problems
with this. First, those being evaluated will con-
ORGANIZATIONAL CULTURE centrate on B at the expense of lower weighted
AND SYSTEM CHANGE indicators. Second, it is unusual for those con-
sidering the measures or being evaluated by
As experience grows with quality im- them to agree on the relative weights to be
provement, more and more emphasis is being used, thus undermining the credibility of the
placed on the environment in which the QIP is project.
operating, i.e., the culture of the provider orga- (2) Scoring improvement versus scoring
nization. It is not unusual for a QIP to produce performance. If the goal of QI is to achieve a
a relative improvement of 30% or so and find specified level of performance or to develop
thereafter that further improvement becomes a hierarchy of providers from best to worst,
extremely difficult. Further, when more than the target of the QI effort is performance,
one provider is involved in the QIP, improved i.e., the remeasurement value. Performance
performance across providers is often simi- must be distinguished from improvement.
lar and they often share performance charac- As we have seen, QI requires two measure-
teristics. If provider A fails to examine a pa- ments, baseline and remeasurement follow-
tient’s feet, it is quite likely that provider B ing the application of an intervention. The
will not examine them either. When there is difference between the two expresses the de-
a very large gap between one provider and gree of improvement. If provider X exam-
others, it often means that the organizational ines the feet 20% of the time at baseline and
culture of the outstanding provider differs sig- 40% of the time at remeasurement, this is
nificantly from the norm. Organizational cul- an improvement of 100% ((Remeasurement –
ture subsumes the shared perceptions, beliefs, Baseline/Baseline) X 100). Consider another
and expectations of its personnel, and organi- provider, Y, who examined the feet of 70%
zational culture mediates any effort to bring of patients at baseline and 90% at remeasure-
about change. Financial health, willingness ment. Both providers increased performance
to innovate, customer and employee satisfac- by 20 percentage points, yet Y’s improvement
tion, and especially leadership, all seem to be is only 28.6% ((90 − 70/7) × 100 = 28.6%).
key components of an organization’s culture.1 Y would appear to have improved far less than
X even though Y’s baseline score was 3.5 the combination of baseline and remeasure-
times better and Y’s remeasurement was 2.5 ment performance that result in a relative im-
times better than X’s. What is wrong with provement of at least 50%.
this picture? The problem has to do with the (3) Absolute versus relative standards.
nature of percentages. The lower the base- What is the objective of a QI project compar-
line value, the greater the percentage increase ing the management of diabetes among physi-
at remeasurement. What is used to correct cian groups within a managed care plan? Is it
this difficulty is the relative improvement, absolute, i.e., everyone is expected to achieve
sometimes referred to as the reduction in er- a performance level of 90% and anything be-
ror rate, where the “error rate” is the differ- low that is unsatisfactory? Is it relative, i.e.,
ence between the baseline and 100%. Rela- success is defined by groups in the 90th per-
tive improvement thus ties the improvement centile based on some sort of benchmarking
score to the goal of all providers, which is hierarchy? For most purposes, relative stan-
providing the service in question to all pa- dards are preferable in part because they are
tients, or 100%. It shows the extent to which less likely to encounter significant resistance
the provider has narrowed the gap between from providers and in part because relative
what he provided at baseline and the goal standards are seen as more attainable than ab-
of 100%. The formula is (100 − baseline) − solute. In addition, absolute standards may
(100 − remeasurement)/(100 − baseline) × send the wrong message. If they are too high,
100. Using this formula, X improved 20% no one will reach them, thereby undermining
while Y improved 67%. Relative improve- the face validity of the project and arousing
ment also takes into consideration the well- provider hostility. If they are too low, everyone
known fact that it is easier to improve the will reach them, in which case the project may
lower your baseline score. It is harder to go be settling for performance that still has much
from 90% to 95% than it is to go from 5% to room for improvement. Finding the right ab-
10%. Table 1.3 shows the relative improve- solute standard can be difficult. One way of
ment for any combination of baseline and re- dealing with this problem is to deliberately
measurement values. The shaded area shows start out with a relatively low standard that
TABLE 1.3. Relative Quality Improvement

Baseline Remeasurement
10 20 30 40 50 60 70 80 90 100
10 0.00 0.11 0.22 0.33 0.44 0.56 0.67 0.78 0.89 1.00
20 −0.25 0.00 0.13 0.25 0.38 0.50 0.63 0.75 0.88 1.00
30 −0.43 −0.14 0.00 0.14 0.29 0.43 0.57 0.71 0.86 1.00
40 −0.67 −0.33 −0.17 0.00 0.17 0.33 0.50 0.67 0.83 1.00
50 −1.01 −0.60 −0.40 −0.20 0.00 0.20 0.40 0.60 0.80 1.00
60 −1.53 −1.00 −0.75 −0.50 −0.25 0.00 0.25 0.50 0.75 1.00
70 −2.38 −1.67 −1.33 −1.00 −0.67 −0.33 0.00 0.33 0.67 1.00
80 −4.12 −3.00 −2.50 −2.00 −1.50 −1.00 −0.50 0.00 0.50 1.00
90 −8.00 −7.00 −6.00 −5.00 −4.00 −3.00 −2.00 −1.00 0.00 1.00
1
For an excellent review of organizational culture, see Boan & Funderburk (Unpublished).
2
One graphic device is the radar chart. Radar charts are not familiar to most consumers and many professionals. They can be
constructed using Microsoft PowerPoint, which also contains a description of their use.
3
This may seem to be a small amount but an official from one of the larger Phoenix hospitals told me that for his institution it was
estimated to be worth about 1.5 million dollars.
a
All meter readings are based on whole blood. “Plasma” meters have a built in algorithm that converts whole blood reading to its
plasma equivalent. The “plasma” reading should be 12–15% higher than the whole blood reading. Plasma readings are popular
because they are closer to the value obtained when blood sugar is determined by a laboratory.
most can reach. Such “victories” encourage evidence that a service was provided. Further,
further effort and the standard can be gradu- payment is closely tied to documentation of
ally raised over time. services provided and there is thus a strong in-
(4) Composites versus individual indica- centive for providers to record what they do.
tors. The indicators comprising a QI project Be it reimbursement or QI, the rule is “if it
should be independent of all other indicators. isn’t documented, it didn’t happen.”
That is, provision of one service should not (6) Face validity. The success of QI is
flow automatically from provision of another. wholly dependent on the cooperation of the
In addition, each indicator used is specific providers whose data are being examined.
unto itself. It is incorrect to speak of high This cooperation in turn depends on the face
quality in diabetes care if this is based en- validity of the QI project. In other words, the
tirely on the proportion of patients receiving project must make sense and be comprehensi-
a dilated eye examination. It is also incorrect ble to the provider-subjects. Project elements
to express the quality of diabetes care as the like scoring, weighting, documentation, rules
simple average of the scores of the individual governing patient inclusion, statistical anal-
indicators. The average can be just as mislead- ysis, etc., must be fully explained and fully
ing as overemphasis on a single indicator. On understood before the project begins.
the other hand, averages, also known as com- (7) Evidence-based medicine. Evidence-
posites or aggregates, are the easiest way for a based medicine (EBM) is the rational ba-
consumer to assess quality. It is the rare consis for face validity. One of EBM’s earliest
sumer who has sufficient knowledge to eval- advocates, David Sackett offered this defini-
uate individual indicators. One way of deal- tion: “Evidence-based medicine is the con-
ing with this problem is to use average scores scientious, explicit, and judicious use of cur-
and include scores on individual indicators rent best evidence in making decisions about
through the use of a graphic device so the the care of the individual patient” (Sackett
patient can see exactly where two providers et al., 1997, p. 2). Best evidence is most com-
differ if he is so inclined.2 Individual indica- monly found in relevant, methodologically
tors on the other hand are most useful to pro- sound medical research and implies physician
fessionals trying to pinpoint areas that need familiarity with such research. Such familiar-
improvement. Composites are the preferred ity is often lacking even for the motivated
way of presenting data to consumers, albeit physician due in part to the vastness of the
with the inclusion of indicator information as medical literature and in part to the high pro-
well. portion of published material whose method-
(5) Reliability of data. Quality improve- ology is flawed. Those conducting QI must
ment projects get data from medical records use indicators that reflect a strong evidence
and other sources of information about pa- base not only for credibility but also as an in-
tients. Since, for example, the prescribing of direct means of educating physicians whose
an ACE inhibitor for a diabetes patient with performance is being measured. EBM is the
hypertension is not actually observed, the pa- surest way of knowing that what is done for
tient’s medical record is the only source of the patient is likely to benefit him.
information. Or is it? It is often claimed, es- (8) The challenge of small case numbers.
pecially by those new to QI, that services are Ideally, QI is a game everyone should play.
provided that do not find their way into the However, providers with small numbers of pa-
record. They feel that QIPs measure quality tients are often, if not usually, exempted from
of documentation rather than quality of care. QI because they have so few patients that the
From a QI perspective, the two are one and proportions are volatile and unreliable. One
the same because documentation is the only way to deal with this problem and include
all providers regardless of size is the ad- patients. The prudent physician would not ad-
justed percentage fraction (APF) (Weissman vise his patient to take aspirin daily to prevent
et al., 1999). The APF represents the best AMI if the same patient were taking warfarin
predictor of how a provider with small case for atrial fibrillation. One common way to deal
numbers would perform if there were many with these issues is to count the indicator as
patients. It is done by adding one to the having been completed if there is a note from
numerator and two to the denominator, i.e., the physician saying why the indicator ser-
APF = (N + 1)/(D + 2) × 100. The APF is vice was withheld. Finally, sets of indicators
part of a benchmarking methodology called should be open to additions and deletions as
achievable benchmarks of care (ABC). Be- warranted. The list of process indicators in Ta-
cause ABC uses relative rather than absolute ble 1.2 shows what are commonly used; it is
standards, it is not universally accepted. How- not meant to exclude all other potential indi-
ever, this in no way depreciates the value of cators.
the APF. The APF and raw percentages tend For a number of years, it has been
to be very close at case numbers above 30, and the conventional wisdom that mortality from
beyond this number, raw percentages should coronary artery bypass graft (CABG) is in-
be used. The APF is usually acceptable to versely proportional to hospital volume, and
providers once they understand its use and it a volume standard for hospitals was usually
solves a major difficulty. It is reasonable to ex- set at no less than 200 cases per year (Hartz
pect that all providers who provide the same and Kuhn, 1994). The HSAG, Arizona’s QIO,
services should be equally accountable. The did an assessment of CABG surgery in the late
APF lets all the players into the game. 1990s and found that although mortality rates
(9) Flexibility in QI. Locking in prac- were comparable to national data, only two of
tices that may be scientifically obsolescent the 20 hospitals offering CABG averaged 200
is a danger inherent in QI. Indicators should cases per year and that surgeon volume rather
not be regarded as being beyond criticism or than hospital volume was the primary deter-
change. All indicators need to be reviewed at minant of outcome (Marshall and Murcko, un-
regular intervals to assure that they are not published). These observations were recently
having a negative influence on provider prac- supported by Birkmeyer et al. (2003). If, as
tice. For example, if an indicator specifies the it appears, CABG mortality does not depend
use of an ACE inhibitor for patients with acute on hospital volume, this standard needs to
myocardial infarction while many physicians be revised and perhaps refocused on the in-
favor the use of angiotensin receptor block- dividual surgeon. Volume requirements for
ers (ARBs) instead because they have fewer CABG are written into law in New Jersey
side effects, the indicator should be reviewed. (New Jersey Administrative Code, n.d.) and
If review fails to demonstrate that ARBs are Pennsylvania (Dethlefs et al., 1991) and how
equal to ACE-Is for AMI patients, there is still soon they are amended will be a major test of
an important problem. If the indicator is one flexibility.
widely used by CMS in a QIP involving Medi- (10) Limitations of indicator-specific QI.
care patients in all U.S. hospitals, how will the The more indicators, the more one learns
research required to definitively demonstrate about the management of diabetes patients.
the value of ARBs relative to ACE-Is be car- However, as the list of indicators grows so
ried out? In a case like this, a QIP may have the does the expense of collecting data and, of-
unintended and paradoxical consequence of ten, the intrusiveness of the entire project.
freezing practices that should be reassessed. To avoid overwhelming expense, indicators
Similar flexibility is required to deal with in- should be reviewed by performance. If an in-
dicators that may not be appropriate for all dicator service is provided to 95% of patients,
its value as an indicator is dubious because to effects of multiple factors on a response can-
a considerable extent it no longer represents not be separated. The extent to which change
an opportunity to improve care. The replace- in the desired direction is the result of the na-
ment of indicators as they become obsolete or tional effort or of a smaller unit effort or both
reach full compliance also serves to maintain remains unknown.
the attention of providers who are continually
offered new challenges. In a somewhat differ-
ent vein, QI is always incomplete because it DISEASE MANAGEMENT
rarely includes structural variables that affect
the process of care such as the financial via- Targeted as a method to improve care and
bility of the organization, the availability of control rising health costs, DM is a movement
sufficient personnel, or the satisfaction of pa- backed primarily by insurers and managed
tients with services provided. Even when this care plans. DM focuses on high cost, high-risk
kind of information is available, it is difficult patient populations, and aims to reduce costs
to relate it to indicator-specific quality as to by making visits to the physician secondary to
cause and effect. QI reveals how diabetes is measures taken by the patient himself. This is
managed but does not divulge what changes in done under the guidance of a health care pro-
the organization, i.e., system changes, might fessional (nurse, educator, pharmacist, dieti-
serve to further improve care. cian, respiratory/physical/occupational thera-
pist, etc.) who serves as case manager (also
known as a disease manager or care man-
QI ON THE NATIONAL, STATE, ager). Standard protocols using evidenced-
AND REGIONAL LEVELS base guidelines are drawn up for each dis-
ease being managed, including such illnesses
Broadly applied QI activities such as as depression, heart failure, and diabetes. The
these do not usually include any kind of for- case manager communicates with the patient
mal remeasurement. Rather, they have been on a regular basis to assure that the patient
demonstrated in smaller venues to be effec- is adhering to the protocol, thus improving
tive and they are utilized based on this evi- the quality of care. Case managers are some-
dence. Their success is judged by changes in times available 24 hours a day and further
pertinent national, state, or regional data. An communication is provided through websites.
example would be a national education cam- The case manager is also in contact with the
paign to promote improved eating habits as a patient’s physician and reminds him or her
means of countering the related “epidemics” of services needed by specific patients. Dis-
of obesity and diabetes. The success of such a ease management is a rapidly growing field
program is not formally measured and it might that is increasingly offered through employ-
be judged by a drop in the average weight of ers. A DM trial among Medicare beneficia-
adults over time, fewer hospitalizations for di- ries is part of the Medicare Prescription Drug
abetes or diabetes-related conditions, a fall in Benefit and Modernization Act of 2003. DM
the sale of antidiabetic pharmaceuticals, etc. is not without flaws. Relationships between
Results are rarely “clean” because our educa- doctors and case managers are often frustrat-
tional program is not the only source of infor- ing to both parties, and the involvement of
mation about nutrition and diabetes. Lots of pharmaceutical houses in DM might be seen
smaller units such as state health departments, as a ploy to push prescription medications.
managed care plans, health centers, individ- Because it is of greatest interest to its back-
ual physicians, and a major segment of the ers, DM tends to be judged not by changes in
food industry are all busy promoting the same quality but by changes in cost (Clark, Kim,
thing. This is the problem of confounding. The 2004).
PUBLIC REPORTING AND agreed to tie their Medicare reimbursement

PAY-FOR-PERFORMANCE in part to performance on 34 quality indica-
tors covering AMI, heart failure, pneumonia,
By far, the biggest player in contempo- CABG surgery, and hip and knee replace-
rary QI is the Centers for Medicare and Med- ment. The indicators bear the imprimatur of
icaid Services. CMS now requires periodic prominent organizations involved in QI such
public reporting of data on selected conditions as JCAHO, National Quality Forum, Quality
and indicators from nursing homes, home Improvement Organizations, and CMS itself.
health agencies, and managed care plans. Pub- Using annual composite quality scores, hos-
licly reported data from managed care plans pitals that finish in the top decile (>90%) will
includes diabetes. In addition, hospitals face a receive a 2% bonus on Medicare reimburse-
small percentage loss of 0.4% of the increase ment. Those in the second decile (>80%) will
in Medicare reimbursement for the following receive a 1% bonus. At the other end of the hi-
year if they do not agree to publicly report erarchy, those in the ninth decile (>20%) will
data.3 There is little doubt that the data from lose 1% whereas those in the bottom decile
individual physicians will become public in (<10%) will lose 2% after 2 years of such sub-
the near future. Public reporting is an inter- par performance (Medicare Fact Sheet, 2004).
vention intended to stimulate quality improve-
ment efforts and to enable consumers to make
informed choices about providers. Forty per- ELECTRONIC MEDICAL
cent of consumers say that a hospital’s qual- RECORDS
ity is important to them when choosing where
to be admitted (AHQA Matters, 2004). How Electronic medical records (EMR),
effective it will prove to be is not known, sometimes called electronic health records
but it is uncertain that it will significantly af- (EHR), is QI’s hitherto impossible dream.
fect patient’s choice of hospital or nursing EMR compiles all the data on an individ-
home since many patients have this choice ual patient in one electronically accessible
made for them by their physician or managed database. A thorough EMR would include
care plan, and others make decisions based on laboratory tests, radiology reports, inpatient
such considerations as nearness to home, ex- notes for each hospitalization, outpatient
perience of friends and relatives, and general notes for each visit and each physician visited,
reputation. surgical notes, and medications. The patient’s
Pay-for-performance is perhaps the ulti- entire experience with the health care system
mate intervention. Carried to its logical end would be immediately available to the current
point, it means that the patient is not pay- provider. Patient data could be sorted so that
ing for service or time; he is paying in- the specific problem of interest to a provider
stead for a level of care identified and re- could be addressed and those interested in QI
quired by the payer. Pay-for-performance is could be certain that the patient receives care
not a new idea to health care. Indeed, in a up to the existing standard. It is the next log-
free market, the consumer chooses to pay the ical step after disease management. To date,
provider he uses in the belief that the provider EMR is in use at large systems of care such as
provides care that is worth the fee. Pay- the Department of Defense and the Veterans’
for-performance tied to specific performance Administration. EMR is increasingly frequent
measures is new, however, and it would seem in hospitals and managed care plans as well,
to be the most powerful of all interventions. often in a hybrid form that retains some fea-
A pay-for-performance demonstration is now tures of the paper record. In these cases, EMRs
underway involving a nationwide system of reaching across hospitals or managed care
nonprofit hospitals. About 300 hospitals have plans are exceedingly rare. The biggest hurdle
to expanded use of the EMR is the individ- in the rate of improvement is best expressed
ual physician or physician group. Cost, steep at the Reduction in Error Rate, i.e., the dif-
learning curves, avoidance of disruption of ference between the level of care achieved
an ongoing method of record keeping, and and the highest possible level, which is, of
doubts about the ability of EMR to live up course, 100%. In contrast, quality assessment
to its advance billing are formidable barriers. is “snapshot” of care as it existed at a point
Some of the doctor’s concerns are real enough. in time and does not measure improvement.
Like any other electronic data storage device, Quality assessment often leads to QI, how-
security and confidentiality are major issues. ever, in which case the assessment becomes
There is no existing legislation that establishes the baseline measurement. QI does not pertain
ground rules for how medical information can only to diseases. It is equally applicable to is-
be used, who should be able to access it, and sues of patient safety and patient satisfaction.
which parts of the record should be acces- Among providers, hospitals and man-
sible. Records accessed through the world- aged care plans probably have the most
wide web are almost certainly vulnerable to well-developed internal methods of quality
access by the unauthorized and the curious. improvement. QI is relatively new among
The number of parties with an interest in a nursing homes, home health agencies, and the
patient record includes government agencies, offices of individual or groups of physicians.
insurance companies, health care administra- States are involved in QI through Medicaid
tors, managed care plans, physician groups, and the activities of health departments, and
etc. Each of these is a potential source of unau- there are a host of private or university-based
thorized access by unauthorized personnel. programs that address quality issues. The
biggest influence on improving quality, how-
ever, is the federal CMS. Medicare is the
SUMMARY largest purchaser of health care in the United
States, and Medicare beneficiaries account
Quality improvement in the management for a disproportionate number of hospital ad-
of a disease entity like diabetes is dependent missions, consumption of prescription drugs,
on the knowledge that how the patient is man- and visits to physicians. Since Medicare re-
aged has a positive impact on his well-being imburses providers for this care, its influence
to a greater or lesser degree. Thus, one may is enormous. QI activities of CMS are the re-
trace the origins of QI in diabetes to the dis- sponsibility of QIOs, one of which serves each
covery of insulin in 1922 and the DCCT study state.
of 1993. In many diseases, the result is death Recent developments in the field of
no matter what the physician does or does not QI include public reporting of selected pa-
do. Once the physician does what he can, he tient care data by hospitals, nursing homes,
can do no more. For this reason, QI based on managed care plans, home health agencies,
the process of care is more appropriate than and, increasingly, individual physicians. Pub-
QI based on patient outcomes. lic reporting is the precursor to pay-for-
Quality improvement uses specific activ- performance care under which high quality
ities that patients require, called “indicators” providers are rewarded by higher reimburse-
or “performance measures,” to determine the ments and poor performers face reduced re-
quality of care. A typical indicator in diabetes imbursement. Much attention is now focused
care is whether a patient with diabetes re- on the spread of electronic records to facili-
ceived a timely eye examination. QI compares tate the access of patient information to those
the difference between the completeness of providing for his care. Attention also is in-
the process of care at a baseline time to that at creasingly directed to the corporate “culture”
a later time. This difference in completeness under which care is provided and whether the
characteristics that define this culture promote Institute of Medicine. (2001). Crossing the Quality
or impede high-quality care. Chasm: A New Health System for the 21st Century.
Washington, DC: National Academy of Sciences.
Quality improvement is a work in
Jencks, S., Huff, E.D., and Cuerdon, T. (Jan. 15, 2003).
progress with vast potential benefits for pa- Change in the quality of care delivered to Medi-
tients. As fiscal rewards become more im- care beneficiaries, 1998–1999 to 2000–2001. JAMA
portant, such incentives will not only stimu- 289:305–312.
late improvement efforts by providers but also Karter, A.J., Stevens, M.R., Herman, W.H., Ettner, S.,
Marrero, D.G., Safford, M.M., Engelgau, M.M.,
provide a concrete payoff for their efforts.
Curb, J.D., and Brown, A.F. (August 2003). Out-
of-Pocket Costs and Diabetes Preventive Services.
Diabetes Care 26:2294–2299.
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2
The Chronic Care Model

Blueprint for Improving Total Diabetes Care
Anita C. Murcko1, Jean Donie2, Scott Endsley3 , and Larry Cooper4

1 MD, FACP Medical Director, Healthcare Group of Arizona Phoenix, Arizona
2 RN, MBA, CPHQ Director of Clinical Organizational Development,
Dell Webb Hospital, Sun City, Arizona
3 MD, MSc Medical Director, System Design Health Services Advisory Group, Phoenix, Arizona
4 MA Director of Health Education & Publication Department Corporate Development/Communications Health
Services Advisory Group, Phoenix, Arizona
Problems cannot be solved at the same level of

awareness that created them.
—Albert Einstein
INTRODUCTION blindness, kidney disease, amputations, ner-

vous system disease, obesity, and dental dis-
Chronic disease is a national epidemic. ease can be prevented or lessened by proac-
Over 100 million Americans, including nearly tive chronic-illness care, yet less than half of
80% of seniors, suffer illness, disability, and those diagnosed with diabetes receive care
death related to chronic illnesses. One in five that is consistent with guidelines (Boden-
seniors has five or more chronic conditions, heimer et al., 2002; Casalino et al., 2003;
visits on average 14 different physicians, and Hoffman et al., 1996; Murcko, 2004, March/
uses an average of 50 different prescription April; National Center for Health Statistics,
medications per year. Two-thirds of Medi- 2003).
care funds are used to care for the 20% of The Chronic Care Model (CCM;
seniors with five or more chronic illnesses, Wagner, 1998) is an elegant, intuitive,
while the proportion of Americans with one or evidence-based model that is both practical
more chronic conditions is growing steadily. and useful, and addresses the root causes of
Diabetes, through its myriad complications, the well-articulated gap between the “health
accounts for upwards of 20% of America’s care we have and the care we could have”
chronic illness burden. Diabetes-associated [Institute of Medicine (IOM), 2001, p. 1]
heart disease, stroke, high blood pressure, for patients with diabetes and other chronic
19
20 THE CHRONIC CARE MODEL
illnesses. This chapter describes the princi- THE CHRONIC CARE MODEL: A
ples and practical application of the CCM. MULTIDIMENSIONAL SOLUTION
The Chronic Care Model is not a quick fix or

magic bullet. It is a multidimensional solution to
CLOSING THE QUALITY CHASM a complex problem.
FOR THE CHRONICALLY ILL —Edward Wagner
Chronic Care Model architect
The acute care focus of our health care
system is probably the most formidable bar- Background
rier to optimal chronic care delivery (Wagner,
1998). In the workaday office world, chronic According to Dr. Edward Wagner, suc-
disease management regularly takes a back- cessful chronic-illness care improvement ini-
seat to the sore throat, sprain, or most tiatives have three key features:
recent test results. Limited by inadequate 1. a clear definition of optimal care,
time, and relying on already overwhelmed 2. a roadmap for changing the system, and
provider memories, our health care falls short 3. an effective improvement strategy.
of the IOM’s Crossing the Quality Chasm Derived from the early 1990s work by the
“STEEEP” (IOM, 2001) aims for health care: Group Health Cooperative of Puget Sound
Safe, Timely, Effective, Efficient, Equitable, MacColl Institute for Healthcare Innovation
and Patient-centered. The Chasm authors (Seattle, WA) the CCM (Figure 2.1) is a six-
challenge us to redesign our care so that it element distillation of successful chronic care
meets needs of our patients with chronic ill- delivery interventions. The model is based
ness by: on the recognition that chronic care takes
place within these three overlapping spheres
r a continuous healing relationship, [Improving Chronic Illness Care (ICIC), n.d.;
r regular clinical assessments, Murcko, 2004; Wagner, 1998]:
r effective clinical management,
r information and ongoing support for self-
r community, including its resources and
management, myriad public and private policies,
r a shared care plan, and r health care system, including its payment
r active, sustained follow-up. mechanisms and policies, and
r provider organizations, ranging from the
single physician practice to large, multi-office
Redesigning our care systems while still corporations.
meeting day-to-day patient needs requires a
blueprint that is consistent with the best ev- As we discuss the details of the CCM in the
idence; provides a common taxonomy, ter- next section, you are invited to take the “CCM
minology, and framework that is useful for plunge”: identify the sphere(s) into which you
local and national quality improvement; and is as professional, health system leader, patient,
relevant across all chronic conditions. Based and/or citizen can exert the greatest contribu-
on our experience as Arizona’s Medicare- tions toward ICIC, and create your action plan.
designated Quality Improvement Organiza-
tion [QIO; American Health Quality Associa- Fundamental Care Unit
tion (AHQA), n.d.], we believe that the CCM,
coupled with the Institute for Healthcare Im- The heart of the CCM is predicated upon
provement (IHI, n.d.-a; IHI, n.d.-b) Collab- the creation of the fundamental care unit:
orative framework (described below) meets a prepared, proactive practice team deliver-
these needs for a broad spectrum of health care ing care to an informed, activated patient.
organizations. This prepared, proactive practice team uses
THE CHRONIC CARE MODEL 21
FIGURE 2.1. Chronic Care Model. Used with permission of Effective Clinical Practice.
evidence-based clinical information, is pre- are: community resources and policies, health
pared with patient-specific data before each system organization, self-management sup-
visit, and each team member is empowered by port, delivery system design, decision sup-
having designated roles to contribute to the pa- port, and clinical information systems.
tient experience and optimized outcome. The Community Resources acknowledges the
informed, activated patient (includes family growing importance of linking patients with
and/or caregiver) understands his condition, community programs and services to mobi-
the role he plays in the management of his own lize these resources to meet patient needs. As
health, is confident of his self-management professionals, we are challenged to:
skills, and knows what to expect from the
health care system. This unit, repeated many r Encourage patients to participate in ef-
times over, delivers simultaneously improved fective community programs, particularly exercise
functional and clinical outcomes, i.e., the right and educational programs.
care for the right patient in the right place at r Form partnerships with community orga-
the right time (Murcko, 2004 May/June). nizations to identify, support, and develop inter-
ventions that fill gaps in needed services, including
the creation and dissemination of resource guides,
Chronic Care Model Defined development of outreach programs using lay work-
ers/health coaches, and the sponsorship of commu-
The well-studied and validated inter- nity events.
ventions (Wagner, 1998; Wagner 1996; Von r Advocate for policies to improve patient
Korff, 1997; Bodenheimer et al., 2002; care, including the crafting of messages for the
Casalino et al., 2003) that comprise the CCM public.
Examples include case managers to co- rials, and patient guidelines (Wagner, 2001a;
ordinate referral to community resources, Wagner, 2001b).
peer group support groups, televised self- Delivery system design refers to the or-
management courses, working with den- ganization and scheduling of planned proac-
tists, offering patient incentives for self- tive care to assure effective, efficient clinical
management activities, and diabetes walks. care, and self-management support. The key
Organization of Health Care addresses features of delivery-system design include the
the culture and policies of the system in which need to:
care takes place. The mission, business plan,
r Define roles clearly and distribute tasks
and goals of your organization must clearly
promote safe, high-quality care. Organization among empowered team members.
r Use planned interactions, including
leaders are role models who:
group medical appointments for self-management
r Visibly support improvement at all or- training, to support evidence-based care.
r Provide clinical case-management ser-
ganizational levels, starting with the leadership
vices (when available) for complex patients.
team. r Ensure regular follow-up by the care
r Endorse effective improvement strategies
team.
aimed at comprehensive system change. r Give care that patients understand and
r Encourage open and systematic handling
that fits with their cultural background.
of errors and quality problems to improve care.
r Provide incentives based on quality of
Examples include revised team roles with
care.
r Develop agreements that facilitate care scripted activities, group visits/planned vis-
coordination within and across organizations. its, posted notices to remove shoes and socks,
telemedicine use, and health care coach as-
Examples include pay-for-performance in- signments.
centives (Murcko, 2004, May/June), forma- Clinical information systems allow prac-
tion of a chronic-care department, recruitment tices to integrate patient and population data
of senior leaders, and use of the CCM in ini- to facilitate efficient, effective, and proactive
tiative designs. care. Electronic patient tracking tools, such as
Self-management support includes activ- electronic disease and population health reg-
ities that empower and prepare patients to istry modules, are essential to:
understand their health behaviors and to de- r Improve patient health outcomes and pro-
velop strategies to live life as fully as possi-
motion of early intervention strategies.
ble. Simultaneously, as the most rewarding yet r Provide timely reminders and feedback to
most challenging CCM component, we strive patients, health care managers, and providers.
to: r Identify relevant subpopulations based on
specific or multiple clinical parameters (conditions,
r Emphasize the patient’s central role in
comorbidities, evidence-based measures, etc.) for
managing his health. proactive care. Facilitate individual and patient
r Use effective, culturally competent self-
population care planning.
management support strategies that include assess- r Share information with patients and
ment approaches, goal setting, action planning, providers to coordinate care and support self-care
problem solving, and follow-up. and self-education about relevant evidence-based
r Organize internal and community re-
guidelines.
sources to provide ongoing self-management sup- r Monitor performance of practice teams
port to patients. and the care system.
r Reduce clinical practice variation by em-
Examples include lay-health coach develop- bedding evidence-based measures that describe
ment and use, goal sheets, low literacy mate- care pathways into daily clinical practice.
r Improve patient safety by reducing med- IMPROVEMENT

ication errors of omission or commission. COLLABORATIVES
r Establish connectivity to other clinical
ACCELERATE CCM ADOPTION
stakeholders so information between providers
and patients can be shared [primary care
provider (PCP)-referred specialist, health plan
Redesigning health care systems to im-
disease management nurses, patient self-report prove chronic-illness care is not easy. One
health risk assessment survey results for PCPs, way to accelerate change is by working
etc.]. collaboratively with other organizations that
r Reduce malpractice liability costs by doc- share similar goals. The implementation of the
umenting conformity with defensible medical stan- CCM through participation in an IHI Break-
dards. through Series (BTS) Collaborative (ICIC,
r Automate reporting and assessing of out-
n.d.) is a systematic approach that has been
comes for individuals and patient populations. demonstrated to improve health care delivery
r Save time with easy access to clinically
(IHI, n.d.-b). A collaborative is a systematic
useful information on individuals as well as groups
approach to health care quality improvement
of patients.
in which organizations test and measure prac-
tice innovations. Practices accelerate learn-
Examples include registry/electronic health
ing and spread the implementation of best
record use, performance feedback, pread-
practices by sharing via a series of structured
dressed reminders, linking labs, and phar-
venues. A collaborative comprises three main
macy data to registry.
phases: development, planning, and execu-
Decision support promotes clinical care
tion (American Health Quality Association,
that is consistent with scientific evidence and
n.d.).
patient preferences through several mecha-
nisms:
r Embed evidence-based guidelines into Development Phase

daily clinical practice by implementing protocols, During the development phase, activities
reminders, and the use of standing orders that make are conducted to create supporting materials
it easy to do the right thing for each patient.
r Share evidence-based guidelines and infor an IHI BTS-style collaborative. These ac-
formation with patients to encourage their partici-
tivities include the prerequisites of topic se-
pation. lection and convening the expert panel that
r Use proven provider education methods, assists the supporting material creators in the
such as academic detailing and motivational inter- development of a document that is broadly de-
viewing that inspire behavior change. fined as a collaborative framework. The col-
r Integrate specialist expertise with pri- laborative framework has three components: a
mary care through regular access and discussion. charter, a change package, and a measurement
strategy.
Examples include flow sheets, progress note The charter includes the problem state-
templates, referral guidelines design and use, ment, mission and goals, and methods
pocket cards, and registry data use to discuss and expectations. The charter presents the
adherence to guidelines. gap between science and current practice.
Focusing on these six essential CCM Ideally, a business case is included as
components (Figure 2.2) can foster pro- well. The charter also describes the com-
ductive interactions between patients who mon aim of all participants—to work to-
take an active part in their care and gether to achieve breakthrough results that
providers who are supported by resources and one organization working alone would not
expertise. achieve.
FIGURE 2.2. Chronic Care Model, detailed version. Used with permission of Effective Clinical Practice.
A change package is the second major Planning Phase

component of the collaborative framework.
The change package organizes the key ele- During the planning phase, collabora-
ments of a high-performing system, represent- tive sponsors prepare for the kickoff of the
ing the ideal system of care for the collabora- collaborative. This involves recruiting partic-
tive topic. The purpose of the change package ipants, developing marketing materials, and
is to provide guidance to the collaborative par- preparing the sponsor team for the capture of
ticipants on changes they can make that will data and information necessary for assessing
result in improvements. impact.
The measurement strategy is a compi-
lation of outcomes, processes, and balancing Execution Phase
measures. These measures, required and/or
optional, are tracked over the course of the This phase occurs over 12–16 months,
collaborative and demonstrate that a team’s begins with prework, and culminates in a fi-
changes resulted in improvements and, there- nal meeting “outcomes congress” that show-
fore, spreading this work throughout the or- cases participant results and promotes expan-
ganization is imperative. Key measures are sion or “spread” of successful chronic-care
required to assess progress on each team’s strategies. Over the course of the collabo-
aim. rative, teams from each organization attend
“best strategies” for improving care. Refining

and evaluating internal systems changes using
the model for improvement (Figure 2.3) are
built upon the Plan–Do–Study–Act (PSDA)
cycle (Figure 2.4). Between learning sessions,
teams refine their plans with input from the
core faculty of recognized experts in chronic-
condition care and measurement, and submit
monthly reports to their organizational and
collaborative leaders.
The IHI-style collaboratives improve on
traditional quality-improvement programs by
encouraging participants to “share openly and
steal shamelessly,” so that, by using actual
tests and examples, they learn from one an
other’s mistakes as well as successes. Collab-
oratives are also action-oriented: teams make
changes to their organizations within a week
of attending a learning session. Participants
get instant access to the strategies best proven
for chronic-illness care. Since the first IHI
FIGURE 2.3. Model for Improvement (Langley et al.,
1996, p. 10).
BTS collaborative in 1995, more than 700
teams from over 450 North American health
periodic learning sessions, which include the care organizations have successfully partici-
incorporation of the CCM within their orga- pated in a collaborative, including those spon-
nizations, and the examination and sharing of sored by the ICIC program (see Figure 2.5).
FIGURE 2.4. PDSA Improvement Cycle (Langley et al., 1996, p. 7).

FIGURE 2.5. ASDC Framework. Based on IHI BTS (IHI, n.d.-a; IHI, n.d.-b).
STATE AND REGIONAL as financial success (IHI, n.d.-a; IHI, n.d.-b;

COLLABORATIVES IMPROVE Murcko 2004, May/June; ICIC, n.d.; Wagner
CHRONIC-ILLNESS CARE et al., 2003). Interventions that are too nar-
row in scope or weak with regard to system
Breakthrough series collaboratives range change have minimal impact health outcomes
from small, local practice groups to large, and cost, and have, for some, created skep-
national initiatives, such as those sponsored ticism about engaging in improving chronic
by the Bureau of Primary Health Care for care. In addition, many disease-management
community health centers (IHI, n.d.-a; IHI, programs have fallen short of the overly opti-
n.d.-b). Diabetes is (and has been) the focus mistic expectations they create (Wagner et al.,
for numerous collaboratives, as outlined in 1999).
Table 2.1, creating a community rich in ex- The typical reported cost of CCM inter-
perience for all to draw upon. Detailed re- ventions ranges from $200 to $500 per patient
sources are available from the sponsoring or- per year, with savings varying in condition and
ganizations which can be used “shamelessly” population (ICIC, n.d.). Cost savings may be
by those with a similar mission. greatest for congestive heart failure (and for
asthma, among populations with high rates of
hospitalization), with less short-term returns
on investment for diabetes.
BUSINESS CASE FOR QUALITY Revenues generally rise in the fee-for-
IMPROVEMENT? service environment, since checkups and
screenings not routine to acute care can in-
Multipronged efforts, such as those us- crease billable utilization. Patients who re-
ing the CCM, have met with clinical as well ceive better care also are less likely to
TABLE 2.1. Regional and Statewide IHI BTS-style Diabetes Collaboratives

Total Diabetes
State Sponsors Collaboratives Years
Alaska Qualis Healtha 1 2000–2002

Arizona Health Services Advisory Group,a State Diabetes Control 2 2002–2004
Program
Arkansas University of Arkansas, State Diabetes Control Program, 1 2002
Arkansas Foundation for Medical Carea
California Lumetraa 1 2003–2004
Hawaii Mountain-Pacific Quality Health Foundationa 1 2003–2004
Idaho Qualis Healtha 1 2003
Illinois Midwest Business Group On Health, Institute of Medicine of 2 2002
Chicago, Illinois Foundation for Quality Healthcarea
Iowa Iowa Foundation for Medical Carea 1 2003–2004
Indiana State Department of Health Services, Health Care Excela 2 2003–2004
Kentucky Health Care Excela 1 2004
Maine MaineHealth 2 2003–2004
Missouri MissouriPROa 2 2002–2003
Nevada HealthInsighta 2 2002–2004
New Mexico New Mexico Medical Review Associationa 2 2001–2004
New York IPROa 1 2003
North Carolina State Diabetes Control Program, Medical Review of North 2 2003–2004
Carolinaa
North Dakota North Dakota Health Care Review, Inc.a 1 2003
Oregon Oregon Medical Professional Review Organizationa 2 2001–2004
Rhode Island State Department of Health Services, Quality Partners of Rhode 2 2003–2004
Islanda
Utah HealthInsighta 2 2002–2004
Vermont Vermont Program for Quality In Health Care 3 2001–2004
Washington State Diabetes Control Program, Department of Health, Qualis 4 2000–2004
Healtha
Wisconsin MetaStara 2 2002–2004
a
State Medicare Quality Improvement Organizations (QIOs). Additional information regarding each QIO can be obtained at
http://www.cms.hhs.gov or www.ahqa.org. Organizations sponsoring collaboratives are encouraged to centralize contact information
on the ICIC Web site, http://www.improvingchroniccare.org.
leave for another practice, which reduces enrollment. A system that provides better
the fixed costs of establishing new patients. care for people with illnesses may attract
Capitated systems benefit from reductions chronically ill patients, although there are
in hospitalizations and specialty care. Sys- no clear data to suggest this outcome (ICIC,
tems also can use low-cost patient contacts n.d.).
(e.g., telephone calls), and low-cost person-
nel for some services. Both systems benefit
from patient loyalty and enhanced provider MEDICARE QUALITY
productivity. IMPROVEMENT
Satisfaction with visits, especially early ORGANIZATIONS: QUALITY
visits, is a powerful predictor of continued PARTNERS
use. The better the interaction between the
patient and the team of providers, the more The IHI and ICIC have recently part-
likely a patient is to be satisfied—and a sat- nered with the Centers for Medicare &
isfied patient is more likely to stay. Cur- Medicaid Services (CMS, n.d.) through its
rent data are unclear about impacts on new QIO program. For the past 20 years, under
Congressional mandate, CMS has maintained morbidity and mortality among the U.S.
contracts in each state with a community- population as a whole and specifically, se-
based organization. These entities, formally niors) to focus the work of providers and
known as peer review organizations (PROs), QIOs. CMS and national partners have de-
are now designated as QIOs to more accu- veloped “quality measures” for the pri-
rately reflect their CMS-directed change in ority topics, and have agreed upon cer-
focus from case review to case-based and tain evidence-based intervention strategies
systems-based quality improvement. The QIO upon which to base local interventions.
goals are to improve the quality of health care MedQIC, http://www.medqic.org, is a search-
services provided to people with Medicare able, online clearinghouse of public-domain,
and to safeguard the integrity of the Medicare evidence-based materials launched in late
trust fund. 2003 to support the quality improvement ac-
The QIO mission is to collaborate tivities of providers and QIOs. In addition
with providers and patients to achieve to its capacity as a comprehensive depos-
significant and continuing improvement itory of information, MedQIC is designed
in the quality, safety, and effectiveness of to serve as a dynamic internet-based com-
health care at the community level. With munity for medical professionals and QIOs
a diverse staff comprising of physicians, to exchange ideas, quickly contribute and
nurses, statisticians, communications ex- distribute new resources, and connect users
perts, and other professionals focused in the nationwide.
four priority settings (physicians’ offices, As might be expected, diabetes and car-
hospitals, nursing homes, and home health diovascular diseases are prominent among
agencies) of Medicare’s Health Care Quality the CMS clinical priorities, and interventions
Improvement Program (HCQIP), QIOs, using the CCM top lists of national and state-
such as our organization, Health Services based quality improvement activities (See Ta-
Advisory Group, Inc. (HSAG), employ the ble 2.1). QIOs collaborate with public and pri-
following general strategy: vate provider and payer organizations locally
and nationally through CMS and its sister U.S.
r Identify opportunities to improve care.
r Analyze national and state-level quality Department of Health and Human Services
(HHS) divisions: Centers for Disease Control
performance data.
r Communicate with professional and and Prevention (CDC), Agency for Health-
provider communities about performance mea-
care Research and Quality (AHRQ), National
sures and their use in quality improvement projects. Institutes of Health (NIH), Health Resources
r Design and collaborate on quality im-
provement projects that emphasize improving sys- TABLE 2.2. ASDC Core Measure Set
tems of care.
r Implement effective quality improvement Target
strategies and evaluate the success of quality im- Measure Measure definitiona (%)
provement activities.
r Use pretested educational materials for HbA1c Most recent 75
HbA1c < 7%
providers and patients, including supporting CMS LDL Most recent 85
public reporting of performance measures. LDL < 100 mg/dl
r Foster collaboration among providers, Blood pressure Most recent 75
payers, and others to improve care and increase BP < 130/80 mmHg
the value of health care expenditures. Eye exam Dilated eye exam 70
Self-Management Self-management 70
Together with many national organizations, goal goal(s)
CMS has selected “priority topics” (i.e., con- a
A detailed description of measurement strategy can be found in
ditions that represent important causes of the ASDC Pre-Work Handbook, http://www.azdin.com.
and Services Administration (HRSA), Sub- sector health care leadership learned the
stance Abuse and Mental Health Services CCM terminology and concepts and became
Administration (SAMHSA), Indian Health acquainted with the framework and imple-
Service (IHS; CMS, 2004), and through other mentation of IHI BTS-style Collaboratives.
national health quality organizations—such This is graphically portrayed by overlays on
as the AHQA and the national QIO associ- an Arizona map (Figure 2.6).
ation. Predating by nearly 2 years the actual ex-
Additional assistance for providers, ecution of ASDC, AzDIn provided a culture
plans, and QIOs to promote quality and safety change nexus that manifested itself through
related to chronic care is being made avail- ASDC and in the adoption and use of the CCM
able through the legislation making the most and collaborative framework in managed care,
sweeping changes in Medicare since its in- state health departments, academics, con-
ception more than 20 years ago. The Medi- sumer organizations, and vendors’ activities.
care Prescription Drug, Improvement, and The goals of ASDC (Murcko, 2004)
Modernization Act of 2003 (MMA) includes were to:
several specific studies (Sections 649 and 721) r Promote awareness and adoption of the
to identify new ways to deliver and reimburse
CCM with particular emphasis on dissemination
for care provided to those with chronic dis-
of information, communications technology, and a
ease. Under Section 721, CMS is required to change package of quality improvement activities.
sign three-year contracts with “chronic care r Create and support multistakeholder im-
improvement organizations” to develop, test, provement activities through alignment of state and
and evaluate programs to improve the qual- national diabetes quality improvement work coor-
ity of chronic-illness care. Section 649 estab- dinated by HSAG.
lished a three-year demonstration project to r Identify and assist a diverse provider base
pay physicians at four United States sites to of early adopters, both demographically and geo-
adapt and use health information technology graphically.
r Develop participants’ individual and col-
and outcomes measures to promote continuity
lective improvement skills for ongoing CCM-
of care or minimize chronic conditions. The
based patient safety and quality improvement ac-
terminology, taxonomy, and concepts of the
tivities.
MMA have the CCM as their foundation. The
influence of the federal government upon ac- ASDC comprised 65 participating prac-
celeration of health information technology is tices throughout Arizona, representing the
detailed in “Chapter 6”. diverse settings of small-group community
primary-care practice, academic and teach-
ing practice, and the state network of feder-
CASE STUDY ally qualified community health centers. The
practices participated in one of three tracks,
The Health Services Advisory Group including an intensive track with expectations
(HSAG), Arizona’s Medicare QIO sup- to implement a full range of collaborative in-
ported by a Robert Wood Johnson grant, terventions, a “collaborative-lite” track with
organized a statewide diabetes collaborative expectations to implement a partial package
[Arizona State Diabetes Collaborative of interventions, and a more peripheral track
(ASDC)]. ASDC was developed and sup- with expectations to implement at least one
ported by a statewide community coalition of diabetes improvement activity.
over 80 organizations, the Arizona Diabetes Effectiveness of ASDC was measured
Initiative (AzDIn). By titling and tasking by two categories of outcomes. First, a
AzDIn workgroups according to the CCM standard (core) diabetes set of quality
elements (Figure 2.2), public and private indicators selected by the advisory panel were
FIGURE 2.6. Synchronous collaboratives: Arizona state diabetes collaborative (Murcko, 2004) sponsoring organi-
zations and partnerships.
tracked to measure clinical effectiveness. Sec- Each practice was asked to identify a co-
ond, communications and culture change in- hort of diabetes patients, aged 18–75, with at
dicators were measured to assess adoption of least one diabetes visit during the preceding
a quality culture in practice. Practices also 12 months. Table 3 presents the results for the
had the ability to collect a set of optional 12 participating practices in the intensive col-
diabetes∗ and preventive care indicators, as laborative track.
well as assistance in designing related mea- Three practices implemented the inno-
sures to meet their own needs (e.g., two vative Delivery System Design intervention,
practices tracked referrals for eye care to val- group visits (IHI, n.d.-a; IHI, n.d.-b; McCul-
idate their assumption that they were mak- loch et al., 1998). These practices noted a
ing the referral, but either the patient was not clinically important increase in the quality of
adherent to the advice and/or the specialist care indicators, including control of HbA1c
was not providing the feedback to the PCP; values, blood pressure, and lipids, as well
Table 2.2). as the provision of eye care. In view of the
TABLE 2.3. Performance of ASDC practices who committed to the intensive

Collaborative Teams (12 Teams) collaborative track—but did not possess the
software and/or expertise necessary to record
June 2003 April 2004
N = 2,536 N = 3,327 and electronically transit ASDC measures.
Measure patients (%) patients (%) Data entered at the practice level were aggre-
gated monthly by HSAG and displayed on
HbA1c < 7.0% 33.7 37.9
the secure HSAG extranet portal. Participants
LDL < 100 41.2 46.2
Blood pressure 32.1 32.8 could view and print individual results as well
Eye exam 43.3 27.1 as collaborative aggregate data. Practices
Self-management 14.8 31.7 using other registries (non-DocSite users)
goal submitted summary data through the HSAG
Note: Overall, HbA1c decreased from 7.85% at baseline to 7.47% Web site, and results were incorporated into
at remeasurement. the monthly reports.
A sample of the challenges encountered
remarkable success of these three group-visit by ASDC participants and sponsors included
programs, group visits have been targeted for staff turnover, competing priorities with lim-
spread efforts, starting with the formation of ited resources, inconsistent senior leader sup-
a task force to facilitate future activities. port, and too slowly evolving expertise in in-
The centerpiece of ASDC was imple- formation technology and population man-
mentation of the Clinical Information System agement by participants and sponsors. ASDC
component: electronic disease tracking soft- confronted these challenges by accessing and
ware evaluation, installation, and use. Care presenting top-notch faculty and program-
interventions and other patient information ming, multipronged, frequent, and multilevel
that teams need to track and deliver the de- communication, incentive award programs,
sired care must be balanced with the level and an easily accessible (web-based), fre-
of effort to collect information, number of quently refreshed series of training modules.
measures used to focus patient encounters, The advice and information obtained from
and the time required to enter data. Col- ICIC, IHI, and other sponsoring organizations
laborative participants learned to evaluate (see Table 2.1) (AHQA, n.d.; IHI, n.d.-a; IHI,
patient tracking/population monitoring soft- n.d.-b; Murcko, 2004, May/June; MedQIC,
ware, including the ability of the product to n.d.) also was invaluable.
concurrently: ASDC’s reach will be expanded by
1. focus on multiple disease states and ASDC-2 to common diabetes comorbidi-
conditions, ties, e.g., congestive heart failure, hyper-
2. coordinate patient care, tension, and depression, with the focus on
3. proactively track conditions and the implementation of an array of information
health status of individual patients and populations technology resources. This community-wide
of patients, effort includes development of the infrastruc-
4. support outreach, and
ture to support financial and nonfinancial in-
5. report outcomes.
centives for providers and patients, i.e., a
After piloting a public domain—but “pay-for-performance” component (Murcko,
resource-intensive—“stand-alone” registry, 2004, May/June, p.14).
HSAG’s PDSA included the purchase of
a limited number of software licenses for
DocSite Patient Planner (DocSite, n.d.), SUMMARY
a web-based registry meeting established
requirements for an optimal registry product. Employing the CCM in collaboration
The licenses were provided at no cost to with actual and virtual peers can help you
transform the care you deliver to those with IDCOP. Available at: http://www.ihi.org/idealized/
diabetes and other chronic illnesses by estab- idcop/background.asp. Accessed June 20, 2004.
Institute for Healthcare Improvement. (n.d.-b) Overview
lishing:
of Breakthrough Series Collaboratives. Available
r Well-developed processes and incentives at: http://www.ihi.org/collaboratives/ breakthrough-
series. Accessed July 2, 2004.
for making changes in the care-delivery system. Institute of Medicine. (2001). Crossing the Qual-
r Behaviorally sophisticated self- ity Chasm: A New Health System for the 21st
management support systems that give priority Century. Washington, DC: National Academy
to improving and sustaining patients’ ability to Press.
manage their own care. Langley, G.J., Nolan, K.M., Nolan, T.W., Norman, C.L.,
r Functional care teams and practice sys- and Provost, L.P. (1996). The Improvement Guide:
tems, such as appointments and follow-ups, to meet A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass Pub-
the unique needs of patients with chronic illness.
r Evidence-based guidelines and guideline lishers.
McCulloch, D.K., Price, M.J., Hindmarsh, M.,
supports through provider education, reminders, Wagner, E.H. (1998). A population-based approach
and increased and effective interactions between to diabetes management in a primary care setting:
primary care physicians’ and referral physicians’ Early results and lessons learned. Eff Clin Pract 1:
information systems—including disease registries, 12–22.
tracking systems, and reminder systems. Medicare Quality Improvement Community (MedQIC).
(n.d.). Available at: http://www.medqic.org./
content/help/ help.jspReference. Accessed June 20,
2004.
REFERENCES Murcko, A. (2004, March/April). Chronic care model is
blueprint for improving diabetes care in Arizona.
American Health Quality Association. (n.d.). Fact sheets: AzMed, pp. 8–9.
Medicare Quality Improvement Organizations. Murcko, A. (2004, May/June). Restructuring reimburse-
Available at: http://www.ahqa.org/pub/media/159 ment: Pay for performance? AzMed, pp. 14–15,
766 4230.CFM. Accessed June 20, 2004. 22.
Bodenheimer, T., Wagner, E.H., and Grumbacj, K. Murcko, A. (2004). Celebrate, activate: Milestones for the
(2002). Improving primary care for patients with journey. Presentation made at the Arizona State Di-
chronic illness. JAMA 288(14): 1775–1779. abetes Collaborative Outcomes Congress, May 21.
Casalino, L., Gillies, R., Shortell, S., Schmittdiel, J.A., Available at: http://www.azdin.com/meetings/asdc
Bodenheimer, T., Robinson, J.C., Rundall, T., Os- oc 052004/26 DrMurcko.pdf. Accessed June 20,
wald, N., Schauffler, H., Wang, M.C., et al. (2003). 2004.
External incentives, information technology, and or- National Center for Health Statistics. (2003). Special fea-
ganized processes to improve health care quality for ture: Diabetes. In Health, United States, 2003. Hy-
patients with chronic diseases. JAMA 289(4): 434– attsville, MD: Author.
441. Von Korff, M., Gruman, J., Schaefer, J.K., Curry, S.J.,
Centers for Medicare & Medicaid Services (CMS). (n.d.). Wagner, E.H. (1997). Collaborative management
Available at: http:// www.cms.hhs.gov/. Accessed of chronic illness. Annal Intern Med 127: 1097–
June 20, 2004. 1102.
DocSite, LLC. (n.d.). Point-of-care outcomes track- Wagner, E.H. (1998). Chronic disease management:
ing and decision tools for population health and What will it take to improve care for chronic illness?
chronic disease management. Available at: http:// Effective Clin Pract 1: 2–4.
www.docsite.com. Accessed June 20, 2004. Wagner, E.H. (2003). Testimony: Hearing before the
Hoffman, C., Rice, D., and Sung, H.Y. (1996). Persons Health Subcommittee of the House Committee on
with chronic conditions: Their prevalence and costs. Ways and Means, 108th Cong., 1st Session.
JAMA 276(18): 1473–1479. Wagner, E.H., Austin, B.T., Davis, C., Hindmarsh, M.,
Improving Chronic Illness Care. (n.d.). The Chronic Care Schaefer, J., Bonomi, A. (2001). Improving chronic
Model. Available at: http://www.improvingchronic- illness care: Translating evidence into action. Health
care.org/change/model/components.html. Accessed Aff 20(6): 64–78.
June 20, 2004. Wagner, E.H., Austin, B.T., and Von Korff, M. (1996).
Institute for Healthcare Improvement. (n.d.-a). Idealized Organizing care for patients with chronic illness.
design of clinical office practices: Background on Milbank Quart 74: 511–544.
Wagner, E.H., Davis, C., Schaefer, J., Von Korff, M., Wagner, E.H., Glasgow, R.E., Davis, C., Bonomi, A.E.,
Austin, B. (1999). A survey of leading chronic Provost, L., McCulloch, D., Carver, P., Sixta, C.
disease management programs: Are they consis- (2001b). Quality improvement in chronic illness
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56–66. prov 27(2): 63–80.
3
Promoting Cultural Competence through

Community Partnerships
Isela Luna
Healthcare Legal Consultant, Tucson, Arizona
“Pray to God not for the life you want, but for the
strength to live the life you have been given.
—Gurumayi Chidvilasananda, 2003
INTRODUCTION a country joined the coalition to restore civil

life in Iraq has important significance on
There has never been a greater need for its cultural competence at the international
the understanding of cultural proficiency in level.
the global society we find ourselves today. A This chapter will discuss what cultural
global society assumes an understanding and competence is and the different levels of cul-
acceptance of each other’s cultural assets and tural competencies. Tools that assist in mea-
liabilities and does not imply the idea of the suring the cultural competence will also be
“melting pot” concept of the 1970s and 1980s reviewed. Cultural sensitivity is an impor-
or the “salad” concept of the 1990s. It is rather tant component for cultural competence and
a more sophisticated understanding and ac- will be part of the discussion on competence
ceptance of what each human being brings to in this chapter. Also note that cultural terms
the table of negotiation. used within this chapter are not rigidly de-
The political climate that existed in the fined (e.g., Hispanic, Mexican American, and
United States when it started the war in Iraq Latino may be used interchangeably) and can
and the lack of and/or inclusion of NATO be interpreted by the context in which they are
members are perfect examples of an opportu- discussed.
nity to promote cultural proficiency. The exact The challenge in a global society is how
role of each country is carefully defined, not so do we as professionals work with individuals
much because of the will but rather because from diverse cultures and with perspectives
of the assets and liabilities that each coun- different from our own? Every field needs to
try possesses. The political dispute whether ask this question. Microsoft, for example, has
35
36 PROMOTING CULTURAL COMPETENCE
been able to diversify its components to meet to decrease these disparities. As an example,
the global needs of our society, but this also the death rate for all cancers is 30% higher
applies to the basic principles in virtually ev- for African Americans than for Whites. His-
ery language and culture in the world. Health panics living in the United States are almost
care professionals who wish to care univer- twice as likely to die from diabetes than are
sally with a personal touch must understand non-Hispanic Whites.
the process of culture and culture change in These disparities can be explained by
individuals. several key factors. For example, they can
Considering culture helps us understand be addressed by the educational level and
the values, attitudes, and behaviors of others, poverty. In the 65+ population, which is
it also aids in avoiding stereotypes and bi- the largest growing age group in the United
ases that can undermine our efforts. In terms States, the percentage of non-Hispanic Whites
of care delivery, culture plays a critical role with a high school diploma or higher is
in the development of services that truly re- 71.6% compared to 29.4% for Hispanics. In
spond to the needs of the recipient. As a com- the same age group, the percentage of non-
mon definition, culture is the shared values, Hispanic Whites with a bachelor’s degree or
traditions, norms, customs, arts, history, folk- higher is 16% compared to 7.0% for non-
lore, and institutions of a group of people Hispanic Blacks. When comparing poverty
(Leininger, 1997). Traditions are not the only and inequities, non-Hispanic Blacks are al-
factors that influence culture. Culture is in- most three times poorer than non-Hispanic
fluenced virtually by everything we are (see White people. By recognizing the disparities
Table 3.1). Not considering culture in the in the level of education and poverty, we begin
health care setting may lead to misunderstand- to see a relationship between cultural factors
ings and most importantly create inaccessibil- and health inequities.
ity to care. In turn, this may be a root cause Cultural competence not only plays a key
of health disparities that result in an increased role for the professional who is delivering
financial burden on society and increased bar- care, but also for the recipient of this care.
riers for marginalized population to contribute Cultural competence is a set of cultural be-
to society. haviors and attitudes integrated into the prac-
Demographic information from the U.S. tice methods of a system, agency, or its pro-
Census (1993) begins to paint a picture of fessionals, enabling them to work effectively
diversity and cultural disparities. Minority in cross-cultural situations. Given that almost
groups are no longer a minority. From 1970 any situation can be classified as cross cul-
to 2050, it is expected that the proportion of tural, knowledge of cultural competence be-
minority groups in the U.S. population will comes the key to providing effective health-
rise from 16% to 50%. The issue of health care.
disparity in the United States is so grave that Before we can achieve competency, an
healthy people 2010 has made its main goal understanding of how culture change occurs
can provide us with a framework to interpret
TABLE 3.1. Factors that Influence Culture people’s behavior. There are generally four
models discussed in the literature of culture
Age
change or acculturation that explain the pro-
Gender
Geography cess. Three of these models are a result of
Socio-economic status the work carried out by the Social Science
Educational attainment Research Council in the mid-1930s, which
Individual experiences identified acculturation as an area of scientific
Place of birth
inquiry that required the attention of sociolo-
Length of residency in U.S.A.
gists and anthropologists (Broom et al., 1954).
PROMOTING CULTURAL COMPETENCE 37
New Culture
High Low
Host High
Culture Assimilated Bicultural
Low
Marginalized Acculturated
FIGURE 3.1. The two-culture matrix model.
From there, Keefe and Padilla presented knowledge and the change in the new and
three models of acculturation that included, original culture. Figure 1 shows a simple ma-
for the first time in the literature, the idea of trix that can be used to interpret where indi-
biculturalism (Keefe & Padilla, 1987). These viduals are at any trait in terms of their cul-
models grew mostly from the civil unrest in ture change process. For example, you may
the United States in the 1960s and 1970s, and encounter many people in the health or com-
have evolved as our understanding of human munity setting who identify themselves not
behavior has grown. These models include: as Mexican, nor American, but as being in
the single continuum model, the multidimen- the middle of both cultures. These individu-
sional model, the bicultural model, and the als in the matrix model are at the margin of two
two-culture matrix model. cultures and in terms of their behavior, they
These models range from culture change are denied meaningful roles in either culture.
in one direction, to equal culture change in Marginality, according to many anthropolo-
both directions, to culture trait gain and loss, gists and psychologists, can result in a type
and to the matrix model. For example, the first of cultural schizophrenia. These individuals
model, the single-continuum model assumes would fall in quadrant 3. The two-culture ma-
the gradual replacement of traditional cultural trix model is interpreted by taking into con-
traits with Anglo American traits. There was sideration where individuals are in terms of
a trend in the early 1950s, when it was “un- cultural traits in the host and new culture.
patriotic” to speak anything but English and,
as a result, many children of non-White cul- For example, someone who is not acculturated
in language would be an individual who knows
tures never learned their parents’ language of
a little English, is low in the new culture, and is
origin. Oral stories from many of these peo- high in Spanish or the host culture. They would
ple relate that their parents were afraid that fall in quadrant 1. At the same time, they can
their children would be discriminated against be high in the trait of cultural exposure of both
or treated differently for speaking the parents’ the new and the original or host culture falling in
quadrant 2. This knowledge can quickly translate
original language. This generation is now be-
to application of care. An individual such as this
tween 50 and 60 years old. This is an illustra- one is most likely to be open to other ways of
tion of a replacement of a cultural trait with accepting or receiving care, but unless it is done
an Anglo American trait. in the host language, the recipient will most likely
The two-culture matrix model can be not accept it.
Someone who is acculturated in the trait of
most helpful in understanding culture change
language would be high in the new culture and
and in clearly articulating the dynamic move- low in the host culture falling in quadrant 4.
ment of cultural behavior. The matrix model
proposes that at any given time for any given This matrix begins to illustrate the com-
trait, people can be at different stages of plexity of culture change, but it can also
culture change, depending on their level of be useful in providing care. We know, for
38 PROMOTING CULTURAL COMPETENCE
example, from research results on the relation- Denial

ship between cultural factors and health care Defense
that language, religion, and eating preferences Minimization
Acceptance
are key to determining the health care out- Adaptation
comes of an intervention (Domino & Acosta, Integration
1987).
In terms of providing health care, how FIGURE 3.2. Continuum of Intercultural Sensitivity
(Bennett, 1993).
culture change occurs can begin to give the
health provider a framework to evaluate health
behaviors. If research shows that language, care organization speaks or understands
religion, and eating patterns are the high- Korean. Some might choose to avoid the pa-
est determinants of cultural change, then a tient; some may choose to make use of the
health professional can begin to make an as- translator service available in almost every
sessment of those traits and adjust teaching health care institution. Communication is one
or information accordingly. Much research of the many factors that lead to cultural sensi-
has been done on many areas of care and tivity, which, in turn, increases cultural com-
acculturation. More attention is being paid petence. Like acculturation, cultural compe-
by researchers to identify the different lev- tence is a path, a continuum that we constantly
els of generations in a cultural group, since are managing and growing in.
we know that older generations are usually You might be asking, what about me?
closer to their traditional traits than younger How will I know how culturally compe-
generations. tent I am? Dissonance between a health care
How then do you begin to understand provider’s beliefs and respect for cultural dif-
how culturally competent you are as a care- ferences and behaviors will leave you with
giver, as a nurse, as a researcher, as a busi- inefficient health care. A provider becomes
ness owner, or as a consumer? It can begin more culturally proficient as these factors
with a simple introductory class on cultural match and become more refined with experi-
competence, but it does not end there. What ence. As a type of report card, you can check
our society has failed to acknowledge is that your actions against the items in Figure 2
immigrants as well as nonimmigrants are in and decide where you are in the continuum.
a constant evolution of development when it The list of items in Figure 2 can also be use-
comes to culture. The mass media reflects ful in evaluating a department or agency for
this change in many areas. Take for example, competency. Just as every human being has
Taco Bell’s latest slogan “Think outside the certain developmental processes to achieve
bun.” Tortillas as the alternative to buns are be- during their lifetime, cultural competence
ing widely accepted by many groups besides practice is a long developmental process.
Hispanics. The models presented earlier have During the 1960s and 1970s, it was per-
different paradigms that establish the rules fectly acceptable to say, “I treat everyone the
and boundaries for the ways we see things. same.” This was considered a fair and liberal
These paradigms can assist in interpreting way to treat others. However, this stance as-
the behavior of someone who is non-White sumes that sameness equals fairness, an as-
and where they are in their process of culture sumption that only holds true if the values and
change. norms of people involved in an interaction are
Communication is one of the most basic similar. In order to move beyond the assump-
means of getting your idea across, but when it tion of similarity, Milton Bennett authored the
comes down to communicating with someone Developmental Model of Intercultural Sen-
outside your comfort zone, things can become sitivity (Bennett, 1993). According to this
a little unnerving. Say for example, you have model, such a statement places an individual
a Korean patient, and no one in your health at an early stage of intercultural sensitivity.
PROMOTING CULTURAL COMPETENCE 39
The first stage, denial, does not rec- SUMMARY

ognize cultural differences. It would repre-
sent someone seeing no color. The second To know that a person comes from a cer-
stage, defense, recognizes some differences, tain ethnic background does not tell us where
but sees them as negative. Part of cultural they are in terms of their values and behaviors.
sensitivity requires that we step outside our- However, it can alert us to possible arenas of
selves to observe without judgment. This miscommunication, and can lead us to closer
takes some practice. Minimization involves a observations about where they are in the de-
lack of awareness of the projection of our own velopment of culture change. In addition, the
cultural values and seeing our own values as stages of intercultural sensitivity can be used
superior. For example, the political model of for our own evaluation as we make interpre-
the United States is often painted as the ideal tations of the behaviors of others.
model for many other countries. Acceptance
shifts the perspective to understanding that
the same behavior can mean different things REFERENCES
in different cultures. For example, the com-
mon Mexican saying “Mi casa es su casa,” Bennett, M.J. (1993). Towards ethno relativism: A de-
is equivalent to extending your home here in velopmental model of intercultural sensitivity. In
America. However, in the Mexican culture, Education for the Intercultural Experience. 2nd ed.
the degree of integration into the family ex- Yarmouth, ME: Intercultural Press.
pected of a guest is much more intense and Broom, L., Sieger, B.J., Vogt, E.Z., Watson, J.B.,
and Barnett, B.H. (1954). Acculturation; An ex-
interactive. Adaptation is when a person can ploratory formulation. Am Anthropologist 56:973–
evaluate other’s behavior from their frame of 1000.
reference and can adapt their own behavior to Domino, G., and Acosta, A. (1987). The relation of accul-
fit the norms of a different culture. Integration turation and values in Mexican Americans. Hispanic
is the final stage and it includes shifting the J Behav Sci 9(2):131–150.
Keefe, S.E., and Padilla, A.M. (1987). Chicano Ethnicity.
frame of references and integrating the iden- Albuquerque, NM: University of New Mexico
tity issues that may result from that behavior. Press.
For example, as a Mexican individual, your Leininger, M. (1997). Transcultural nursing research to
own Mexican peers may interpret integrating transform nursing education and practice: 40 years.
Anglo music into your everyday life as hav- Image J Nurs Sch 29(4):341–347.
ing “Anglosized” yourself. Managing cultural
differences between cultures and among peers
of the same culture requires a savvy culture FURTHER READING
broker who can turn the outcome into a com- www.diversityrs.org
munal rather than a separating experience. www.omhrc.gov
3A
Hispanic American Culture and Diabetes

Lourdes G. Barrera
Arizona International College, University of Arizona, Tucson, Arizona
In 2000, 2 million Hispanic people (8.2%) betes is not a topic that is shameful for these
had diabetes. Hispanic Americans made age groups. Among adults and elders with di-
up 12.5% of the U.S. population. The U.S. abetes, diabetes is a common topic of con-
Census divides Hispanics into Mexican, versation. A reason for this is that Hispan-
Puerto Rican, Cuban, and other Hispanic ics like to know who has had diabetes and
subgroups (http://quickfacts.census.gov/qfd/ how they treated it. Using examples of how
states/00000.html). Mexican Americans are people deal with diabetes is a good way
1.5 times more likely to have diabetes than to teach the Hispanic population about self-
non-Hispanic Whites of similar age. Puerto management.
Ricans are 1.8 times more likely to have Compliance in taking medications for
diabetes diagnosed than non-Hispanics adults and elderly is usually good at the begin-
Whites (Centers for Disease Control and ning, but over time this stops because they feel
Prevention, 2004). The prevalence of diag- better and decide to discontinue their medi-
nosed diabetes for Hispanic males (4.46%) cation. When they feel unhealthy again, they
in 2002 was higher than for females (4.39%) typically resume a healthier diet and their
(http://www.cdc.gov/diabetes/statistics/prev/ medications. Being compliant in dieting is not
national/tprevhmemage.htm). These demo- as successful sometimes for older Hispanics
graphics can be improved by having more of because they do not want to stop eating foods
a cultural awareness of how diabetes plays a that they have been eating their whole lives.
role in the life of Hispanics and suggesting Adults are more compliant than the older gen-
healthy ways to control diabetes that work erations depending on whether or not they
with their cultural practices. are more acculturated and have more health
Diabetes is more common among awareness. Educating Hispanic patients about
middle-aged and elder Hispanic Americans. diabetes complications and how to avoid these
For Hispanic Americans, 50 or older, about via better self-management is essential and,
25–30% have been diagnosed or undiagnosed typically, motivates adult and elderly Hispan-
with diabetes (http://diabetes.niddk.nih.gov/ ics to be more compliant because they fear
dm/pubs/hispanicamerican/index.htm). Dia- getting the complications.
41
42 HISPANIC AMERICAN CULTURE
Obesity, being overweight, low fiber in- 2000). Eating is a social aspect for Hispanic
take, high dietary fat, and lack of exercise families and it is a challenge to detour from
are modifiable risk factors for diabetes. These the foods that the rest of the family eats when
risk factors are higher in Mexican American a person has diabetes. Having separate food
adolescents than non-Hispanic White ado- served for the person with diabetes makes
lescents (De La Torre and Estrada, 2001). them feel left out of the family’s activities.
The younger generations of Hispanics do not If the family tends to eat traditional Hispanic
feel like talking about diabetes as much as foods, it may be that the person with dia-
older generations because it is perceived as betes needs to cut the amount of servings that
something that older and overweight people they eat, so they do not have to eat separately
have and, therefore, they feel they should from their families. Encouraging the family
not have it because they are young. Having to eat more traditional Hispanic home-cooked
to adapt to the changes in diet and medica- foods will help the patient consume healthy
tion is embarrassing for them and they do foods.
not feel that they are having normal lives. A large number of Hispanic people have
Compliance in taking medications and diet jobs that require physical labor, but it is not the
are higher for the younger generation than kind of exercise that contributes to aerobic ac-
for the older because they are more accultur- tivities. A study in San Antonio, Texas, found
ated and demonstrate lifestyles more oriented that Mexican Americans engaged in aerobic
to health promotion and preventing diseases exercise less often than any other group. A
(Lipson et al., 1996). Younger generations study conducted by the Centers for Disease
also are more likely to have the support of their Control and Prevention found that high school
family to motivate their compliance. Talk- adolescent males are about twice as likely as
ing about diabetes complications can cause adolescent females to report engaging in vig-
a great deal of worry for young Hispanics, orous physical activities (National Alliance
so enforcing a healthier lifestyle instead is for Hispanic Health, 2000). No matter what
a better way to increase compliance in self- age or sex, Hispanics need to be constantly
management. told about the benefits of making aerobic ac-
Hispanics have a great amount of trust tivities part of their lives. Providing sugges-
in medications and they feel that changing tions on how to start easily integrating exer-
their diet will not help them as much with cise into the day is a good way to motivate
their diabetes. It is suggested to emphasize people.
diet as if it were being prescribed to them The Hispanic population is diverse in
instead of it being something that is sug- cultural behaviors based on individuals ori-
gested (Lipson et al., 1996). According to a gin. The information given here provides only
U.S. Department of Health and Humans Ser- broad information and suggestions that should
vices publication, Quality Health Services for be applicable to all Hispanics. Efforts toward
Hispanics: The Cultural Competency Com- making this population understand the sever-
ponent, the Hispanic populations tend to eat ity of diabetes and the importance of im-
their traditional diets. Acculturation among proved self-management is critical because of
immigrant Hispanics weakens the positive the immense prevalence of diabetes for this
health factors by eating unhealthy American group.
foods. The Hispanic diet is high in fiber, green
leafy vegetables, relies on vegetable rather
than animal proteins, and includes few dairy REFERENCES
products. Countries that produce cattle tend
to include a greater amount of animal pro- Data and trends: Prevalence of diabetes. Centers
tein (National Alliance for Hispanic Health, for Disease Control and Prevention. Available at:
HISPANIC AMERICAN CULTURE 43
http://www.cdc.gov/diabetes/statistics/prev/national/ National Alliance for Hispanic Health. (2000). Quality

fig2002.htm. Accessed July 26, 2004. Health Services for Hispanics: The Cultural Compe-
De La Torre, A., and Estrada, A. (2001). Mexican Amer- tency Component. Special Educational Guide (Un-
icans and Health: ¡Sana! ¡Sana! Tucson, The Uni- published).
versity of Arizona Press. National Diabetes Fact Sheet: General Information and
Diabetes in Hispanic Americans. (2002). National Dia- National Estimates on Diabetes in the United States.
betes Information Clearing House (NDC). Available (2003). Rev ed. Atlanta, GA, U.S. Department of
at: http://diabetes.niddk.nih.gov/dm/pubs/hispanic- Health and Human Services, Centers for Disease
american/index.htm. Accessed July 26, 2004. Control and Prevention, 2004.
Lipson, J.G., Dibble, S.L., and Minarik, P.A. (1996). Cul- U.S.A. QuickFacts. (2000). U.S. Census Bureau. Avail-
ture & Nursing Care: A Pocket Guide. San Fransisco: able at: http://quickfacts.census.gov/qfd/states/
CUSF Nursing Press. 00000.html. Accessed July 23, 2004.
3B
Cultural Competency
Native Americans
Terilene Glasses
Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
There are more than 500 Native American (Centers for Disease Control and Prevention
tribal organizations who maintain cultural [CDC], 2003).
identification through tribal affiliations or The Association of American Indian
community recognition. There exist a diver- Physicians reported one tribe, the Pima
sity of language, culture, location, lifestyle, Indians of Arizona, as having the highest
and genetic heritage among American Indians rate of diabetes in the world. About 50% of
and Alaska Natives (AI/AN) (National Pimas between the age of 30 and 64 have
Diabetes Information Clearinghouse [NDIC], diabetes (Association of American Indian
2002). In 2002, the U.S. Bureau of the Cen- Physicians [AAIP], 2001). The prevalence
sus estimated the American Indian and Alaska of diagnosed diabetes among AI/AN fe-
Native population to be 2,475,956 or 0.9% of males (15.9%) in 2002 was higher than
the total U.S. population. males (14.5%) (CDC Morbidity and Mortality
The prevalence of diabetes among Amer- Weekly Report, 2003). These demographics
ican Indians and Alaska Native has reached indicate that the prevalence of diabetes will
epidemic proportions. According to a fact continue to increase as risk factors increase
sheet provided by the Centers for Disease and the population continues to age.
Control and Prevention, 14.9% of AI/AN 20 Interventions that promote exercise, im-
years or older and receiving care from the prove nutrition by reducing fat and calorie
Institute of Health Services (IHS) have dia- intake, and reduce body weight have been
betes. Regionally, diabetes is least common shown to prevent and delay the onset of di-
among Alaska Natives (8.2%) and most com- abetes among persons developing type 2 dia-
mon among American Indians in the South- betes (CDC Morbidity and Mortality Weekly,
eastern United States (27.8%). On average, 2003). With the help of these interventions
AI/AN are 2.3 times as likely to have dia- and the awareness of diabetes and the incor-
betes as non-Hispanic Whites of similar age poration of cultural practices and beliefs, the
45
46 CULTURAL COMPETENCY
prevalence of diabetes will decrease in the American Indians and Alaska Natives. The
AI/AN population. changed diets are higher in fat and calories
Cultural beliefs and values toward hav- than traditional diets. Increased fat consump-
ing diabetes among Native Americans is to tion, decreased physical activity, and obe-
“Identify and reinforce values on total well- sity are some of the major contributors to
being” (The Pathways, 1999). With the help diabetes. These changes are highly associ-
of traditional medicine and western medicine, ated with the increased prevalence of type
one is able to treat and heal the physical 2 diabetes. Researchers suggest that “if mi-
and emotional well-being of the individual. nority populations returned to their native
In many cases, a patient may consult a tradi- diet and lifestyle, the risk of diabetes could
tional healer to diagnose or remove the cause be reduced and people who already have
of a disease before consulting a western physi- the disease might be healthier” (Marchand,
cian to cure the symptoms (http://erc.msh.org/ L, available at: http://diabetes.niddk.nih.gov/
quality&culture), (Providers Guide to Quality dm/pubs/pima/focus/focus.htm, 2002).
and Culture, 1999, accessed July 24, 2004). American Indian communities have de-
According to the Provider’s Guide to Qual- veloped school-based programs, such as Path-
ity and Culture, “. . . Indians use “white man’s ways and Quest, to increase physical activity,
medicine” to treat “white man’s diseases” improve diet, and reduce obesity among chil-
(e.g., diabetes, cancer, gallbladder disease) dren. Other programs emphasize traditional
and use Indian medicine to treat Indian prob- physical activities such as running, horseback
lems (e.g., pain, disturbed family relation- riding, and walking. Adults and the elderly
ships resulting in physical symptoms, sick- are encouraged to do these types of activities.
nesses of the spirit).” American Indians tend As mentioned, “Traditional diets were low in
to believe that a disease such as diabetes is fat with season variability, but high fat pre-
only a side effect and that the real problem dominate today. Indian fried bread, mutton
is soul loss, intrusive objects, spirit intrusion stews, and other rich soups and stews are com-
or possession, breach of taboo, and witchcraft mon foods among American Indians” (Lipson
or sorcery. Because of this belief, they do not et al., 2003, p. 14–15). One obstacle that is
seek the help that they need for diabetes. This faced with someone who has diabetes is to
delays the necessary and proper education and have separate foods served that meet the diet
intervention that is needed to control and pre- requirement. Doing this makes them feel as
vent diabetes. if they were different. Yet some do not want
This also affects the compliance of dia- others to know why they have a different food
betes management by not taking the medica- diet.
tion they need for diabetes, because they do Open discussions about having diabetes
not want to believe the doctor’s diagnosis of to relatives and friends do not usually happen
diabetes and that it is due to traditional ill- because they want to maintain their privacy,
nesses. This is more common among adults especially among adults and the elderly. One
and the elderly. way to deal with this is to have traditional
In the end, the combined use of tra- foods, but in smaller portions.
ditional and modern medicine is used to Compliance to diabetes management
help and manage diabetes. This incorpora- among young adults is “faced with unique
tion of traditional practices of healing with challenges such as lack of symptoms, ab-
western medicine is an efficient way to be- sence of family support and denial of the
gin and follow through in management of disease” (The Pathways, 1998). Many times
diabetes. they think that they are young and that dia-
Diet and physical activity have changed betes is something young adults should not
tremendously over the past several decades for have to worry about or be concerned with.
CULTURAL COMPETENCY 47
To successfully manage the disease, the mo- a culturally appropriate diabetes education program:
tivation to adopt healthy eating habits and ad- The Native American Diabetes Project. Diabetes
Educator. 25:351–363.
equate coping skills are needed to adapt to
Centers for Disease Control and Prevention. (2003). Di-
living with diabetes. Among adults and the abetes prevalence among American Indians and
elderly, storytelling (a traditional education Alaska Natives and the overall population United
tool) to communicate information and skills States, 1994–2002. MMWR 52:702–704.
about diabetes is a more successful means of Diabetes in American Indians and Alaska Na-
tives. (2002). Available at: http://diabetes.niddk.nih.
managing the disease (Griffin et al., 1999).
gov/dm/pubs/americanindian/index.htm. Accessed
This is exemplified in a program as a story July 29, 2004.
“Through the Eyes of the Eagle” among the Lipson, J.G., Dibble, S.L., and Minarik, P.A. (1996). Cul-
Pueblo Indians, which “helps participants rec- ture & Nursing Care: A Pocket Guide. San Fran-
ognize the problem of diabetes through cultur- cisco: CUSF Nursing Press.
Marchand, Lorraine H. The Pima Indians: Focus on Pre-
ally relevant medium of storytelling” (Grif-
vention (2002). Available at http://diabetes.niddk.
fin et al., 1999). Sensitivity toward AI/AN nih.gov/dm/pubs/pima/focus/focus.htm. Accessed
cultural traditions and their integration into July 29, 2004.
programs and curriculums help and assist in National Diabetes Fact Sheet: General Information and
their understanding of diabetes management, National Estimates on Diabetes in the United States,
(2003). Rev ed. Atlanta, GA: U.S. Department of
which, in turn, provides behavioral changes
Health and Human Services, Centers for Disease
toward living with diabetes in a healthy Control and Prevention, 2004.
way. National Diabetes Information Clearinghouse. (2002).
Diabetes in American Indians and Alaska Na-
tives. Available at http://diabetes.niddk.nih.gov/dm/
pubs/americanindian/index.htm. Accessed July 29,
REFERENCES 2004.
The Pathways. (1998). The Pathways Curriculum.
Association of American Indian Physicians (AAIP). Available at: http://hsc.unm.edu/pathways/ publica-
(2001). Diabetes Facts—Diabetes Among Na- tions/pblctns.htm. Accessed July 30, 2004.
tive Americans. Available at: http://www.aaip.com/ Provider’s Guide to Quality & Culture: American Indi-
resources/diabetesamongna.html. Accessed July 28, ans and Alaska Natives and Diabetes. (1999). Man-
2004. agement Sciences for Health (MSH). Available at:
Carter, Janet S., Griffin, J., Gilliland, S., Helitzer, D., http://erc.msh.org/quality&culture. Accessed July
Perez, Georgia. (1999). Participant satisfaction with 29, 2004.
4
Preparing for the Technology Revolution in

Health Care
Brian L. Foster
Health Services Advisory Group, Phoenix, Arizona 85020
Quality is something we expect in every ser- The problem with doing this is the appar-
vice encounter we experience. From the gro- ent assumption people often have that those
cery store where we shop to the restaurants who are involved in the service delivery are
in which we eat, we are very attentive to doing the best they can and that if there were
those aspects of service that do not measure room for any significant improvement in the
up to our expectations of quality and we ex- quality of the service, they would provide it.
pect someone to correct it so that it does meet In a competitive market environment, this as-
our expectations. When we think of health sumption would be absolutely correct because
care, which also is a service industry, we have those who do not adjust their service quality
thoughts about the quality of the encounters to meet or exceed that of their competitor will
we have personally experienced or that of find themselves out of business.
friends or loved ones. The quality of many of In order to effectively compete in a mar-
those encounters could be considered good, ket, there are two fundamental questions that
but we also are aware of the poor quality side need to be answered:
of health care. But how do we come to the r What is my competitor doing?
conclusion about whether the overall quality r Where am I relative to my competitor?
of any service experience is good or bad? If
what we experience firsthand or read or hear However, to answer those two funda-
about a particular service experience consists mental questions requires knowledge based
of a mixture of mostly good and a little bad, on information about both parties. This is
and without anything else to suggest that it where the distinction between health care and
should be otherwise or that it is different any- other service industries arises. With perhaps
where else, we will naturally make such ser- the exception of multi-hospital communities
vice levels our expectation and accept them as where the population is not sufficient to ensure
the norm. all hospital facilities are at optimal operating
49
50 PREPARING FOR THE TECHNOLOGY REVOLUTION
census capacity at all times and thereby driv- to become standard clinical practice. Important
ing competition, health care is not viewed constituencies in health care view innovation as
a problem rather than a crucial driver of success.
as a competitive market, especially by those
Taken together, these outcomes are inconceivable
delivering the care. With a lack of a sense of in a well-functioning market. They are intolerable
competition, the first key question (what is in health care, with life and quality at stake. We
my competitor doing?) is never asked, which believe that competition is the root of the problem
makes the second key question (where am with U.S. health care performance.
I relative to my competitor?) of little or no
value. Further, without the perception of com- Stemming from the Institute of Medicine
petition and when financial circumstances are (IOM, 2000) report, which identified that
favorable, there is little if any incentive to thousands die each year unnecessarily in our
collect any information about measures per- health care system due to medical errors, the
taining to quality performance or outcomes. spotlight has been on health care in all settings
Hence, any information pertaining to the qual- to eliminate errors and improve the quality
ity of health care services provided at the prac- of the services provided. This report raised
tice level is largely anecdotal. This is the sit- the awareness of the problems in health care
uation today in health care—no competition across the country and claimed that health care
means little or no improvement. A recent ar- should and could be much better. As a result,
ticle in the Harvard Business Review (Porter expectations changed from accepting histori-
and Tiesbeg, 2004, pp. 65–66), summarizes cal health care quality as the norm (the way
the situation more succinctly: we have always done it) and began demand-
The U.S. health care system has registered unsat- ing the health care industry make those qual-
isfactory performance in both costs and quality ity improvement changes that would signifi-
over many years. While this might be expected cantly improve patient safety. In the 4 years
in a state-controlled sector, it is nearly unimagin-
since the release of that IOM report, there is no
able in a competitive market—and in the United
States, health care is largely private and subject longer a question of whether the system needs
to more competition than virtually anyplace else to be improved, but the challenge is how do
in the world. we go about improving it.
In healthy competition, relentless improve- If quality improvement is the product of
ments in processes and methods drive down costs.
incentive and measures, how do we change
Product and service quality rise steadily. Innova-
tion leads to new and better approaches, which dif- a noncompetitive industry (which lacks both
fuse widely and rapidly. Uncompetitive providers incentive and measures) into one that exhibits
are restructured or go out of business. Value- the characteristics of one that is competitive
adjusted prices fall, and the market expands. This (having both incentive and measures)? One
is the trajectory common to all well-functioning
method could be by creating a community,
industries—computers, mobile communications,
banking, and many others. state, and national information infrastructure
Health care could not be more different. and system that creates incentives for change
Costs are high and rising, despite efforts to re- and identifies and collects the measures that
duce them, and these rising costs cannot be ex- will determine whether improvements are be-
plained by improvements in quality. Quite the op-
ing made.
posite: medical services are restricted or rationed,
many patients receive care that lags currently ac- This method was the major focus of
cepted procedures or standards and high rates of the Secretarial Summit on Health Informa-
preventable medical error persist. There are wide tion Technology sponsored by the U.S. Sec-
and inexplicable differences in costs and qual- retary of Health and Human Services in
ity among providers and across geographic ar-
Washington D.C. July 21–23, 2004. The
eas. Moreover, the differences in quality of care
last for long periods because the diffusion of best newly appointed National Health Information
practices is extraordinarily slow. It takes, on av- Technology Coordinator, Dr. David Brailer
erage, 17 years for the results of clinical trials opened the summit with the presentation of
PREPARING FOR THE TECHNOLOGY REVOLUTION 51
his framework for strategic action (Thomp- ment techniques. The same quality evolution
son and Brailer, 2004) for implementing a that occurred in the manufacturing industry,
national health care information infrastruc- and transformed it, will need to occur in the
ture designed to realize a vision of electronic health care industry to transform it as well.
health records for Americans within a decade. This is not to say that there have not been any
The summit was attended by broad represen- improvements in health care. Just as in the
tation from across the industry by leaders who manufacturing industry in which there were
not only recognize the need for change, but companies that initiated quality improvement
who all agreed to actively participate or con- techniques before competition made it essen-
tinue participating to achieve the objectives. tial for others to follow, there have been initia-
These individuals and groups repre- tives and studies, many that are currently on-
sented and communicated a groundswell of going, that have found the best ways, or best
support and determination to bring health practices, needed to bring quality improve-
care into the 21st century through the infu- ment changes to health care in some areas.
sion of information technology. Senator Bill Adopting and applying these best practices is
Frist, Senate Majority Leader, emphasized the what remains to be done on a national basis
importance of ensuring that the technologies to realize quality improvement gains in health
brought to health care need to be, “. . . patient care that have been realized in the manufac-
centered, consumer driven, and provider turing industry.
friendly, and that they need to be powered The costs for significant change in health
by information, choice, and control.” Qual- care quality improvement are going to be sig-
ity improvement in any industry begins with nificant, both in dollars and the impacts it will
measurement of that which is to be improved. have on the workflow and processes. Reflect-
But unless there is a method of systematic re- ing back to the manufacturing industry, the
measuring after the initial baseline measure, costs of achieving significant quality improve-
there is no way to know whether the actions ment often meant changing their legacy sys-
to improve have had the intended results. As tems, infrastructure, workflow, and processes
one summit presenter remarked, “You don’t in the business setting. This is expected to be
pay attention to what you don’t measure.” the same for the health care industry.
While the summit emphasized the im- As we anticipate the changes that are cer-
portance of information technology, it also tain to come in the health care industry, we
was clearly communicated that technology need to look within our daily activities for
alone will not solve the problems. Technology what we can do to make improvements today
is an improvement enabler, the successful im- and what we can do to make that effort contin-
plementation and use of which is dependent uous and embrace the changes as they come.
on the user and how well they know how to Some areas of health care may be more
use it and how well they have adapted their challenging than others in realizing qual-
workflows and processes to accommodate it. ity improvement changes. Chronic disease
Fortunately, we have a great history of quality management may be one such area due to
improvement in other industries that can help the closer relationship and interdependence
bring success to our efforts to bring quality needed between providers and their patient
improvement to the health care industry. population. The provider can provide the best
During the 1970s and 1980s, there were care possible, but if the patient does not partic-
huge gains in product quality improvements ipate in self-care management, then the qual-
in the manufacturing industry. This was ity improvement outcomes for diabetes, for
achieved by two key factors: a strong compet- instance, will not be achieved. It is very impor-
itive market (incentive and measures), and the tant to be aware of the available resources that
adoption and application of quality improve- can help provide the guidance for these special
FIGURE 4.1.
health care settings. The implementation of triad previously identified: people, processes,
the Chronic Care Model (Improving Chronic and technology, which will be the center of
Illness Care, n.d.) is just such a resource. (See focus for the remainder of this chapter after
an excellent overview of the Chronic Care stepping through a brief overview of the five
Model by Dr. Anita Murcko in “Chapter 3” service delivery segments of the paradigm.
of this handbook.) Service begins with a customer who ac-
In addition to the awareness of resources cesses a service provider (1). Once accessed,
within the health care industry, we also will the customer goes through the service en-
need to look at how we do business on a counter exchange (2), followed by an outcome
daily basis. As mentioned, the changes needed or result (3) of the exchange. Any expected in-
in health care amount to a paradigm shift formation the customer is waiting for or that
from the way we have always done it to new could be of value to the customer from the ser-
ways that achieve the desired improvements. vice provider is provided once available (4).
Achieving this paradigm shift in health care Finally, the customer has a means of provid-
will require significant change in and contin- ing their customer satisfaction feedback to the
uous synthesis of the components that com- service provider (5).
prise the triad of service delivery which are This service paradigm general diagram
common to any competitive service industry: can be applied to virtually any service
People, Processes, and Technology. provider including restaurants, retail stores,
Figure 4.1 encapsulates the service deliv- auto parts stores, fast food chains, travel agen-
ery paradigm that contains the various com- cies, etc., anywhere that a customer interacts
ponents that comprise the entire service deliv- with a service provider of any kind, including,
ery experience. The center triangle shows the of course, health care services from hospitals
FIGURE 4.2.
and individual physician practices. Figure 4.2 Feedback: This final but equally important
reflects a modification of the general diagram component is essential for keeping the patient and
for application in a physician office setting the provider informed. From the patient perspec-
with the service delivery segments adjusted tive, feedback is provided by the physician as to the
as follows: status of any pending tests performed during the
visit. From the physician perspective, feedback is
Service entry or access: This element defines provided from the patient as to their satisfaction
how the patient gains access to the service setting. with the quality of the services provided during
Depending on the design of the practice, access their visit(s).
generally happens by having a scheduled appoint-
ment. As we consider the changes that are com-
Service encounter exchange: It is here, in the ing as a result of the national interests and de-
service environment, that the patient enters the se- mands for health care quality improvement,
ries of processes, or workflow, designed by the we need to have a more holistic view of the
practice. This segment consists of an exchange of health care setting in which we function in
information between the provider, staff, and the order to maximize our quality improvement
patient. effectiveness and efficiency. By clearly un-
Service encounter results: This is the initial derstanding the interdependence between the
area of assessment of the results of the encounter
triad components: people, process, and tech-
exchange at the point of patient departure. Was the
experience what it should have or could have been?
nology utilized each day in our service deliv-
Did all the important information get exchanged? ery settings, we will be able to more effec-
Status update: Any pending information for tively apply quality improvement techniques
the patient is provided here, such as lab results and in a more focused and deliberate manner,
appointment reminders, and so on. thereby enhancing the likelihood for success.
The triangular area in Figure 4.2 shows (2) Encounter exchange:

the interconnectedness and interdependence Professionalism/demeanor of office staff Envi-
of the service delivery triad. In an ideal, bal- ronment considerations—temperature Respon-
anced setting, we would have the right peo- siveness to patient needs/questions Timeliness
ple with the right skills and experience, proof provider to seeing patient Communication/
education of patient Patient information
viding optimal productivity, by utilizing and
collected/recorded Clinical information collected/
fully exploiting the capability of the right recorded
technology for the job through the effective (3) Outcome:
development and use of the right processes Patient informed appropriately and understands
for maximum efficiency. Balance is achieved Prescriptions provided Follow-up identified and
and maintained by adjusting each compo- communicated
nent of the triad as needed, continuously. The (4) Status update:
mechanism that is used to continuously keep Patient contacted in timely manner
the triad components in balance is the diligent (5) Customer satisfaction feedback:
and perpetual application of quality improve- Many of the above items could be used as the basis
ment techniques, such as the Plan, Do, Check, of a patient satisfaction survey to determine their
assessment of the service delivered.
Act (PDCA) improvement cycle (Dartmouth
Medical School, 2004), as reflected in the cen- The feedback provided by a patient sat-
ter of the triangle in Figure 4.2. isfaction survey should not be a surprise since
Quality improvement techniques must we should be measuring many if not all of the
be applied to every aspect of service deliv- survey components internally. While it is an
ery: (1) access; (2) service encounter expe- important measure, patient feedback should
rience; (3) service outcome; (4) status up- not be the only method for measuring the qual-
date; and (5) customer satisfaction feedback. ity of our internal processes. The central prin-
The application of quality improvement ne- ciples for process improvement, as applied
cessitates measures and measurement to know in the manufacturing industry, suggests that
whether improvement efforts are actually suc- we know the quality of our product before it
ceeding. This is the very basis of evidenced- leaves our door rather than relying only on
based best practices and why it is important customers (patients) to tell us some time after
to adopt them—the hard work of determining the fact that there is a problem. To achieve this,
the best approaches have already been deter- there must be internal measures taken as the
mined through continuous process improve- patient moves through our internal processes
ment with evidence to support them. Each of and workflow.
the service delivery areas must have a process Each service delivery area has certain
identified and documented for it. From the people, processes, and technology associated
process there needs to be a set of key indica- with it. The holistic approach to quality im-
tors (or measures) that will determine, through provement in our service delivery environ-
continuous measurement, whether the service ment requires us to look at all areas of the ser-
delivery quality objectives are being achieved vice delivery function individually as well as
in that area. The following identifies some collectively to determine whether office work-
possible measure points for each area: flow is designed (or needs to be redesigned)
to function optimally with the service triad
(1) Access: components for each service delivery area.
Reasonable times available on provider schedules Everything detailed above, the national
to meet patient needs Wait/hold time before call is interest and focus on health care quality im-
answered Professionalism/demeanor of scheduler provement, the service delivery paradigm, and
Schedule reminders the importance and value of applying quality
improvement techniques, brings us to the in- understanding of the information systems ap-
dividual and collective components of the ser- plications that are used in the various aspects
vice delivery triad (people, processes, and of the physician office, such as scheduling,
technology) and the huge importance each billing, computerized physician order entry,
will play in the effort to achieve significant electronic health records, and so on, which all
quality improvement in the health care in- have databases at their core and from which
dustry. As we look to what we can do to- reports will be needed. Someone with at least
day to begin this improvement process, we the basic office applications skills would have
must evaluate each component to ensure they a shorter learning curve for new, yet simi-
are equipped and ready to perform the crucial lar, clinical applications than one who does
functions they must perform to ensure suc- not. The skills the people possess, especially
cess, starting with the most important of the the quality improvement techniques, will be
three—our People. essential in effectively creating and manag-
People: Without doubt people are health ing the dynamic processes that comprise the
care’s most valuable resource. It is the peo- workflow in the physician office.
ple who utilize the technology within defined Process is defined as a series of actions,
processes that collectively provide the service changes, or functions bringing about a result
encounters that our patients experience. If our (www.dictionary.com). We use processes to
people lack the skills, experience, or customer get things done, so it is important that they
service attitude necessary for the service ar- are efficient and remain appropriate for the
eas in which they are placed, we should expect purpose for which they were designed. As we
that service quality will be diminished and the think about our daily lives, from the moment
entire service encounter as a whole will be less our alarm clock awakens us in the morning un-
than optimal. til we fall asleep at night, our days are filled
As the shift in health care quality be- with processes, possibly hundreds of them, all
gins to occur, there will be an increase in of finite duration with a predetermined begin-
the demand on the skills that our people will ning and end.
need to ensure our service encounter environ- Our work environment is made up of pro-
ments are adequately postured to embrace the cesses too; scheduling, billing, charting, re-
changes that are coming. To ensure readiness, minding, mailing, analyzing, decision mak-
there should be a minimum skill set for every ing, etc., and many of these processes include
employee in a health care service encounter the use of technology (software applications)
business environment, which should include to achieve the process objective. If processes
intermediate skills in quality improvement are inefficient, following inefficient processes
techniques, intermediate computer skills, and will replicate inefficiency and waste, which
intermediate skills utilizing standard office increases costs. A properly designed and man-
management software, such as word process- aged process, on the other hand, provides
ing and spreadsheets. A broader and more consistent results and assures continued ef-
valuable skill set would include the previous ficiency by having only the minimum steps
items as well as skills in creating a simple needed to accomplish the objective.
database and mastering a report writing ap- Following a process can be expected to
plication, such as Crystal Reports. produce the same result each time, thereby
While it may be that the database and minimizing the variations (waste) that may
report writing skills will not be used on a otherwise occur when not following a process.
frequency that would require an intermedi- A process that is documented well provides
ate level expertise, some minimal skills in the ability to identify key measure points to
those areas will help provide a rudimentary determine the effectiveness and efficiency of
the process. There are several factors that can going on. There also is training that needs to
necessitate the change of a process: be conducted and a learning curve is required
for staff to reach a level of proficiency that has
Environmental conditions: Office air condi-
minimal mistakes. None of these things can be
tioning/heating not functioning properly.
avoided; they are all integral components of
Technology: Installing a new electronic
health record (EHR) application. growth and improvement.
People: Turnover or skill changes. Before a decision is made for any new
technology system, careful considerations
To improve a process, there must be a need to be made to ensure the product selected
method of measuring the results of the pro- is the best one. Some of those considerations
cess as well as key steps that make up the are not about the new application itself, but
process. This is where process improvement about the infrastructure into which it is to be
techniques come in. With a poorly designed placed. Consider, for example, the following
process some things might get done, but with- modes of application deployment and their
out process improvement things done poorly pros and cons:
will never get better. Given the changes that ASP (Application Service Provider—
are perpetually affecting our environment, it where the application access is provided via
is reasonable to expect that a process will secure internet connection using a web brow-
need to be changed at some time to accommo- ser such as Microsoft’s Internet Explorer)
date those environmental and technological
Pros: Desktop computer and broadband in-
changes. This being the case, the techniques ternet access is all that is required to access and
we utilize must take this changing nature into use the application. Least complicated approach.
account and provide for continuous process Server hardware in the physician office is not
improvement. needed, which means that data backups and ap-
The interdependent relationship between plication upgrades and hardware maintenance are
the service delivery triad components (peo- handled at the ASP facilities thereby minimizing
ple, processes, and technology) should be ev- the added housekeeping responsibilities and dis-
ident. Any significant change in any one of ruptions in the physician office.
the triad components, or of the environment Cons: Application access subject to depend-
ability of internet access. Clinical data is not read-
in which they operate, will likely have an im-
ily available for analysis or ad hoc reporting. Ac-
pact and necessitate a change in one or more
cess to clinical data limited to whatever is available
of the other components. Consequently, it is through the application (unless other arrangements
essential that when significant changes occur are made with vendor).
in any of the components, whether planned or
unplanned, a review of the other components Office based (application requires a
be conducted to determine whether changes server at the physician office)
are needed in them as well. One of the signifi- Pros: Clinical information is retained locally
cant changes to processes is brought about by and may be readily accessible for analysis and re-
changes in our technology. porting needs.
Technology: This is the component of Cons: Server hardware in physician office—
the service delivery triad that gives organi- upgrades, backups, maintenance, and other house-
zations the greatest challenges. This is due keeping activities may impact office staff. Most
to the complex nature of many of the tech- complicated approach. Support disruptions from
two possible sources: application vendor and hard-
nologies employed in the health care work
ware maintenance.
environment. Implementing a new schedul-
ing, billing, or practice management system, Neither of these options can be said
for example, can cause significant upheaval in to be the right solution as much of it de-
the workplace as configuration and testing is pends on the risk tolerance or aversion of the
decision makers and which model is a best way health care is delivered. The 10-year
fit for them. Such decisions are often made strategic plan, mentioned at the beginning
after considerable consultation with multiple of this chapter, proposes sweeping changes
vendors and with association representatives, across the health care industry, including the
such as the American College of Physicians creation of an electronic health record for all
(ACP), American Academy of Family Physi- Americans. Along with these changes will be
cians (AAFP), and so on who have evaluated significant health care quality improvements
various systems on behalf of their members. across the entire industry. But, the revolu-
Other considerations include: tion will not be easy and it will not be rapid.
This chapter identified several ways to pre-
Application Integration: the need for new ap-
plications to integrate or interface with existing pare for and accommodate those significant
applications. Interfaces may need to be developed changes:
for one system to be able to talk to the other. Inter-
face development and testing add significant costs r Having a holistic view of the health care
to an implementation. system so changes can be more readily applied and
Security: in addition to privacy standards that adopted in a broader context.
are already in place, the Health Insurance Porta- r Understanding the components of the
bility and Accountability Act (HIPAA) guidelines service delivery paradigm in how they can be
require strict security measures to be in place by applied in the physician office environment to
April of 2005. Vendors who are proposing new sys- initiate and sustain continuous quality improve-
tems need to be able to certify that their systems ment.
are HIPAA compliant. r Adopting evidenced-based best practices,
since the hard work of finding the best process has
In addition to needs assessment/ already been done.
evaluation tools provided by health care r Ensuring health care employees have in-
professional associations, there are a number termediate skills in quality improvement tech-
of websites that offer helpful information niques (PDSA), computer literacy, and standard
as well on various subjects that may be of office applications.
interest to physician offices: r Understanding the interdependencies of
the service delivery triad (people, processes,
Electronic Medical Record (EMR/EHR): and technology) to determine where significant
http://www.expert-system.com/howtobuy.htm
changes may drive other changes in our work en-
http://www.emrconsultant.com/
vironment and where opportunities may arise for
Computerized Physician Order Entry (CPOE): process improvement changes.
http://www.insidehealth.com/info.cpoestudy.go.html r Giving consideration to the various meth-
Registries: ods for technology implementations and the ef-
http://www.docsite.com/whyReg.htm fects each can have in the physician office environ-
Workflow assessment: ment.
http://www.globalvisioninc.com/en/services/
r Using professional associations and other
workflow.asp references for consideration when assessing the
http://www.icsbhs.org/presentations/pawlson.pdf need for various clinical applications quality im-
Quality Improvement Tools: provement tools.
http://www.dartmouth.edu/∼ogehome/CQI/index.
html Health care is already an exciting and
challenging industry to be in so it will be very
interesting to see what the next few years will
CONCLUSION bring. There is a heightened sense of expecta-
tion as we stand at the cusp of the same kinds
Significant technology changes are com- of changes that revolutionized the manufac-
ing to health care that will revolutionize the turing industry.
REFERENCES Institute of Medicine, (2000). To Err is Human: Building

a Safer Health System. Washington, DC, National
Academy Press.
Dartmouth Medical School. I. (2004). The Clinicians Porter, M.E., and Tiesbeg, E.O. (2004). Redefining Com-
Black Bag of Quality Improvement Tools. Avail- petition in Health Care. Harv Business Rev 6:65–66
able at: http://www.dartmouth.edu/∼ogehome/CQI/ Thompson, T., and Brailer, D.I. (July 21, 2004). The
PDCA.html. Accessed July 26, 2004. Decade of Health Information Technology: De-
Improving Chronic Illness Care (ICIC) I. (n.d.). livering Consumer-centric and Information-rich
Overview of the Chronic Care Model. Available Health Care. Framework for Strategic Action. Avail-
at: http://www.improvingchroniccare.org/change/ able at: http://www.hhs.gov/onchit/framework/ hit-
model/components.html. Accessed July 26, 2004. framework.pdf. Accessed July 26, 2004.
II
Caring for People with Diabetes

5
Concepts on the Origin of Diabetes

Hirisadarahally N. Nagaraja and Patrick J. Boyle
Division of Endocrinology, Diabetes, and Metabolism, University of New Mexico Health Sciences Center,
Albuquerque, New Mexico
ORIGIN OF TYPE 1 DIABETES mellitus differs from type 2 diabetes melli-

MELLITUS tus in that there is actual deficiency of in-
sulin whereas in type 2 diabetes mellitus it is
Type 1 diabetes mellitus results from insulin resistance that plays the fundamental
progressive destruction of the insulin produc- role (ADA, 2004; Becker, 2000).
ing beta cells in the islets of Langerhans.
This disease most frequently occurs in per-
What Causes Islet Cell Destruction?
sons of European descent and is less common
in other racial groups. The incidence ranges Genetic Factors
from a low of 1–2 per 100,000 per year in
Japan to as high as 40 per 100,000 per year Susceptibility to develop diabetes is con-
in Finland (Green et al., 1992). In the United ferred by genes in the HLA region. The life-
States, the prevalence of type 1 diabetes mel- long risk of type 1 diabetes increased in close
litus by the age of 20 is about 1.7 cases per relatives of a patient with type 1 diabetes and
1,000 people and the overall annual incidence the risk appear to be about 6% in offspring,
is approximately 18 new cases per 100,000 5% in siblings, and about 30% in identical
people younger than 20. The risk of develop- twins (Atkinson and Maclaren, 1994). The
ing type 1 diabetes before age 20 is approxi- main gene associated with a predisposition to
mately 0.5% (American Diabetes Association type 1 diabetes mellitus is the major histocom-
[ADA], 1996). The incidence appears to be patibility complex (MHC) on chromosome 6
age-dependent with increase occurring from in the HLA region. A single, unique amino
birth to a first peak around puberty. A sec- acid transition in this HLA protein is present
ond peak in the onset of the disease is noted in about 95% of patients with type 1 diabetes,
in those in their 20s to 30s. This later pre- but is also present in about 20% of the U.S.
sentation of type 1 diabetes appears to have population. Thus, it is not sufficient to have
the same pathogenic origin as in the earlier the genetic predisposition, otherwise 20% of
presentation. Pathogenesis in type 1 diabetes the adult population would have the disease.
61
62 THE ORIGIN OF DIABETES
We will discuss the coincident environmen- (anti-GAD antibodies) are present in at least
tal factors that contribute to trigger diabetes. 70% of the patients with type 1 diabetes. In-
There are other non-MHC genes that induce sulin also is another potent autoantigen and
type 1 diabetes mellitus and these are chromo- there is evidence that antibodies to insulin
some 11, chromosome 15, and chromosome may even appear before the anti-GAD anti-
2. In addition, at least 16 other regions have bodies. Other autoimmune diseases may co-
shown linkage with type 1 diabetes mellitus. exist since the same autoimmune response
may trigger antibodies to other organ systems.
Autoimmunity Example of such diseases includes adrenal in-
sufficiency and poly glandular autoimmune
Antibodies to islet cells develop over a disease.
period of time but can be seen much earlier in Autoantibodies appear as early as 9–12
life. Only after sufficient numbers of islet cells months of age in individuals susceptible to
are destroyed do clinical manifestations ap- type 1 diabetes and they are seen in 3–8% of
pear. In real life situations, manifestations of first-degree relatives of type 1 diabetes. Half
type 1 diabetes mellitus, which include hyper- of these individuals will develop the disease
glycemia and ketosis, occur late in the course eventually (Besser, 2002). Although this can
of the disease: that is, after most of the islet be used to predict the susceptibility to type
cells are destroyed (this may not be true based 1 diabetes, currently it is only used in re-
on the animal studies). search settings. To have a complete autoim-
There is a large body of evidence that in- mune response, the body requires the activ-
dicates that the autoimmune mechanism leads ity of T-lymphocytes or the cellular limb of
to the destruction of beta cells. By far, this ap- the immune system. These white blood cells,
pears to be the most common mechanism for unlike the B-lymphocytes, do not produce an-
beta-cell destruction. tibodies, but instead are involved in the in-
Insulin antibody titers are inversely cor- teraction with antigen presenting cells called
related with age suggesting that the presence dendritic cells that are always present in the
of these autoantibodies in the younger popula- islet. The T-lymphocytes also produce cy-
tion indicate that islet cells are destroyed early tokines, which are proteins that interact with
in the course of the disease as compared to other cells, that recruit more white cells to the
the adults. Islet cell antibodies appear to con- site of the inflammatory event in the islet. Cy-
tribute to the immunologic environment that tokines also trigger an enormous number of
permits the full-blown immune destruction of chemical events that lead to the production of
islets to occur. Studies in autoimmune animal other factors that ultimately lead to the de-
models of type 1 diabetes demonstrate that struction of the islets.
depletion of B-lymphocytes (the cells making
the autoantibodies) with monoclonal antibod- Environmental Factors
ies will significantly retard the development
of diabetes in these animals. The fact that type 1 diabetes is not 100%
There are several antigens in the pan- concordant indicates that environmental fac-
creatic beta cells that may be responsible for tors must be playing a role in the develop-
the triggering and progression of islet cell in- ment of the disease. A wide range of envi-
jury. By far, the common antigen that has ronmental factors may play a role including
been identified to which antibodies are de- common viruses, foods, and vaccines (Upto-
tected is the enzyme glutamic acid decarboxy- Date, 2004).
lase (GAD). This is present in islets and is Viruses can cause diabetes either by di-
also seen in central nervous system and testes rectly infecting and destroying beta cells or by
(Baekkeskov et al., 1990). Antibodies to GAD triggering an autoimmune response. Although
THE ORIGIN OF DIABETES 63
the former is a rare phenomenon, the latter This suggests that hyperglycemia does not im-
could be a possibility and this is supported by ply irreversible destruction of beta cells and
long-term follow-up of patients with congen- interruption of the autoimmune process. Even
ital rubella syndrome. The timing of the in- at this stage it may allow substantial recovery
fection appears to influence the induction of of the beta-cell mass.
type 1 diabetes mellitus since the disease is ob- Tying all of this together, a series of trials
served only in cases of in utero exposure. Post- have been conducted trying to prevent the pro-
natal exposure to the illness does not appear gression of type 1 diabetes after it is initiated.
to be associated with the risk. This reflects the Potent immunologic medications commonly
fact that the timing of infection at the time of used as antirejection drugs in kidney trans-
organ differentiation is important, which in- plant patients have been used to forstall the
cludes islet cell differentiation. Several other full expression of the disease. Unfortunately,
viruses have been implicated in the pathogen- the medications have significant toxicity as-
esis including coxsackie and mumps viruses, sociated with them, and they only worked to
but no definite association has been found. attenuate the immune destruction of the islets
One popular theory for the past decade has for as long as they were used.
been that because of the similarity between the One recent trial used either oral or subcu-
surface proteins produced by some viruses, taneous insulin injections in the “prediabetes”
like coxsackie B27, a common sore throat phase in a group of highly genetically predis-
virus, the immune system misidentifies the posed individuals. The results, unfortunately,
beta cells in the islet as being similar enough demonstrated no benefit in this type of attempt
to the virus that they too are destroyed. In sup- at desensitization to this potential disease ini-
port of this suggestion is the observation that tiating protein. In special strains of mice, 80%
titers of antibodies in the blood to these viruses of the females in the litters develop type 1 di-
rise and fall just before the autoantibodies rise abetes. Injection of a small amount of GAD
and fall. This up and down change in antibody during the first week of life prevented 100% of
concentrations generally goes on for years for the development of the disease (DPP, 2002).
the patient who presents with diabetes. Such human trials are underway now.
Dietary factors may influence the devel-
opment of type 1 diabetes mellitus. A com-
mon factor considered includes cow’s milk. It ORIGIN OF TYPE 2 DIABETES
is thought that exposure to cow-milk protein
early in life may lead to the development of Within recent history, many health care
type 1 diabetes. But the available data are con- practitioners believed that type 2 diabetes was
troversial and the definite association has not the result of overeating. While clearly excess
been made (Norris et al., 1996). Other dietary calorie consumption contributes to triggering
factors implicated are the content of nitrates the overt disease, there is clearly a genetic
in drinking water and introduction of cereals predisposition that is emerging. The primary
early in life. Once again data are controversial distinction between type 1 and type 2 diabetes
here. is that during the prodromal phase of the type
Although it was once thought that about 2 diabetes, the patient is grossly hyperinsu-
90% of the beta cells are required to be de- linemic. Only after a long duration of the dis-
stroyed before hyperglycemia occurs, it has ease does type 2 progress to relative insulin
been shown in animal studies that hyper- deficiency, and, even then, this is not an abso-
glycemia can be seen with even 30–50% of lute. Instead, type 2 diabetes is a state of in-
beta-cell mass destruction. This could be in sulin resistance that is present even in young
part due to the inhibitory effect of cytokines adults; that is, more insulin is required to con-
released from inflammatory cells in the islets. trol blood sugar concentrations.
Recent data collected by Petersen et al. which in turn, leads to a change in the bio-
(2004) at Yale summarize clearly that an in- chemical pathways responsible for normal
herited defect in muscle metabolism plays a muscle glucose uptake. Muscle is responsible
pivotal role in the development of type 2 di- for roughly 80% of glucose disposal.
abetes. In these elegant studies, subjects be- Fasting plasma glucose concentration in
tween an average of 26–28 years of age were the morning after awakening is not deter-
screened for insulin sensitivity with an intra- mined by the final meal the evening before,
venous (IV) glucose tolerance test. In this ex- but instead, it is the result of the difference
periment, the rate of return to a normal, base- between how fast glucose is being produced
line glucose concentration after a bolus of and how fast it is being cleared. The liver is
50% dextrose is an index of insulin sensitiv- the primary site of glucose production (with
ity. Those with normal insulin sensitivity re- a contribution from the kidneys) while skele-
turn to baseline glucose values quickly, while tal muscle accounts for a large fraction of the
those who are resistant returned more slowly. glucose disposal (the brain actually accounts
A bell-shaped distribution of insulin sensitiv- for about 60% of systemic glucose production
ity was developed in these sedentary, other- fasting—but this is a constant amount whether
wise normal individuals. Subjects from both we are fasting or eating). Thus, a high glucose
ends of the spectrum were investigated fur- concentration is either the result of excessive
ther with a conventional oral glucose tolerance glucose production from the liver or inade-
test. The peak glucose concentrations were quate glucose clearance by muscle.
elevated only modestly during the test (peak The primary regulator of glucose pro-
values of about 155 mg/dl compared to those duction from the liver is the insulin concen-
from the other end of the bell-shaped curve tration in the blood coming from the pancreas
who were approximately 140 mg/dl at max- to the liver. If the primary defect is in mus-
imum). However, those persons who had the cle glucose uptake, then the body’s compen-
slowest rate of return (least insulin sensitivity) sation could be to reduce rates of liver glucose
by the IV test generated substantially higher production to match the defect in clearance.
insulin concentrations to maintain a normal Indeed, beta cells sense minor increments in
glucose concentration. This hyperinsulinemia glucose concentrations from inadequate glu-
is the hallmark of type 2 diabetes. These nor- cose clearance. In turn, insulin secretion is
mal appearing, normal body weight, insulin raised to signal the liver to diminish glucose
resistant subjects also had to have at least production since the systemic glucose con-
one parent or grandparent with diabetes and centration is satisfactory to supply the brain
one other first-degree relative with diabetes to and other critical organs with their preferred
be further characterized. Fasting rates of liver energy substrate, glucose.
glucose production were equivalent between What the inherited defects in glucose
these two groups, while the rate of glucose uptake in muscle might be has been the
uptake by muscle was greatly diminished in subject of investigations that have spanned
the resistant subjects. Finally, the investiga- decades. Although the exact explanation has
tors demonstrated that these normal weight not been elucidated, we can summarize some
subjects with the high insulin levels had more of the key findings. The disposal of glucose
fat and less ATP (the stored form of energy) into muscle is triggered by insulin binding
in their muscle. to the insulin receptor on muscle cell sur-
Taken together, this fundamentally faces. Defects in the insulin receptor itself
means that type 2 diabetes is an inherited de- have been found leading to insulin resistance,
fect in muscle energy production. Low rates but this is extraordinarily rare. After insulin
of fat oxidation permit the accumulation of binds to its receptor, a chain of enzymati-
triglyceride and free fatty acids in muscle, cally driven phosporylation steps ultimately
lead to the mobilization of glucose transport diabetes by causing excessive liver glucose
protein pools, which wait to be activated as production. Defects in hnf-4-alpha, a nuclear
cell’s cytosol and mobilized to the cell sur- transcription activating factor necessary for
face causing glucose to traverse the plasma normal insulin sensitivity have been described
membrane. Dozens of steps are involved in as the etiology of type 2 diabetes in people of
this “signal transduction” of insulin bind- Finnish descent.
ing and ultimately result in increased mus- Beyond insulin signaling, beta-cell func-
cle glucose uptake. An inherited defect in any tion and liver glucose production are more
one of the genes responsible for producing metabolic etiologies of this disease that, while
these proteins could theoretically lead to ex- rare, also demonstrate how elegantly regu-
actly the same thing—type 2 diabetes with lated human glucose concentrations really are.
insulin resistance. Dissection of this compli- PPAR-gamma is a nuclear transcription acti-
cated chain of chemical events has allowed vating protein expressed in fat, muscle, liver,
us to discover some of these defects, but and blood vessels. Initially thought to be only
a complete discussion of the investigations involved in regulating genes involved in fat
in this part of the story is well beyond the cell differentiation and lipid oxidation, rare
scope of this chapter. Suffice it to say that subjects with mutations in this protein have
type 2 diabetes is not one disease, but is a now been described and they have diabetes.
family of diseases with a unifying inherited Interestingly, these subjects have rather mun-
feature of poor glucose uptake by muscle dane clinical presentations (gestational dia-
(usually). betes, typical midlife presentation of diabetes,
Undoubtedly, inherited defects in two and one earlier onset diabetes in a woman with
other critical organs also will account for part polycystic ovarian disease). While PPAR-
of the origin of type 2 diabetes in humans. gamma mutations are unlikely to explain more
First, there are primary beta-cell defects in than a couple percent of the entire problem,
insulin secretion from what would otherwise activators of this protein, known as thiazo-
look like histologically normal islets. Muta- lidinediones, have been developed and have
tions in the key initial enzyme in cataboliz- demonstrated remarkable antidiabetic effects.
ing glucose, hexokinase, in beta cells have Although the complete discussion of all of
been demonstrated in patients with early onset the physiologic results of activating this pro-
type 2 diabetes, Maturity Diabetes of Youth tein is also beyond the scope of this chap-
(MODY). Patients with this disease have high ter, one gene regulated by this pathway mer-
glucose concentrations around age 8–10, are its description. Adiponectin is a protein pro-
not overweight, generally do not have ke- duced from fat cells that has a multitude of
toacidsosis (as is seen in type 1 diabetes in metabolic functions after it is released into
children) and they have a strong family history the circulation (Phillips, 2003). One of these
of early onset diabetes that appears to be au- functions is to increase fatty acid oxidation
tosomal dominant in origin. Since hexokinase in muscle. Recalling that one of the funda-
traps glucose when it converts it into glucose- mental underlying defects that antedates the
6-phosphate, a beta cell deficient in this en- development of frank hyperglycemia is the
zyme cannot “sense” the systemic glucose accumulation of triglyceride in muscle, one
concentration and therefore does not know could imagine that adiponectin deficiency or
when to appropriately release insulin. Other subnormal activity would result in muscle
beta-cell defects are being discovered in some fat accumulation and consequently impaired
kindred of patients with diabetes. Following glucose transport (as described above). Muta-
the above description, it should be clear that tions in the adiponectin gene have been doc-
primary hepatic defects in excessive glucose umented to be associated with insulin resis-
production would also be potential causes of tance, but again, this is observed in perhaps
only 4% of the patients with type 2 diabetes. A from the market appeared to prevent 75% of
probable major action of PPAR-gamma acti- the conversion to type 2 diabetes out of the
vation in fat cells is to activate the adiponectin high-risk population at one year after discon-
gene, increasing adiponectin protein produc- tinuing the drug. This effect was unfortunately
tion, and elevated adiponectin concentrations entirely lost by the end of the 4-year study.
turn on fatty acid oxidation, which should Along this same line of thinking, women with
lead to a normalization of muscle glucose histories of gestational diabetes have been
uptake. treated with Troglitazone and demonstrated to
This mechanism would explain the ac- have a 56% reduction in the subsequent con-
tion of the thiazolidinediones. Clinicians have version to type 2 diabetes in the postpartum
long sought to explain why increased body fat period compared to placebo treated women
mass would lead to insulin resistance. As fat (Buchanan et al., 2002). Since 75% of women
mass increases, adiponectin levels fall, which with a history of gestational diabetes later de-
could contribute to reduced glucose uptake velop type 2 diabetes in their adult lives, this
by muscle. Interestingly, as fat mass falls, is an amazing finding.
adiponectin levels rise, which would explain In summary, the origin of type 2 diabetes
part of the improvement in diabetes control is multidimensional. Certainly inherited de-
associated with weight loss. fects in muscle glucose production are respon-
No discussion on the origin of type 2 di- sible for a large number of the cases. However,
abetes would be complete without a discus- this defect is not sufficient to cause the dis-
sion of why a sedentary lifestyle, indepen- ease. A secondary defect in beta-cell function
dent of weight gain, might contribute to the in the islet must occur to reduce the compen-
development of type 2 diabetes. The Diabetes satory hyperinsulinemia that masks insulin re-
Prevention Program (DPP) included a limb sistance for years. In this sense, diabetes is a
of intensified lifestyle modification that not two-step disease: one in muscle, one in the
only included improved nutrition (reduced islet. Primary beta-cell defects can lead to type
calories) but also increased energy expendi- 2 diabetes in youth, while primary hepatic mu-
ture (DPP, 2002). Muscle uses glucose as its tations that lead to reduced liver insulin sen-
fuel, and when muscle contracts, glucose up- sitivity can cause diabetes in some popula-
take increases. This is not only a local effect, tions. Undoubtedly, there will be many other
but also a systemic one. Exercise in one arm defects discovered that enhance the likelihood
increases glucose uptake in the contralateral that one will develop insulin resistance and be
arm. predisposed to diabetes.
In association with weight loss, exercise
in the DPP produced a nearly 60% prevention
of diabetes compared to nonexercised control STANDARDS OF CARE FOR BOTH
subjects with impaired glucose tolerance over FORMS OF DIABETES
a 4-year time span. Due to this very potent
effect on the prevention of type 2 diabetes, The ADA has developed a comprehen-
strategies of how to incorporate exercise as sive list of standards of care for the patient
a routine part of every day in every person with diabetes. The recommendations encom-
at risk is essential. The use of the diabetes pass risk-reducing strategies that work for ei-
medication Metformin at 850 mg twice daily ther form of the disease—so there is no need
was only sufficient to prevent about 26% of to remember that a risk factor is unique to only
the conversion rate. type 1 versus type 2. Since hyperglycemia
Preliminary reports on the use of Trogli- is the defining value for diabetes, targets for
tazone, the first thiazolidinedione, used in the metabolic control are the focus for both dis-
DPP in 585 patients before it was withdrawn ease processes.
All of this care should be conducted dur- Annual physical exam. Because physical
ing routine quarterly visits to the primary exam findings of early complications trigger
care provider. Given the number of organ sys- additional preventive management.
tems involved in the average patient, less fre- Annual retinopathy. Each patient should
quent visits are likely to lead to suboptimal have an annual eye exam. Patients with type
management. 2 diabetes may be followed at slightly longer
Quarterly HbA1c. HbA1c is worthwhile intervals given that retinopathy does not seem
being measured at quarterly intervals given to be as common.
the entire red cell mass turns over in that Annual microalbumin. Every patient
period of time. The ADA recommends an should have urine for microalbumin tested an-
HbA1c value of less than 7.0% (the American nually since finding it leads to institution of
Association of Clinical Endocrinologists rec- ACE inhibitor therapy even if the patient is
ommends less than 6.5%). In order to achieve not hypertensive due to the renal protective
this target, fasting glucose concentrations effects of the compounds (see Chapter 16 for
should be near 110 mg/dl, 2-hour postpran- more information).
dial values should be less than 160 mg/dl, Because all medications have side ef-
and bedtime glucose concentrations less than fects, monitoring pathways for drug clear-
120 mg/dl. Naturally, every patient is unique ance are important, especially for Metformin,
and these targets must be tailored to that per- which is partially cleared through the kidneys.
son’s individual needs and limitations. Pa- Thus, creatinine of greater than 1.4 mg/dl (or a
tients with gastroparesis for instance have glomerular filtration rate less than 60 ml/min)
greater difficulty making the 2-hour postpran- should preclude use of Metformin since 20%
dial glucose less than 160, and those pa- of its clearance is through the kidneys and its
tients with hypoglycemia unawareness per- accumulation leads to lactic acidosis.
haps need a slightly higher glucose prior to Annual foot exam. Each patient should
going to sleep in order to minimize nocturnal have their feet examined annually, and a mi-
hypoglycemia. crofilament test done on the sole of each
Quarterly blood pressure. Since most foot to assess intactness of sensation (see
of the complications of diabetes are vascu- Chapter 12 for more information).
lar in origin, other parameters are also rele- Only about 4,000 board certified en-
vant. Blood pressure is a major contributor docrinologists practice in the United States
to both micro- and macrovascular complica- and there are estimated to be over 19 mil-
tions. The target value is less than 120/80. The lion people with either type 1 or type 2 di-
preferred first line agent in type 1 diabetes is abetes. Certainly, the average type 1 diabetes
an angiotensin converting enzyme inhibitor, patient will benefit from interaction with an
and either an ACE or an angiotensin-II recep- endocrinologist and a team of certified dia-
tor blocking agent (particularly in the setting betes educators. Complicated type 2 diabetes
of microalbumenuria). cases are also appropriate for endocrine con-
Lipids. Cholesterol values are also ag- sult, but the basics of care must be under the
gressively managed since diabetes is a direction of well-educated primary providers
cornonary disease risk equivalent. Thus, LDL just based on the shear volume of cases. Cer-
values should be treated to less than 100 mg/dl tified diabetes educators are another resource
and many would say to near 70 mg/dl. Desir- that can provide extraordinary help in patient
able HDL values are greater than 45 in men management.
and 50 mg/dl in women. Triglycerides, com- For online reference to current standards
monly elevated as part of the metabolic syn- of care, please refer to the ADA Web site:
drome in type 2 diabetes, should be treated to http://care.diabetesjournals.org/cgi/content/
less than 150 mg/dl. full/27/suppl 1/s15.
REFERENCES resistance in high-risk Hispanic women. Diabetes

51:2796–2803.
Green, A., Gale, E., and Patterson C. (1992). Incidence
American Diabetes Association. (1996). Vital Statistics. of childhood-onset insulin-dependent diabetes mel-
American Diabetes Association. litus: The EURODIAB ACE study. Lancet 339:905–
American Diabetes Association. (2004). Diagnosis and 909.
classification of diabetes mellitus. Diabetes Care Norris, J., Beaty, Klingensmith, G., Yu, L., Hoffman, M.,
27:S5–S10. Norris, C., Beaty, J., et al. (1996). Lack of associ-
Atkinson, M., and Maclaren, N. (1994). The pathogenesis ation between early exposure to cow’s milk protein
of insulin-dependent diabetes mellitus. N Engl J Med and β-cell autoimmunity. Diabetes Autoimmunity
331:1428–1436. Study in the Young (DAISY). JAMA 276:609–614.
Baekkeskov, S., Aanstoot, H., Christgau, S., Reetz, A., Petersen, K., Dufour, S., Befroy, D., Garcia, R., and Shul-
Solimena, M., Cascalho, M., Richter-Olson, H., and man, G. (2004). Impaired mitochondrial activity in
Camilli, P. (1990). Identification of the 64K autoanti- the insulin-resistant offspring of patients with type
gen in insulin-dependent diabetes as the GABA- 2 diabetes. N Engl J Med 12;350(7):664–671.
synthesizing enzyme glutamic acid decarboxylase. Phillips, S., Ciaraldi, T., Kong, A., Bandukwala, R.,
Nature 347:151–156. Aroda, V., Carter, L., Baxi, S., Mudalier, S.R., and
Becker, K. (2000). Principles and Practice of Endocrinol- Henry, R.R. (2003). Modulation of circulating and
ogy and Metabolism. 3rd ed. Philadelphia, PA, adipose tissue adiponectin levels by antidiabetic
Lippincott Williams & Wilkins. therapy. Diabetes 52:667–674.
Besser, G., and Thorner, M. (2002). Comprehensive Clin- The Diabetes Prevention Group, including Boyle, P.J.
ical Endocrinology. 3rd ed. Mosby, Edinburgh. (2002). Reduction in the incidence of type 2 diabetes
Buchanan, T., Xiang A., Peters, R., Kjos, S., Marroquin, with lifestyle intervention or Metformin. N Engl J
A., Goico, J., et al. (2002). Preservation of pan- Med 346:393–403.
creatic β-cell function and prevention of type 2 UptoDate. (2004, Volume 12.2). Available at: www.
diabetes by pharmacological treatment of insulin uptodate.com.
6
Medication Management
Carrie M. Maffeo
Director, Health Education Center, College of Pharmacy and Health Sciences, Butler University,
Indianapolis, Indiana
OVERVIEW OF DIABETES of exogenous insulin to support their body’s

MEDICATION MANAGEMENT metabolic needs. In type 1 DM studies, such
as the Diabetes Control and Complications
This chapter will review the current op- Trial (DCCT), it has been established that im-
tions and trends in the pharmacologic man- proving glycemic control can prevent or delay
agement of type 1 and type 2 diabetes mel- microvascular complications. The results in
litus (DM). The overall treatment goals for this study were obtained by intensive insulin
both type 1 and type 2 DM is to maintain tight therapy, multiple daily injections, or an in-
glycemic control while minimizing the risk of sulin pump with frequent blood glucose mon-
hypoglycemia. This chapter will examine dif- itoring. The greatest side effect experienced
ferent types of insulin, insulin regimens, and by these patients is an increased risk of hy-
insulin delivery systems utilized in the man- poglycemia (Diabetes Control and Compli-
agement of type 1 DM patients. In the discus- cations Trial Research Group, 1993). Today,
sion of type 2 DM, the characteristics of the new innovations in insulin analogs and insulin
oral medications available for treatment will delivery systems are being designed to help at-
be reviewed, as well as treatment strategies tain “tight” glycemic control while minimiz-
and rationale for combination therapies. ing the risk of hypoglycemia.
To better understand insulin treatment
strategies, it is helpful to understand the
MEDICATION MANAGEMENT body’s normal insulin release patterns. The
FOR TYPE 1 DIABETES body has two basic types of insulin secre-
MELLITUS tion: first, basal insulin is released from the
pancreas during the fasting state, which com-
Since the discovery of insulin by Banting prises about 50% of our insulin requirements,
and Best in 1921, huge strides have been the second type of insulin secretion is pran-
made in the areas of insulin therapy and in- dial insulin release. This occurs in normally
sulin delivery (Banting et al., 1922). Patients functioning pancreases in response to the
with type 1 DM require the administration ingestion of food. There are two prandial
69
70 MEDICATION MANAGEMENT
TABLE 6.1. Insulin Types

Characteristics of insulin
Onset (h) Peak (h) Duration (h)
Rapid acting
Insulin aspart (Novologr ) 0.25a 1–2 3–5
Insulin lispro (Humalogr ) 0.25a 0.5–1.5 3–5
Insulin glulisine (Apidrar ) 0.25a 0.5–1.5 3–5
Short acting
Regular (Humulinr , Novolinr ) 0.5–1.0 2–4 5–8
Intermediate acting
NPH (Humulin Nr , Novolin Nr ) 1–2 4–12 16–20
Lente (Humulin Lr , Novolin Lr ) 1–2 7–15 18–24
Long acting
Insulin glargine (Lantusr ) 1–2 No peak effect 20–24
Ultralenter 4–6 8–12 36
a
Onset of action is affected by injection site, exercise, and mixing of insulin.
insulin releases, phase 1 and phase 2. Phase 1 acting insulin analogs, short-acting insulin has
insulin release occurs immediately after the fallen out of favor due to its longer onset and
ingestion of food (<10 minutes), whereas duration of action in comparison to rapid-
phase 2 insulin release is stimulated by phase acting insulin. Intermediate-acting and long-
1 and occurs about 20–30 minutes after the acting insulins are used to meet the body’s
ingestion of food (Cefalu, 2004). Remember- basal insulin requirements. Intermediate-
ing the body’s natural insulin release patterns acting insulin such as neutral protamine Hage-
will help understand the types of insulin and dorn (NPH: Humulin Nr , Novolin Nr ) and
the dosing regimens utilized when managing insulin lente (Humulin Lr , Novolin Lr ) are
type 1 DM patients. The premise of insulin usually dosed twice a day to provide 24-hour
administration in type 1 DM patients is an insulin coverage. However, because these in-
attempt to mimic the body’s natural insulin sulins have a peak effect, they do not truly rep-
release patterns. resent a constant “flat” basal insulin release.
Long-acting insulins have a 24-hour duration
of action and are dosed once daily. Insulin ul-
TYPES OF INSULIN tralente (Ultralenter ) has been the mainstay of
long-acting insulins until recently. The intro-
When assessing a patient’s insulin reg- duction of insulin glargine (Lantusr ) has pro-
imen, it is helpful to understand the differ- vided a new alternative in the group of long-
ences among the various types of insulin with acting insulins, in that it provides a constant
regard to onset of action, peak effect, and du- blood concentration without a pronounced
ration of action. The types of insulin are clas- peak (Reinhart and Panning, 2002).
sified into four categories: rapid-acting, short-
acting, intermediate-acting, and long-acting
insulin (see Table 6.1). INSULIN REGIMENS
Rapid-acting insulin (lispro, aspart, and
glulisine) and short-acting insulin (regular in- The ideal insulin regimen would mimic
sulin) are designed to mimic the body’s nat- endogenous insulin secretion, both basal and
ural insulin release in the response to a meal prandial insulin release patterns. Mealtime in-
(prandial). With the introduction of the rapid- sulin would be provided as a bolus insulin
MEDICATION MANAGEMENT 71
dose before the meal and have a duration of insulin dose before meals and an intermediate-
action to cover both phase 1 and 2 prandial in- acting or long-acting insulin dose at bedtime.
sulin release patterns. Thus, the ideal premeal Patients learn how to adjust their doses based
insulin would have a fast onset and short du- on previous trends in blood glucose results.
ration of action. The ideal basal insulin would This is also known as pattern management.
be a continuous, predictable 24-hour insulin Basal–bolus regimens are more complex and
release. require commitment from the patient and ac-
The most common insulin regimens are cess to a diabetes self-management educa-
twice daily injections, multiple-daily injection program. With this type of regimen the
tions, and flexible insulin regimens. Twice patient determines their premeal rapid-acting
daily injections are simple regimens that usu- or short-acting insulin dose based on their
ally consist of a combination of a rapid-acting premeal blood glucose levels, the carbohy-
or short-acting insulin and intermediate- drate content of their meal (by carbohydrate
acting insulin dose in the morning (prebreak- counting), and other factors that may affect
fast) and evening (predinner). This type of blood glucose levels (exercise, stress, illness,
regimen has been associated with midday hy- menstrual cycle, etc.). The long-acting basal
poglycemia (if lunch is delayed or skipped) insulin dose is given usually at bedtime; how-
and/or nocturnal hypoglycemia. If nocturnal ever, some patients may administer their basal
hypoglycemia becomes a reoccurring prob- dose in the morning.
lem, the intermediate-acting insulin dose can
be shifted to bedtime; however, this will in-
crease the number of daily injections to three INSULIN DELIVERY
(Hirsch, 1998). To facilitate twice daily injec-
tions, there are several premixed insulin prod- Traditionally, insulin doses have been
ucts available (see Table 6.2). delivered by subcutaneous injections. There
More intensive insulin therapies such as are several devices available such as insulin
multidaily injections or flexible insulin reg- pens, jet injectors, and insulin pumps that have
imens (also known as basal–bolus insulin improved insulin delivery. Advantages of in-
therapy) allow more flexibility in lifestyle, sulin pens include: greater convenience, easily
but also require more frequent blood glucose carried, smaller gauge needle for injection, are
monitoring. Multidaily injection regimens disposable, and provide accurate dosing via a
comprise a rapid-acting insulin or short-acting dial on the pen (Bohannon, 1999).
An alternative to administering insulin
with a needle is jet injectors. These devices
TABLE 6.2. Premixed Insulin Products
deliver insulin with a high-pressure stream of
Product Mixture components insulin into the skin. These devices are more

r
costly; however, they may offer an alternative
Humalog 75/25 75% insulin lispro protamine
suspension 25% insulin lispro to patients with severe needle phobias (Amer-
Humulinr 70/30 70% human insulin isophane ican Diabetes Association, 2004a).
suspension 30% regular Continuous subcutaneous insulin infu-
human insulin sion (CSII) is a method utilized to imple-
Humulinr 50/50 50% human insulin isophane
ment intensive blood glucose management
suspension 50% regular human
insulin and can provide improved lifestyle flexibility.
Novologr 70/30 70% human insulin isophane CSII or more commonly referred to as “in-
suspension 30% regular sulin pump” therapy, requires motivation, and
human insulin a strong commitment from the patient and/or
Novolinr 70/30 75% insulin aspart protamine
the patient’s family. Patients considering in-
suspension 25% insulin aspart
sulin pump therapy need to be motivated and
taught how to use the insulin pump, make in- appears that the pulmonary delivery of insulin
sulin adjustments, count carbohydrates, and will likely be the first new innovation to be-
trouble shoot potential problems with the income available within the next few years.
sulin pump. Frequent blood glucose moni-
toring is required with insulin pump therapy
(American Diabetes Association, 2004b). MEDICATION MANAGEMENT
There are two different types of in- FOR TYPE 2 DIABETES
sulin pumps: external infusion pumps and MELLITUS
implantable insulin pumps. External insulin
pumps consist of an external infusion pump Type 2 DM is a progressive chronic
with an insulin reservoir that delivers a prede- disease that despite adherence to lifestyle
termined amount of insulin through flexible modifications, patients will eventually require
tubing with a catheter indwelling that is in- pharmacologic intervention to maintain blood
serted subcutaneously (Lenhard and Reeves, glucose goals (United Kingdom Prospective
2001). The external pump is about the size Diabetes Study 24, 1998a). In the past decade,
of a pager, and has a refillable insulin reser- landmark trials have shown that intensive ther-
voir. Implantable insulin pumps are surgi- apy in addition to lifestyle changes will reduce
cally placed into the subcutaneous tissue of the incidence of microvascular complications
the abdomen. A catheter delivers the insulin (United Kingdom Prospective Study Group,
to the intraperitoneal cavity. Over time, the 1998b). To obtain the desired blood glucose
body will form a fibrous tissue layer around levels achieved in these studies, multiple med-
the pump so it stays in place and does not ications with different mechanisms of action
cause discomfort. The insulin pump contains a were often utilized (Turner et al., 1999). The
reservoir that is refilled by the patient’s physi- availability of multiple drug classes with vary-
cian every 1–3 months (Selam, 1999). ing modes of action has increased the com-
plexity of type 2 DM medication regimens.
In this section, the medications avail-
INSULIN INNOVATIONS able for the treatment of type 2 DM will be
reviewed. The physiologic actions of the med-
There has been a considerable amount of ication groups include: stimulating the release
research into noninvasive insulin delivery sys- of insulin from the pancreas, decreasing gas-
tems. Two of these include intranasal delivery trointestinal (GI) absorption of glucose, in-
and inhaled insulin delivery. The feasibility of creasing insulin sensitivity, and decreasing
intranasal insulin delivery has been demon- glucose production from the liver. In some
strated; however, poor absorption through the cases, patients may require exogenous in-
nasal membranes has been a limitation. Sev- sulin administration when oral medications no
eral approaches have been tried to improve the longer maintain adequate blood glucose con-
absorption through the nasal passages, but an trol. The medication classes that are currently
increase in nasal irritations was experienced. available and their mechanisms of action are
This approach to insulin delivery is still in described in Table 6.3.
development. The delivery of insulin by in-
halation has had greater success and is in the
later phases of development. Several studies INSULIN SECRETAGOGUES
are underway examining the safety and ef-
fectiveness of inhaled insulin (AERxr iDMS) The group of medications known as the
and inhaled insulin Exuberar (Cefalu, 2004; insulin secretagogues includes sulfonylureas
Adis International Limited, 2004). Of all the (SFU) and meglitinides (Table 6.4). The first
research into noninvasive insulin delivery, it class of oral medications approved for the
TABLE 6.3. Characteristics of Type 2 Diabetes Oral Medications

Primary mechanism
Medication Generic name Brand name of action
First-generation Tolbutamide Orinaser Stimulates the release of

sulfonylureas Tolazamide Tolinaser insulin from pancreatic beta
Chlorpropamide Diabineser cells
Second-generation Glyburide DiaBetar
sulfonylureas Micronaser
Glynaser
Glipizide Glucotrolr
Glucotrol XLr
Glimepiride Amarylr
Meglitinides Repaglinide Prandinr Stimulates a rapid release of
Nateglinide Starlixr insulin from the pancreas
Biguanide Metformin Glucophager Decreases blood glucose
Glucophage XRr production from the liver
Alpha-glucosidase Acarbose Precoser Inhibits the digestion of
inhibitors Miglitol Glysetr starches; which results in
delayed glucose absorption
and lessens postprandial
hyperglycemia
Thiazolidinediones Pioglitazone Actosr Increases insulin sensitivity in
Rosiglitazone Avandiar the liver, adipose, and
skeletal muscle tissue;
results in increased glucose
uptake
treatment of type 2 DM were introduced in the ducing a more rapid and shorter insulin re-
1950s, these are known as the first-generation sponse. Because of this, these medications
SFUs. The second-generation of SFUs were are taken right before a meal, and have a
introduced in the 1980s. These agents are greater effect on postprandial hyperglycemia
more potent on a milligram per milligram ba- and lesser effect on overnight fasting hyper-
sis and have a longer duration of action, with glycemia (Owens, 1998). These medications
the exception of chlorpropamide (Table 6.4). have a lower risk of hypoglycemia, however,
The SFUs exert their blood glucose lower- it still is a potential side effect especially if the
ing effect by directly stimulating pancreatic patient skips a meal (Damsbo et al., 1999).
beta cells to release insulin. This stimulation
of insulin release mobilizes metabolic path-
ways that affect glucose, protein, and lipid BIGUANIDES
metabolism. This effect can translate into a
modest weight gain for patients taking SFUs. Metformin (Glucophager , Glucophage

r
Due to the direct effect SFUs have on the pan- XR ) is a biguanide that has been used in
creas, the most common side effect is hypo- many countries since the 1950s, but was
glycemia. Additional side effects that patients not approved for use in the United States
may experience include dermatologic reac- until 1995 (DeFronzo, 1999). The primary
tions and GI disturbances such as abdominal mechanism of action for metformin is that
pain and flatulence (Rendell, 2004). it decreases hepatic glucose production. To
The meglitinides, nateglinide (Starlixr ), a lesser extent, metformin exerts its blood
and repaglinide (Prandinr ) are also insulin glucose lowering effect by decreasing glu-
secretagogues. They differ from SFUs in pro- cose absorption from the intestinal tract, and
TABLE 6.4. Dosing Information for the Insulin Secretagogues

Starting dose Total daily dose
Medication Trade name (mg) (mg) Dosage frequency
Tolbutamide Orinaser 500 3,000 Three times daily

Chlorpropamide Diabineser 100 500 Once daily
Tolazamide Tolinaser 100 1,000 Twice daily
Glyburide Diabetar 2.5–5 10–20 Once–twice daily
Micronaser
Glynaser 1.5–3 6–12 Once–twice daily
Glipizide Glucotrolr 5–10 20–40 Twice daily
Glucotrol XLr 5 20 Once daily
Glimepiride Amarylr 1–2 8 Once daily
Repaglinide Prandinr 0.5–2 16 Two–three times daily,
before meals
Nateglinide Starlixr 60 120 Two–three times daily,
before meals
increasing insulin sensitivity in peripheral tis- adequate renal function has been confirmed
sues (Hundal et al., 2000). (DeFronzo, 1999).
Two advantages of receiving metformin When starting metformin, the patient
monotherapy are that patients usually do not may experience gastrointestinal side effects
experience weight gain (some patients may such as nausea, vomiting, diarrhea, and flat-
even experience a modest weight loss) and ulence. These effects may be minimized
the absence of hypoglycemia as a side effect. by starting with a lower initial dose (see
This may make metformin an attractive choice Table 6.5). Other common side effects as-
when selecting an oral medication for a type sociated with metformin therapy include
2 DM patient. Another benefit of metformin headache and abdominal discomfort (Rendell
monotherapy is that it has not been associated and Kirchain, 2000).
with adverse effects on lipid profiles (United When metformin monotherapy is no
Kingdom Prospective Study Group, 1998c). longer able to provide adequate blood glucose
However, metformin is not indicated for all control, other oral diabetes medications or in-
patients. Metformin is primarily eliminated sulin may be added and used in combination
from the body via the kidneys; therefore, it with metformin (Turner and Holman, 1995).
is contraindicated in patients with compro- Combination therapy with metformin is
mised renal function. This may lead to an ac- common, therefore, several combined tablet
cumulation of metformin and place the patient formulations have been marketed. These
at risk for developing lactic acidosis. There- products are available in different dosage
fore, metformin should not be used in patients strengths; the combination products include
with a serum creatinine ≥1.4 mg/dl in fe- metformin and glyburide (Glucovancer ) and
males and ≥1.5 mg/dl in males. Metformin metformin and rosiglitazone (Avandametr ).
also should be avoided in patients with con-
gestive heart failure requiring drug therapy,
liver disease, excessive alcohol use, and re- ALPHA-GLUCOSIDASE
cent myocardial infarction. Patients receiving INHIBITORS
metformin who undergo radiologic studies in-
volving iodinated contrast media should tem- There are two medications available in
porarily stop taking metformin and have it this class, acarbose (Precoser ) and miglitol
withheld for 48 hours. It may be restarted once (Glysetr ). These agents have a direct effect
TABLE 6.5. Dosing Information for Oral Type 2 Diabetes Medications

Starting dose Total daily dose
Medication Trade name (mg) (mg) Dosage frequency
Metformin Glucophager 500 2,000–2,550 Twice daily

Glucophage XRr 500 2,000 Once daily, with evening
meal
Acarbose Precoser 12.5–25 50–100 Three times daily, before
meals
Miglitol Glysetr 12.5–25 50–100 Three times daily, before
meals
Pioglitazone Actosr 15 30–45 Once daily
Rosiglitazone Avandiar 4 8 Once or twice daily
on postprandial blood glucose levels by de- THIAZOLIDINEDIONES

laying the digestion and absorption of carbo-
hydrates from the intestinal tract (Rendell and The thiazolidinediones (TZDs) include
Kirchain, 2000). When used as monotherapy, pioglitazone (Actosr ) and rosiglitazone
these agents will not cause hypoglycemia. (Avandiar ), they are often referred to as the
However, when used with insulin or an insulin “glitazones.” These medications are insulin
secretagogue patients may experience a hypo- sensitizers, that is, they enhance glucose
glycemic reaction. This is an important fact to uptake in skeletal muscle, adipose tissue,
remember when counseling patients on treat- and the liver. They also decrease glucose
ing low blood glucose reactions. The patient production from the liver. The uniqueness of
should be instructed to ingest pure glucose these medications is their ability to decrease
(such as glucose tablets) since these agents insulin resistance, an important target in
delay the absorption of carbohydrates (Mc- the metabolic anomalies of type 2 diabetes
Cormick and Quinn, 2002). (Grossman, 2002).
A limitation to the use of these medica- The unique action of TZDs is also the
tions is the high frequency of gastrointestinal basis for other metabolic effects they have on
side effects. Studies have shown that as many the body. A common side effect of TZDs is
as 30–40% of patients taking these medica- weight gain due to the increased volume of fat
tions will experience GI side effects such as cells (DeFronzo, 1999). The average weight
flatulence, bloating, cramping, and diarrhea. gain reported in studies varies from 1 to 9
The GI side effects can be minimized by start- lbs; it has been demonstrated that the great-
ing with a low dose and slowly increasing it est weight gain occurs when a TZD is used in
over time (see Table 6.5). These medications combination with insulin or an SFU (Gross-
must be present in the small intestine with man, 2002). The effects TZDs have on lipids
food; therefore, each dose should be taken at are variable, data suggest that pioglitazone
the start of the meal (DeFronzo, 1999; Ren- (Actosr ) may have a more desirable effect
dell and Kirchain, 2000). The maximal effec- than rosiglitazone (Avandiar ) (Buse et al.,
tiveness of acarbose and miglitol therapy is 2004). TZDs may have a favorable effect on
seen in patients adhering to a diet consisting blood pressure (Rendell, 2004).
of >50% carbohydrates (Feinglos and Bethel, When therapy with a TZD is initiated,
1999). These medications should not be used several things need to be considered. First,
in patients with inflammatory bowel disease, the blood glucose lowering effect of a TZD is
elevated serum creatinine (>2.0 mg/dl), or usually not seen until 2–4 weeks after ther-
cirrohsis of the liver (DeFronzo, 1999). apy is initiated, with the maximum effect
at 8–12 weeks. Therefore, it is important to and SFU therapy or insulin therapy alone (Fur-
allow enough time to assess the effective- long et al., 2002). Metformin and TZD ther-
ness the TZD has on the patient’s glycemic apy augment insulin’s action differently and
control. Fluid retention and edema should have been found to have a synergistic benefit
be monitored when TZD therapy is started, in lowering blood glucose levels (Fonseca et
and are not recommended for patients with al., 2000). Finally, an emerging trend is triple
New York Heart Association (NYHA) class oral therapy. Although this has been seen in
3 and 4 heart failure (McCormick and Quinn, practice for awhile, more data are becoming
2002). Patients with liver dysfunction should available to support the efficacy and safety of
not receive TZD therapy, and liver function triple oral therapy (Bell and Ovalle, 2002).
monitoring is recommended for all patients The use of insulin injections in com-
prior to the initiation of treatment and pe- bination with oral medications is another
riodically thereafter. Premenopausal anovu- approach to achieve glycemic control. The
latory women with insulin resistance that addition of an intermediate-acting insulin
start TZD therapy should be informed of (NPH insulin or insulin lente) or long-acting
the possible resumption of ovulation due to insulin (insulin ultralente or insulin glargine)
their improved insulin sensitivity. Appropri- to SFU therapy is an effective option to obtain
ate methods of contraception should be dis- glycemic control. A common practice is the
cussed if needed (Avandiar Product Infor- addition of bedtime insulin to daytime SFU
mation, 2004; Actosr Product Information, therapy, this is referred to as “BIDS” therapy.
2003). The advantage of this combination is lower
blood glucose levels in the morning; how-
ever, there is a potential increase in nocturnal
COMBINATION THERAPY hypoglycemic reactions with BIDS therapy
(Riddle et al., 1989). The introduction of
Over time, the ability to maintain ade- insulin glargine (Lantusr ) offers bedtime
quate blood glucose control with monother- insulin therapy with less nocturnal hypo-
apy diminishes. When this occurs, an addi- glycemia (Yki-Jarvinen et al., 2000). Over
tional oral agent or insulin may be added to time, patients with type 2 diabetes may require
the patient’s regimen (Turner et al., 1999). multiple doses of different types of insulin,
When deciding what medication to add, the both rapid-acting and long-acting, a regi-
selection is influenced by the patient’s current men that more resembles a patient with type
therapy. The second medication or “add-on” 1 DM.
therapy is usually an agent with a different
physiologic effect. For example, SFU therapy
plus an alpha-glucosidase inhibitor is effec- ACCESSING MEDICATIONS
tive; however, the addition of metformin or
insulin to SFU therapy provides a greater re- Although there have been great advances
duction in blood glucose levels (Calle-Pascual in therapeutic options for type 1 and type 2
et al., 1995). In addition, when a TZD is diabetes, not all patients have had the oppor-
added to SFU therapy a significant reduc- tunity to benefit. Two barriers in accessing or
tion in blood glucose levels is achieved; how- obtaining medications are: (1) the large per-
ever, the patient may experience a significant centage of the population that lacks health
weight gain. This is also true when insulin insurance, and (2) the skyrocketing costs of
therapy is added to SFU therapy (Kipnes et al., prescription medications. There are several
2001). Metformin and insulin therapy effec- foundations and organizations that have re-
tively reduces blood glucose levels and has sources available to assist patients in obtain-
a lower incidence of weight gain than insulin ing prescription medications. These resources
TABLE 6.6. Patient Assistance Bohannon, N.J.V. (1999). Insulin delivery using pen de-
Program Resources vices: Simple-to-use tools may help young and old
alike. Postgrad Med 106:57–68.
www.phrma.org Buse, J.B., Tan, M.H., Prince, M.J., and Erickson, P.P.
www.rxassist.org (2004). The effects of oral anti-hyperglycemic med-
www.helpingpatients.org ication on serum lipid profiles in patients with
www.needymeds.com type 2 diabetes. Diabetes Obes Metab 6(2):133–
156.
Calle-Pascual, A.L., Garcia-Honduvilla, J., Martin-
are listed in Table 6.6. To access these pro- Alvarez, P.J., Damsbo, P., Marbury, T.C., Hatorp,
V., Clauson, P., Müller, P.G. (1995). Comparison be-
grams, paperwork and supporting financial tween acarbose, metformin, and insulin treatment in
documents may be required. A limited supply type 2 diabetic patients with secondary failure to sul-
(usually 3 months) of medications is usually fonylurea treatment. Diabetes Metab 21:256–260.
provided per application. Cefalu, W.T. (2004). Evolving strategies for insulin de-
livery and therapy. Drugs 64(11):1149–1161.
Damsbo, P., Marbury, T.C., Hatorp, V., Calle-Pascual,
A.L., Garcia-Honduvilla, J., Martin-Alvarez, P.J.,
CONCLUSION
Vars, E., Calle, J.R., Munguire, M.E., Maranes, J.P.
(1999). Flexible prandial glucose regulation with
The approach to managing type 1 and repaglinide in patients with type 2 diabetes. Dia-
type 2 DM varies greatly; however, the overall betes Res Clin Pract 45:31–39.
goal is to attain glucose homeostasis. Patients DeFronzo, R.A. (1999). Pharmacologic therapy for type 2
diabetes mellitus. Ann Intern Med 131:281–303.
with type 1 diabetes require exogenous insulin
Diabetes Control and Complications Trial Research
administration whereas, for those with type 2 Group. (1993). The effect of intensive treatment
diabetes oral medications and insulin are uti- of diabetes on the development and progression of
lized. There have been large accomplishments long-term complications in insulin-dependent dia-
in the area of diabetes treatments, as well as betes mellitus. N Eng J Med 329:977–986.
Feinglos, M.N., and Bethel, M.A. (1999). Oral agent ther-
exciting research is underway that will pro-
apy in the treatment of type 2 diabetes. Diabetes
vide knowledge and treatments to improve the Care 22(Suppl 3):C61–C64.
quality of care for patients with DM. Fonseca, V., Rosenstock, J., Patwardhan, R., Salzman,
A. (2000). Effect of metformin and rosiglitazone
combination therapy in patients with type 2 dia-
betes mellitus: A randomized controlled trial. JAMA
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Actor (pioglitazone) Product Information. (December, (2002). Repaglinide versus metformin in combina-
2003). Eli Lilly and Company: Indianapolis, IN. tion with bedtime NPH insulin in patients with type
Adis International Limited. (2004). Insulin inhalation NN 2 diabetes established on insulin/metformin combi-
1998. Drugs R D 5(1):46–49. nation therapy. Diabetes Care 25:1685–1690.
American Diabetes Association. (2004b). Continuous Grossman, L.D. (2002). New solutions for type 2 diabetes
subcutaneous insulin infusion (Position Statement). mellitus: The role of pioglitazone. Pharmacoeco-
Diabetes Care 27(Suppl 1):S110. nomics 20(Suppl 1):1–9.
American Diabetes Association. (2004a). Insulin ad- Hirsch, I.B. (1998). Intensive treatment of type 1 diabetes.
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Can Med Assoc J 12:141–146. zone hydrochloride in combination with sulfony-
Bell, D.S., and Ovalle, F. (2002). Long-term efficacy lurea therapy improves glycemic control in pa-
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Endocr Pract 8:271–275. placebo-controlled study. Am J Med 111: 10–17.
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2300. 2012.
McCormick, M., and Quinn, L. (2002). Treatment of type Turner, R.C., and Holman, R.R. (1995). Lessons from UK
2 diabetes mellitus: Pharmacologic intervention. J prospective diabetes study. Diabetes Res Clin Pract
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apy of type 2 diabetes mellitus. Ann Pharmacother tients with type 2 diabetes (UKPDS 33). Lancet
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(1999). Glycemic control with diet, sulfonylurea, ing insulin combination therapy in type 2 diabetes.
metformin, or insulin in patients with type 2 diabetes Diabetes Care 23:1130–1136.
7
Nutrition for Individuals with Diabetes

Catherine M. Robinson and Judith Beck
St. Elizabeth of Hungary Clinic, Tucson, Arizona
Significant advances in the understanding of peripheral neuropathy, and blindness. There is

the pathophysiologies of type 1 and type enough evidence that improved glucose con-
2 diabetes mellitus (DM) have been made in trol, cholesterol profile, and blood pressure
the past century, and particularly in the past decreases the morbidity and mortality associ-
30 years. About 10% of people with diabetes ated with diabetes. In addition, the Diabetes
have type 1 DM, and about 90% have type 2 Prevention Program showed that individuals
DM. These numbers include a small percent- with impaired glucose tolerance who exer-
age of individuals with latent autoimmune di- cised 30 minutes five times per week, who
abetes of adulthood, which has some features decreased their dietary fat intake to less than
of both type 1 and type 2 DM. 25% of their total caloric intake, and who
In type 1 DM, there is a deficiency of in- lost 7% of their initial body weight decreased
sulin, and the focus of treatment involves use their risk of developing type 2 DM by 58%
of insulin to control an individual’s blood glu- compared to study participants who were in
cose. In type 2 DM, which can be caused by a the placebo group. This result was better than
number of different disorders, patients exhibit study participants who were treated with met-
insulin resistance, altered insulin secretion, formin, who had a 31% decreased risk of de-
and elevated blood glucose. Prior to devel- veloping type 2 DM.
oping type 2 DM, an individual has impaired In the last 30 years, the prevalence of
glucose tolerance (also called “prediabetes”), type 2 DM has tripled. This is due in large
with mildly elevated blood glucose levels and part to a dramatic increase in obesity. Obese
elevated insulin levels. It has been estimated individuals (those with a Body Mass Index
that about 16 million Americans have predia- or “BMI” greater than 30) are at a fivefold
betes, and somewhere between 1% and 10% greater risk to develop type 2 DM than those
of them will go on to develop diabetes every with a BMI less than 25. Since approximately
year. 80% of people with type 2 DM are overweight,
People with diabetes have an increased weight loss is a crucial component of treat-
risk of lipid abnormalities, atherosclero- ment. Inherent challenges exist in setting up
sis, heart attacks, strokes, kidney disease, a diet plan that allows an individual to be
79
80 NUTRITION
TABLE 7.1. Determining Body Mass Index How to use this chart:
1 Find height (in feet and inches) in the left column
2 Look across the row to find weight (in pounds)
3 Find the number at the top of the column to determine the BMI
BMI 19 20 21 22 23 24 25 26 27 28 29 30 35 40
Height
(ft/inches) Weight (lbs)
4 10 91 96 100 105 110 115 119 124 129 134 138 143 167 191
4 11 94 99 104 109 114 119 124 128 133 138 143 148 173 198
5 97 102 107 112 118 123 128 133 138 143 148 153 179 204
5 1 100 106 111 116 122 127 132 137 143 148 153 158 185 211
5 2 104 109 115 120 126 131 136 142 147 153 158 164 191 218
5 3 107 113 118 124 130 135 141 146 152 158 163 169 197 225
5 4 110 116 122 128 134 140 145 151 157 163 169 174 204 232
5 5 114 120 126 132 138 144 150 156 162 168 174 180 210 240
5 6 118 124 130 136 142 148 155 161 167 173 179 186 216 247
5 7 121 127 134 140 146 153 159 166 172 178 185 191 223 255
5 8 125 131 138 144 151 158 164 171 177 184 190 197 230 262
5 9 128 135 142 149 155 162 169 176 182 189 196 203 236 270
5 10 132 139 146 153 160 167 174 181 188 195 202 207 243 278
5 11 136 143 150 157 165 172 179 186 193 200 208 215 250 286
6 140 147 154 162 169 177 184 191 199 206 213 221 258 294
6 1 144 151 159 166 174 182 189 197 204 212 219 227 265 302
6 2 148 155 163 171 179 186 194 202 210 218 225 233 272 311
6 3 152 160 168 176 184 192 200 208 216 224 232 240 279 319
6 4 156 164 172 180 189 197 205 213 221 230 238 246 287 328
BMI = weight/height2 .
Source: From American Association of Diabetes Educators (2003). Core Curriculum for Diabetes Education, Diabetes Management
Therapies, Chicago, IL.
content with food choices, physically com- Optimal weight is easily defined by using
fortable (e.g., not hungry all the time), and the BMI. This is calculated by the formula:
which can be maintained over time.
The objective of this chapter is to dis- BMI = [weight (lbs)/height (inches)2 ] × 703.
cuss principles of good nutrition and the If you are using the metric system, the formula
importance of exercise in the prevention or is:
control of diabetes.
Using Medical Nutrition Therapy (some- BMI = weight (kg)/height (m)2 .
times referred to as MNT), maintaining an op- BMI tables are available to simplify
timal weight, and exercising daily are crucial identifying an individual’s BMI
in the treatment of both type 1 and type 2
DM, and in individuals with impaired glucose A BMI less than 25 is currently de-
tolerance. fined as normal, 25–30 is defined as over-
Medical Nutrition Therapy is the use of weight, and greater than 30 is defined as obese.
specific nutrition interventions to treat an ill- As greater numbers of Americans, both chil-
ness or condition. It involves the provision dren and adults, become obese, we are see-
of individualized nutrition care including as- ing increasing numbers of people with type 2
sessment, education, goal-setting for lifestyle diabetes—even in children.
change, and follow-up evaluation (American Different people have different philoso-
Association of Diabetes Educators, 2003). phies about food. “Shall I eat to live? Or
NUTRITION 81
shall I live to eat?” Whether or not dia- TABLE 7.2. Historical Perspective of
betes is present, the individual subconsciously Nutrition Recommendations
chooses to follow one of these paths. Food
Distribution of Kcalories (%)
and eating are essential for existence but must
be balanced against energy expenditure if one Year Carbohydrate Protein Fat
is to maintain a healthy weight. In Western
Before 1921 Starvation diets
civilizations, many people have chosen, to 1921 20 10 70
their detriment, the second option—“I live to 1950 40 20 40
eat.” To further complicate matters, modern 1971 45 20 35
lifestyles do not require exercise on a regular 1986 Up to 60 12–20 <30
1994 a 10–20 a,b
basis. As a result, there is a growing epidemic
of obesity and diabetes, and an associated in- a
Amount is based on nutritional assessment and treatment goals.
b
creased morbidity and mortality for individu- Less than 10% of kcalories from saturated fats.
Source: American Diabetes Association (1997).
als and an increased economic burden on the
health care system.
day. Treatment strategies have changed and
People from different cultures and eth-
ideally each patient should receive an individ-
nic backgrounds frequently abandon their tra-
ual meal plan based on height/weight, BMI,
ditional diets in favor of the Western diet.
laboratory readings, current nutritional intake,
For example, the Pima Indians of Arizona
food preferences, lifestyle, and pertinent med-
incorporated the Western diet and lifestyle
ications.
with disastrous consequences (Whitney and
In order to improve diabetes care, the
Rolfes, 1996). Until about 1930, their diet in-
ADA has developed evidence-based nutri-
cluded fish, venison, fruit, legumes, cactus,
tion recommendations that are implemented
and seeds. A scarcity of native foods led to
in MNT (American Diabetes Association,
their replacement with white flour products,
2002a&b). The goals of MNT may be sum-
sugar, animal fats (lard and butter), and con-
marized as follows:
venience foods. Traditional exercises (hunting
and working in the fields) were replaced with 1. To achieve and maintain:
more sedentary activities. The Pima Indians r Normoglycemia,
now have the highest per capita rate of dia- r Lipid profiles within normal limits,
betes in the world. and
The challenge for health care profes- r Blood pressure levels within normal
sionals is to reverse the trend toward obesity limits.
among our diverse population. Tools for re- 2. To prevent and treat complications of
versing this trend involve Medical Nutrition diabetes.
Therapy (MNT), weight loss (if indicated) to 3. To improve health with appropriate food
choices and physical activity.
achieve ideal body weight, and regular daily
4. To address the needs of individuals with
exercise.
sensitivity to cultural/ethnic preferences.
Medical Nutrition Therapy for diabetes
has undergone dramatic change over the past Medical Nutrition Therapy has been
century (see Table 7.2). Prior to the intro- shown to improve glycemic control, as
duction of insulin therapy in 1921, people demonstrated by improved hemoglobin A1 c.
with diabetes were subjected to starvation Table 7.3 shows the positive effect on
diets. hemoglobin A1 c (HbA1 c) levels of patients
Before 1994, many patients received who received MNT.
generic American Diabetes Association Studies demonstrate that a registered di-
(ADA) meal plans based upon certain kcalorie etitian (RD) is best qualified to provide MNT.
levels ranging from 1,500 to 2,400 kcalories/ Although an RD is the ideal provider for
82 NUTRITION
TABLE 7.3. Effect of MNT on HbA1 c whole grain products, fruits, vegetables, and
(Franz et al., 1995; Kulkarni et al., 1998; low-fat milk products.
UKPDS Group, 1990)
Type 1 newly Type 2 newly Type 2 of 4 years Fiber
diagnosed diagnosed duration
1% decrease 2% decrease 1% decrease Fiber intake by people with diabetes is
HbA1 c HbA1 c HbA1 c encouraged in the same amounts as recom-
mended for the general population. The In-
stitute of Medicine (IOM) Dietary Recom-
nutrition counseling, it is essential that all mended Intakes (DRI) for daily fiber intake
health care professionals understand and sup- is 25 g for females less than 50 years old, 21 g
port the vital role of MNT in the treatment of for older females, 38 g for males less than
the patient with diabetes. 50 years, and 30 g for older males. Fiber re-
quirements also decrease with reduced food
consumption.
Information regarding the fiber content
CURRENT ADA
of various foods may be found in reference
RECOMMENDATIONS FOR materials (Bowes et al., 1998) and on food
MACRONUTRIENTS (Whitney labels. Individuals who consume adequate
and Rolfes, 1996) quantities of fruit, vegetables, and whole
grains on a daily basis can easily incorporate
Macronutrients may be defined as those sufficient fiber into their daily menus.
elements required in the greatest amounts for
normal physiologic body processes. These in-
Nutritive Sweeteners
clude carbohydrate, fat, protein, and water.
In contrast, micronutrients are those elements Nutritive sweeteners (sucrose, fructose,
required in small amounts for normal body sugar alcohols, and nonnutritive sweeten-
processes and include vitamins, minerals, and ers) have been the subject of debate in the
trace elements. past few years. The current recommendations
follow.
Carbohydrates
Sucrose (Table Sugar)
The term carbohydrates is derived from
carbo (carbon) and hydrate (with water). Car- In the past, it was thought that sugar (e.g.,
bohydrates provide the energy (fuel) required jelly, candy) was digested and absorbed more
to perform our daily activities. The brain rapidly than starch (e.g., bread, potatoes). Sci-
needs glucose to function optimally, and mus- entific evidence has disproved the widespread
cles need glycogen. Under starvation condi- belief that sucrose causes rapid and dramatic
tions, the brain can utilize ketone bodies that blood glucose elevations. Therefore, sugar-
are breakdown products of fatty acids, but ke- containing foods may be incorporated into the
tone bodies are a less efficient energy source. meal plan, but may not be taken in addition to
Under these circumstances, individuals of- the total carbohydrate allowance! Preference
ten complain of feeling groggy and having should be given to carbohydrates that pro-
headaches. vide essential nutrients such as whole grain
Therefore, carbohydrates are an essential bread and a variety of vegetables. In general,
component of a well-balanced diet in all in- since jelly and candy provide empty kcalories
dividuals, whether or not diabetes is present. only, they should not be eaten on a regular
Recommended carbohydrate sources include: basis.
NUTRITION 83
Fructose they are lower in kcalories than sucrose, fruc-

tose, or glucose. They have 2 kcal/g instead
Fructose, the sugar found in fruits, is me- of 4 kcal/g found in carbohydrates. Therefore,
tabolized by a different pathway than starch or a product labeled sugar free does not neces-
sucrose and is absorbed more slowly. There- sarily mean kcalorie free. Also, certain sugar
fore, it does not cause a rapid increase in blood alcohols can cause diarrhea if taken in quan-
glucose levels. It is a potentially useful sweet- tities greater than 10 g/day.
ener for individuals with diabetes. However, if
consumed in large amounts, fructose can be
Nonnutritive Sweeteners
associated with dyslipidemia.
Studies have demonstrated that in the Certain low-kcalorie sweeteners have
U.S. population, approximately 33% of di- been approved as safe for consumption by the
etary fructose is obtained from natural sources FDA. Included in this category are:
including fruits and vegetables. The remain-
ing 67% comes from food and beverages in r Saccharin (e.g., Sweet and Low),
r Aspartame (e.g., Equal or Nutrasweet),
which fructose is frequently listed on the food
r Acesulfame K (e.g., Sweet One),
label as “high fructose corn syrup.” The lat- r
ter contributes empty kcalories that exacer- Sucralose (e.g., Splenda).
bate the obesity epidemic and dyslipidemia. These sweeteners provide an acceptable
Empty kcalories do not provide essential alternative to sugar if consumed in moder-
nutrients; they only provide energy. Individ- ation. The FDA has defined an Acceptable
ual daily kcaloric requirements are not as large Daily Intake, which is the amount that may be
as we would like to assume. One, therefore, taken on a daily basis without risk to overall
must concentrate his/her essential nutrient in- health (Powers, 1999). Although these sweet-
take in the daily allotted kcalories. In order to eners may be used in moderation, individuals
consume adequate essential nutrients, an indi- should be encouraged to take food and bever-
vidual needs to use his/her kcaloric allotment ages in their natural form without added sugar
judiciously. Intake of foods containing empty or sweeteners.
kcalories should therefore be minimized.
Foods containing empty kcalories have the
What is a “Net Carb?”
predominant function of making people
overweight. “Net carbs” is a term seen on food la-
The practical approach is to encourage bels. Since the FDA prohibits the use of un-
moderate consumption of fruit, while discour- defined nutrient claims, manufacturers should
aging foods and beverages with added fruc- not use terms such as “low carb” and have in-
tose. stead started using “Net carb.” This term is
derived by a manufacturer subtracting sugar
Sugar Alcohols (Polyols) alcohols, fiber, and any other carbohydrates
that minimally impact blood glucose levels
These compounds are closely related from the food’s carbohydrate content. The
to carbohydrates. Hydrogenated starch hy- definition of “Net carb” is imprecise, how-
drolysate, sorbitol, mannitol are included in ever, because there is no standard definition
this category. They are listed on the food labels for “minimal impact” on blood glucose lev-
of sugar-free products and frequently have the els. In addition, the actual impact on blood
“-ol” suffix (e.g., maltitol). Used as sweeten- glucose level may well not have been proven
ers, they produce a lower glycemic response (Bonnie Liebman, MS. Director of Nutrition,
than sucrose or glucose. Since they are only Nutrition Action Health Letter, March 2004,
partially absorbed from the small intestine, pp. 8–9).
84 NUTRITION
The Glycemic Index levels are termed low-GI foods. The cate-
gories (and values) used to define the different
This concept was first developed in 1981 glycemic indices are high (70 or more), inter-
by Dr. David Jenkins at the University of mediate (56 to 69) and low (55 or less).
Toronto in Canada. In their belief that all car- It is reasonable for individuals with di-
bohydrates are not equal, Dr. Jenkins and his abetes to substitute some low-GI foods for
team tested the effect of many carbohydrate high-GI foods in their daily menus. The most
foods on blood glucose levels (Brand-Miller practical way to use the glycemic index is
et al., 2003). to encourage use of low-GI foods within the
Studies in the United States, Europe, prescribed meal plan. For instance, one could
Canada, and Australia have demonstrated substitute whole grain, pumpernickel, or sour-
that the glycemic index (GI) may be a dough bread for white bread made from en-
valuable tool in the nutrition therapy of the riched wheat flour. Another example would
individual with diabetes. Since low-GI foods be substituting All Bran cereal or Oatmeal for
cause a less pronounced rise in blood sugar, a higher glycemic cereal such as Corn Flakes.
they may be less insulinogenic than high-GI For more information about glycemic indices
foods. This effect may decrease some of of foods that have been tested in this way,
the stress placed on the pancreas to produce please refer to The Glucose Revolution Life
insulin, and thereby decrease the rate at Plan by Brand-Miller et al. (2001).
which individuals with insulin resistance Perhaps even more helpful than the
progress to type 2 DM. Since insulin plays a glycemic index is the concept of glycemic
role in storing fat, lower postprandial insulin load, which incorporates both the quantity of
levels may help decrease the tendency toward carbohydrate in a meal as well as its glycemic
weight gain and subsequent development index. The glycemic load may be calculated
of further insulin resistance. In addition, by multiplying the glycemic index percent-
lower GI foods seem to result in greater age by grams of carbohydrate. Care must
satiety than higher GI foods. Consumption be taken when considering these concepts.
of lower GI foods may, therefore, decrease A high glycemic index does not necessar-
the urge to overeat. As of January 2005, the ily equate to a high glycemic load. If we
use of the glycemic index is recommended consider a low-GI food, such as chick peas,
by the ADA as well as The Harvard School one notes that a serving size of chick peas
of Public Health and Boston Children’s (150 g or 1 cup) contains 30 g of carbohy-
Hospital. drate and has a glycemic index of 28. The
The glycemic index is the classification glycemic load for 1 cup of chick peas is, there-
of foods based on their effect upon blood glu- fore, 30 × 0.28 = 8.4. Similarly, a high-GI
cose levels. Glucose, having a strong impact food such as potatoes has a standard serv-
on these levels, is used as a standard and has ing size of 150 g (1 cup) and contains 30 g
the value set at 100 on this scale. Other foods of carbohydrates. It has a glycemic index of
are then classified on a scale of 0–100 or more, 85, and the glycemic load for a serving of
depending on their effect on blood glucose potatoes is 30 × 0.85 or 25.5, which is quite
levels. high. The complication in these concepts oc-
Using standardized procedures, hun- curs with foods such as popcorn, which has
dreds of foods have been tested and classified. a high glycemic index, but does not contain
Carbohydrates that are broken down rapidly many grams of carbohydrates. Popcorn has a
and have an immediate impact upon blood glycemic index of 72, and an individual might
glucose are termed high-GI foods, whereas therefore think popcorn should be avoided.
those foods that are gradually broken down That is not the case, however, since a standard
and do not immediately impact blood glucose serving size of two cups contains only 11 g of
NUTRITION 85
carbohydrate. Therefore, the glycemic load of of body weight. This means that a typical
a standard serving of popcorn is 7.92, which is 70 kg individual would consume approxi-
quite low. One can readily see, then, that even mately 70 g of protein per day, contrasted with
though popcorn has a high glycemic index, an RDA of 56 g. In individuals with poorly
a standard serving has a low glycemic load. controlled diabetes, the protein requirement
When considering use of the glycemic index, may be slightly higher than those with opti-
one should also make a point of calculating mal diabetic control. In patients with impaired
the glycemic load. renal function, the protein requirement is gen-
Another consideration is that milk and erally reduced to try to prevent further loss of
milk products (yogurt, ice cream) have a low renal function.
glycemic index when consumed without ad- A well-balanced meal plan with appro-
ditional sugar. They are, however, fairly in- priate numbers of servings from each food
sulinogenic; the significance of this property group will ensure optimum protein intake.
in an individual with prediabetes is currently Portion size is the key to attaining and main-
unclear. taining an optimum daily protein intake.
Protein Type of Protein
People frequently associate protein with Certain types of poultry and meats are
meat and muscle strength, and overestimate recommended over others because of their
the quantity required in an individual’s diet. content of total fat and saturated fat. Table 7.4
Not only is protein essential for muscle, it is illustrates preferred and not preferred protein
required for structural integrity and function sources.
of all cells. In addition to meat, there are many
sources of protein (see Table 7.4). Fat
Most adults eat considerably more than
the Recommended Daily Allowance (RDA) Controversy and confusion surround
for protein. While the usual daily protein in- the issue of dietary fat intake. It is well
take is about 1.0 g protein per kg of body documented that in individuals with diabetes,
weight, the RDA for protein is about 0.8 g/kg there is a two to four times greater risk of
TABLE 7.4. Preferred and Not Preferred Protein Sources

Preferred Not Preferred
Poultry Skinless chicken or turkey breast Duck, goose

Fish All types; the best choices have more omega-3 –
fatty acids: Salmon, tuna, mackerel and
sardines
Meat Beef: eye of round, very lean ground beef. Pork: Prime rib, spare ribs, sausages, bologna
tenderloin, very lean ground pork
Cheese Low fat cottage cheese Part skim mozzarella All regular cheese, including cheddar.
Soft cheese, e.g., Brie
Eggs Egg white, egg substitute Egg yolks
Peanut butter In 100% natural form Those processed with partially
hydrogenated oil; those containing
high fructose corn syrup
Soy products, tofu All types are good protein sources. Check the –
food labels for carbohydrate content.
86 NUTRITION
TABLE 7.5. Effects of Various Types of Fat on Lipid Profile

High-density Low-density
Total cholesterol lipoprotein lipoprotein Triglyceride
Monounsaturated fats ↓ ↑ ↓ ↓
N-6 (omega-6) polyunsaturated fats ? ? ? –
N-3 (omega-3) polyunsaturated fats ? – ↑ ↓
Saturated fats ↑ – ↑ –
Transunsaturated fats ↑ ↓ ↑ –
developing Coronary Artery Disease (CAD) occur in fried foods, margarine, and spreads.
than that seen in the general population. These Intake of trans fats should be minimized.
individuals have a risk profile comparable to Table 7.5 (American Diabetes Associa-
that seen in individuals who have already sus- tion, 2002a&b) summarizes the effect of dif-
tained a myocardial infarction. Because dys- ferent fat sources upon lipid profiles.
lipidemia is a risk for CAD, in people with dia- As you can see, not all fats are equal!
betes the recommendations for optimal lipid The types of fats that predominate in different
profiles are more stringent than in the general foods are listed in Table 7.6 (Bowes et al.,
population. 1998; Brand-Miller et al., 2001).
The lipid profile comprises total choles- An individual’s total fat intake should not
terol, high-density lipoprotein (HDL or “good exceed 30% of total kcalories. Strategies to
cholesterol”), low-density lipoprotein (LDL decrease fat intake include:
or “bad cholesterol”), and triglycerides (TG). r choosing lean cuts of meat,
High-density lipoproteins carry fatty acids r using low-fat dairy products,
from the arteries to the liver, and appear to r using low-fat soft margarines and
protect the arteries and promote plaque re- spreads, and
moval. Low-density lipoproteins promote the r using less fat in food preparation.
accumulation of plaque in arteries.
There are different kinds of fats: Water
monounsaturated, polyunsaturated, saturated
fats, and transunsaturated fats. See Table 7.6 Water is an essential nutrient critical for
for examples of fats in these different cate- life, involved in all body processes (Whitney
gories. and Rolfes, 1996). Water comprises between
Ingestion of monounsaturated and 50% and 75% of the body weight. Without wa-
polyunsaturated fats (especially omega-3 ter, an individual can survive only for a few
polyunsaturated fats) tend to improve the days. Water needs vary depending upon age,
lipid profile. Since saturated fat has a major climate, and activity. Additional water will be
unfavorable impact on LDL levels, the required in hot, dry weather conditions, or
primary goals of MNT are to reduce saturated during intense physical exertion. Intake rec-
fat and modify cholesterol intake (cholesterol ommendations are also based upon energy
is only found in animal products, including expenditure, e.g., an individual who expends
meat, cheese, and egg yolks). 2,000 kcal per day needs about 2–3 liters
Transunsaturated fats (or “trans fats”) (seven to eleven 8-oz cups) of water each day.
also unfavorably impact the lipid profile, rais- When an individual has a water deficit, the first
ing the LDL and lowering the HDL levels. symptom usually noted is thirst. A recent re-
Trans fats occur naturally in meats and dairy port from the Institute of Medicine noted that
products. They are also formed during the hy- the vast majority of healthy people adequately
drogenation of vegetable oils, and therefore meet their daily hydration requirements
NUTRITION 87
TABLE 7.6. Types of Fats that Predominate in Different Foods

Monounsaturated Polyunsaturated Polyunsaturated Trans
Source N-6 N-3/Omega 3 Saturated unsaturated
Fats/oils Olive oil, canola oil, Corn oil, safflower Flaxseed oil, Lard or Hard/stick
peanut oil oil, sunflower oil, canola oil shortening, margarines,
soybean oil butter, partially
cream, sour hydrogenated
cream, vegetable oils
cream
cheese
Other foods Peanuts, almonds, Walnuts, margarine, Flaxseed, salmon, Fatty meat, Processed baked
cashews, peanut mayonnaise mackerel, tuna, coconut, goods, deep
butter, avocado, rainbow trout, bacon, fried foods,
olives sardines chitterlings, crackers/snacks
sausages containing
partially
hydrogenated
oil
by letting thirst be their guide (Institute of Micronutrient recommendations are similar

Medicine, 2004). A good rule of thumb is to for individuals with or without diabetes
drink enough water to keep one’s urine clear. (American Diabetes Association, 2002a&b).
This is particularly true in dry environments. However, deficiencies may occur in those
The best source of water is water itself, with uncontrolled diabetes due to altered
but foods such as fruits and vegetables con- metabolic processes.
tribute a significant amount of fluid to the The Institute of Medicine Food and
daily intake. Because caffeine and alcohol Nutrition Board has established four estimates
cause fluid loss, beverages not recommended of Dietary Reference Intake (DRI) to deter-
as fluid sources include tea, coffee, soda, and mine the amount of micronutrients required
alcoholic beverages. by an individual on a daily basis (Institute of
All individuals, including people with di- Medicine, 2002):
abetes should be encouraged to drink adequate r Estimated average requirement (EAR).
amounts of water every day to prevent de- r Recommended dietary allowance (RDA).
hydration. Elderly people, who have reduced r Adequate intake (AI).
thirst sensation, are at increased risk of dehy- r Tolerable upper limit (UL).
dration and should especially be encouraged For our purposes, the RDA is most help-
to drink fluids in adequate quantities. ful, and is defined as the amount of a micronu-
In keeping with achieving the goal of trient required to meet the needs of 97–98% of
weight loss, overweight individuals may find healthy individuals. There is currently no ev-
that the habit of drinking one or two glasses idence to support the view that consumption
of water prior to a meal promotes a feeling of vitamin and mineral supplements is benefi-
of satiety and may help to decrease the con- cial, unless there is an underlying micronutri-
sumption of excess kcalories. ent deficiency, with the following exceptions:
r Folate supplements must be taken before
Micronutrients and during pregnancy to prevent birth defects in
the infant.
Consumption of adequate vitamins, r Calcium and Vitamin D supplements are
minerals, and trace elements is crucial for recommended for older adults in order to prevent
the health and well-being of all individuals. bone disease.
88 NUTRITION
Having said that, we acknowledge that in Sodium

this fast-paced age, many people do not con-
sume a well-balanced diet. This is particularly Studies have shown that limiting sodium
true for the elderly, for pregnant or lactating intake (total 2,400 mg/day) and decreased
women, for strict vegetarians, and for those body weight (in obese individuals) both
following very low-kcalorie regimens. This improve blood pressure levels, though few
also is true for individuals following very low studies have been performed specifically upon
carb diets. In these cases, it is prudent to sug- persons with diabetes. To reduce sodium in-
gest a daily multivitamin supplement, which take, one should:
provides no more and no less than 100% of r avoid processed, canned, or preserved
the RDA. Generic pharmacy brands are quite foods,
acceptable. r use minimal salt in food preparation,
The use of megadoses of vitamins and r use herbs, spices, lemon juice, lime
minerals must be strongly discouraged. Indi- juice, or vinegar (instead of salt) to add flavor,
viduals should be warned about the potential and
r use minimal salad dressings, salted chips,
toxic effects of megadosing.
nuts, bacon bits.
Herbal Preparations The recommended sodium intake is

2,400 mg/day. For reference purposes, one
Studies on certain herbal preparations, teaspoon of table salt is equal to 2,300 mg.
such as ginseng, have shown positive effects
on glycemia in the short term. However, there
is no evidence of long-term benefit with use ALCOHOL (ETHYL ALCOHOL
of herbal supplements. More importantly in OR ETHANOL)
1994, The Dietary Supplement Health and
Education Act (DSHEA) mandated that di- Alcohol has been consumed by mankind
etary supplements would be regulated like for over 5,000 years (Whitney and Rolfes,
foods instead of drugs and are not required 1996). Moderation is the key!
to be tested unless proved to be unsafe. The For individuals with diabetes, there are
FDA can remove them if there is proof that certain points to remember:
they are unsafe but does not otherwise mon- r Alcohol blocks glucose production by the
itor or regulate them prior to marketing, as
liver and may induce hypoglycemia
it does with the prescription drugs. Conse- r Alcohol may adversely affect the action
quently, the concentration of active ingredi-
of medications
ents can vary greatly from brand to brand. r Excess alcohol use may cause malabsorp-
Because processing methods are not stan- tion, altered nutrient metabolism, and malnutrition
dardized, unwanted and potentially dangerous
contaminants can sometimes be found in these r Excess alcohol use may cause hyperten-
products. Misidentification of the plants can sion
occur, some herbal products can have unex- r Alcohol may be used in moderation with
pected side effects. For instance, ginseng us- doctor’s permission
r Alcohol use in moderation may induce
age may be associated with bruising. Lastly,
interactions between herbal and other medi- improved insulin sensitivity
r Alcohol use in moderation may reduce
cations can be potentially dangerous. There-
the risk of CAD
fore, health care providers need to carefully
ask their patients appropriate questions about Moderate alcohol consumption is de-
all their medications and supplements. fined as one drink per day for an adult woman
NUTRITION 89
and two drinks per day for an adult man. One restriction. The initial weight loss is largely at-
drink per day is not the same as seven drinks tributed to fluid losses associated with glyco-
on the weekend. The definition of one drink gen storage depletion. Another hypothesis is
is: 12 oz beer or 5 oz glass wine or 11/2 oz that weight loss is related to lower insulin
spirits. levels secondary to decreased carbohydrate
The response of a person with dia- intake.
betes to alcohol is unpredictable; alcohol con- After glycogen stores in the liver and
sumption can result in hypoglycemia, normo- muscles are depleted, an individual develops
glycemia, or hyperglycemia. Because of the ketosis and consequent loss of appetite. Pro-
hypoglycemia risk, if alcohol is to be ingested, tein intake may also help with the increased
it should accompany a meal and the individual satiety that is reported on this diet.
should consider checking blood glucose after Because low-carbohydrate, high-protein
the meal. diets can increase work for the kidneys, de-
One should remember that, like fat, al- creased renal function, which is a common
cohol has a high kcaloric content. One gram condition in people with diabetes, is a con-
of alcohol provides 7 kcal compared to 1 g of traindication to this type of diet.
fat, which provides 9 kcal. Kcalories from al- In a year-long study (Foster et al., 2003)
cohol do not provide nutrients, and therefore involving weight loss, which compared the
provide empty kcalories. use of a high protein/low-carbohydrate diet
with simply decreasing total daily kcalories,
Importance of Weight Loss individuals in the high protein/low carbohy-
drate diet group lost more weight initially.
We face an amazing paradox in the However, after one year there was little dif-
United States in that there is a high value ference between the amount of weight lost by
placed on appearing slender and fit, yet at the members of the two groups.
same time, increasing numbers of our popu- Since the introduction of low-
lation are overweight or obese. People turn to carbohydrate diets, there has been concern
diets popularized in the media for guidance— that the ketotic state generated could predis-
and what an array of different opinions they pose people with diabetes to diabetic keto-
receive! “Cut out all carbs!” “You may be ad- acidosis. Until these questions are answered,
dicted to sugar . . . even if you don’t know it!” such regimens must not be used by those
“Cut out all fat (a view that is now somewhat individuals with type 1 or Gestational Dia-
passé).” “Get into the Zone.” “Follow the New betes. Other concerns are that these regimens
Revolution.” Some of these diets have some are unbalanced and can lead to nutritional
basis in fact; others appear to include a fair bit deficiencies and constipation. Lastly, high-
of wishful thinking. Only the Mediterranean protein diets appear to be associated with
diet and the diet and lifestyle approach doc- increased calcium excretion and the concern
umented in The Okinawa Program (Wilcox about risk of developing osteopenia exists.
et al., 2001) have any long-term results to back While searching for sound dietary ad-
up their promises. vice, patients often question their physicians,
Use of low carbohydrate diets, less than who are commonly so busy with their prac-
60 g/day (Bravata et al., 2003) has become tices that they unfortunately have little time
popular in the nutrition management of in- to read and evaluate the latest trends in diet
dividuals with diabetes. Strict adherence to books, and therefore are unable to provide
these diets induces an initial rapid weight answers. To address this dilemma, we have
loss followed by sustained weight loss at a reviewed a number of the diet books cur-
faster rate than that seen with simple kcalorie rently available, and present our analysis in
90 NUTRITION
Table 7.7. Although an individual’s diet is gram, which needs to be incorporated into an
best tailored to that individual, we found individual’s long-term lifestyle. Lack of ex-
that some of the books may be quite help- ercise is a risk factor comparable to having
ful in providing general concepts and some an unfavorable cholesterol profile or smok-
facts consistent with what is currently under- ing cigarettes. It is crucial that everyone in-
stood to be nutritionally and physiologically corporates exercise into his or her daily rou-
correct. We also found that with any book tine. It does not have to be difficult, and can
that makes unrealistic claims, that unneces- be accomplished simply by taking a brisk 30-
sarily redefines nutritional terms (e.g., uses minute walk daily. But it must become a part
phrases like, “what I like to call ,” of an individual’s lifestyle.
etc), and/or is written in a bombastic tone, one One of the cruel facts of life is that mus-
is well advised to proceed with caution. This cle has a higher metabolic rate than fat. There-
also holds true for books containing many fore, when an individual’s ratio of muscle to
testimonials and little scientific documenta- fat decreases, so does the metabolic rate. If
tion. a person loses weight and loses more mus-
Understanding why an individual cle than fat, his/her metabolic rate will de-
overeats can be very helpful in assisting the crease. Resumption of eating his/her prior diet
necessary lifestyle changes. Does she eat will therefore boomerang his/her weight to a
because she is hungry? Or is she bored? higher level than it was prior to attempting
Anxious? Lonely? Is it a compulsion? Does weight loss.
he drink 3 or 4 beers daily because he is
thirsty and just likes the flavor? Or is he
self-medicating? Or is he an alcoholic? Does ESSENTIALS OF DIET
he eat way too fast and stuff himself before his PLANNING: ESTIMATING
body has a chance to tell him that he is full? KCALORIC NEEDS
Or does he just really like all those flavors
and simply cannot stop eating? Does she Factors to take into account for diet plan-
limit her kcalories all day, and by midevening ning include age, gender, BMI, family history,
find herself so famished that she snarfs medications, physical activity, laboratory pro-
down everything in sight? The reasons an file, current nutritional intake, and readiness
individual overeats are as multifactorial and to change.
varied as the individual. Understanding an Kcaloric needs for weight maintenance
individual’s relationship with food is crucial can be roughly estimated using Table 7.8.
in helping him or her to successfully make Since 1 lb of body fat is equal to
long-term changes in his or her approach 3,500 kcal (Whitney and Rolfes, 1996), over-
to food. Psychologic counseling would best weight or obese individuals who require
address these self-destructive behaviors. A kcalorie reduction typically need to decrease
number of diet/self-help books also address total kcalories by 250–500 per day. For ex-
these issues, for instance, Dr. Kushner’s ample, an obese individual who is 62 inches
Personality Type Diet (Kushner and Kushner, (5 2 ) tall and weighs 190 lb has a BMI of
2003) and Dr. Phil’s Ultimate Weight Loss 35. To maintain this weight, the individual is
Solution (McGraw, 2003). very likely eating 1,900 kcal/day (190 lbs ×
10 kcal/lb = 1,900 kcal). To lose one half to
Exercise one pound per week, this person needs to re-
duce the kcaloric intake by 250–500 kcal/day,
No weight loss/weight maintenance pro- and will be recommended a kcaloric range of
gram is complete without an exercise pro- 1,400–1,650 kcalories/day.
TABLE 7.7. Comparison of Popular Diets
Suitable for Overall assessment for
Diet Basic premise Strengths Weaknesses long-term use? people with diabetes
The Carbohydrate Postulates that eating most of one’s None are apparent. Not a balanced diet. Does not No. Not a balanced diet. Not
Addicts Diet starchy carbohydrates at one distinguish between the different appropriate for people with
meal lasting less than 1 hour kinds of carbohydrates or fats in diabetes.
keeps insulin levels low and one’s diet.
promotes weight loss. With this
diet, one eats a variant of the
formula: 1 or 2 “complementary
meals” and 1 “reward meal” per
day. No snacks are allowed. A
“complementary meal” has 3–4
oz of meat, fish or fowl or 2 oz of
cheese, and 2 cups of vegetables
or salad. A “reward meal” is
“whatever you desire, in
whatever quantity you wish,” but
one must complete that meal in 1
NUTRITION
hour.
Dr. Atkins’ New Postulates that a diet very low in Rapid initial weight loss Induction phase can be boring. No. Unless one Not appropriate for people with
Diet Revolution carbohydrates and high in may keep people People on this diet often do not supplements fiber diabetes. Absolutely
protein and fats causes weight motivated. feel good, as the brain prefers intake, this diet will contraindicated in individuals
loss (mostly fat). Four phases glucose rather than ketones for cause constipation. with diabetes where renal
involved: fuel. On this diet, normal Because of the disease is present.
individuals will have a mild metabolic acidosis,
(1) Induction (most severe metabolic acidosis, which will potential for
carbohydrate restriction) affect calcium excretion. One osteoporosis exists.
(2) Ongoing weight loss (less cannot eat enough calcium to Unless one exercises,
restricted carb intake) meet the RDA (without there will be muscle
(3) Premaintenance (more supplementation) in the loss along with fat
liberalized carb intake) induction phase. People with loss and if one
(4) Maintenance (maximally diabetes who have renal disease resumes eating as
liberalized carb intake, as long as are at risk for diabetic before, one will have
you do not gain weight) ketoacidosis (DKA). The diet is
contraindicated in anyone with
renal disease. One cannot
91
(continued)
92
TABLE 7.7. (Continued )

ingest adequate micronutrients on subsequent

the induction phase without weight gain to a
supplementation. The diet does higher level than
not differentiate between the original baseline.
different kinds of fats. Long-term
Homocysteine is a byproduct of effects unknown.
protein metabolism and is
implicated in CAD. Because of
the high protein intake,
homocysteine levels may be
elevated with this diet.
Eating Well for Eat only foods that are shown to be Recommendations appear Yes. It appears to He recommends a balanced
Optimum Health healthy. Exercise to maintain lean to be balanced and be a reasonable, approach, and supplies factual
body mass. Recommendations based on fact. balanced information. The book appears
include low-GI carbohydrates, approach, to be an excellent resource and
appropriate protein intake, although no is easy to read. The
primarily monounsaturated, long-term studies recommendations appear
NUTRITION
omega-3 and some omega-6 are yet available. well-grounded.

PUFAs, and lots of fruits and
vegetables. Avoid high glycemic
index carbs, and saturated and
trans fats.
Enter the Zone Eicosanoids regulate everything He recommends aerobic While he presents a lot of good Questionable. The Long-term effects are unknown.
important in your body. Eating a exercise, 6 hours/week. information, there appears to be ratios of carb, The diet would be difficult for
strict ratio of carbs to proteins can He recommends low-GI some problematic statements such protein, and fat most people to follow. Without
promote formation of the “good” carbohydrates and as when he calls arachidonic acid do not follow more long-term data, we
eicosanoids, which promotes monounsaturated fats, a “villain fat” that you should not current cannot recommend this diet.
health. Losing weight is not and avoiding trans and eat because it is a “chemical recommended
achieved by cutting kcalories, it is saturated fats. building block for all bad ADA dietary
achieved by being “In The Zone,” eicosanoids.” In fact, arachidonic guidelines.
eating a strict ratio of 40% carbs, acid is a “building block” for all
30% protein, and 30% fat. the eicosanoids that he mentions.
This makes one question some of
his other conclusions.
The New Glucose This book discusses research that Gives a good discussion This book only provides information Yes—in as much as Carbohydrates are an important
Revolution has been done on carbohydrates about the differences in about carbohydrates—it does not one uses it to part of an individual’s diet.
that shows that some are digested carbohydrates. discuss protein intake or the address his/her This book is helpful to better
quickly (high glycemic index or different types of fat. Also, the carbohydrate understand the carbohydrate
“GI”) and some are digested concept of glycemic LOAD is intake portion of one’s diet.
slowly (low GI), and states that it more important than glycemic
is beneficial for humans to index, and if glycemic load is
incorporate more low-GI misunderstood, confusion will
carbohydrates into their diets. arise about the carbohydrate
research in this book.
Jenny Craig We were unable to obtain much
information about this diet
program.
Dr. Kushner’s There are forces in our modern The book outlines healthy Requires prior knowledge of basic Yes. This is a well thought-out,
Personality Type lifestyle that promote weight diet information as well nutrition concepts. reasonable book, which
Diet gain. The book identifies maladaptive eating provides appropriate diet
maladaptive patterns regarding patterns, and has tools information and uses cognitive
eating, exercising, and coping that to help the reader behavioral therapy to help an
make it difficult for an individual identify which of those individual improve on current
to lose weight. patterns are most active behavior patterns, with the
in his/her life. goal of weight loss and
NUTRITION
Suggestions for change improved fitness.

and improving those
patterns are provided.
The importance of
exercise is included.
The Mediterranean One should eat plenty of fresh fruits It involves a whole This book does not differentiate Yes. Population studies of people on
Heart Diet and colorful vegetables, healthy lifestyle plan. between low-GI and high-GI the Mediterranean diet have
whole grains and legumes, olive Recommendations foods. shown improved longevity.
oil, yogurt, cheese, a little fish, appear well thought-out The current assessment of the
and at least six 8-oz glasses of and reasonable. Mediterranean diet is that the
water/day and a touch of wine. whole diet and lifestyle is
Small amounts of meat (less than important, not just using olive
l oz/person) are recommended. oil. Additional input from a
Lots of physical activities are registered dietitian would be
recommended, as are portion helpful for individuals with
control, diabetes.
(continued)
93
TABLE 7.7. (Continued)
94

smoking cessation, getting

enough sleep and relaxation, and
getting regular check-ups.
Suzanne Somer’s “Food combining”—keeping protein Recommends avoiding Her diet recommendations are not No. Some of her recommendations
Eat Cheat and and fat intake separate from processed foods. She based on currently accepted appear sound; others do not
Melt the Fat carbohydrate intake—causes seems to recommend nutrition science. When she appear to have a scientific
Away weight loss. some low-GI foods and includes discussion of physiology basis. The lack of use of
avoidance of trans fats. (e.g., what happens in “the burn,” standard food definitions can
However, not it is not based on scientific fact.) cause confusion to the reader:
infrequently her Inventing her own diet for instance, recommending
recommendations are terminology and “food “real” fats as good, and not
not consistent with groupings” makes her dietary distinguishing between
accepted scientific explanations and monounsaturated,
research and nutrition recommendations confusing and polyunsaturated, saturated,
science. Also, dubious. and trans fats. Cannot
confusion results from recommend this diet for
her lack of use of people with diabetes.
standard nutrition
NUTRITION
terminology.
The New Sugar Postulates that eating a diet of Recommends exercise. Appears fairly restrictive—some Questionable. Many of the recommendations
Busters natural unrefined sugars, whole Recommends people may have difficulty with The ratios of carb, appear reasonable. However,
unprocessed grains, vegetables, controlling portion size. the rigidity of the diet over time. protein, and fat additional input for individuals
fruit, lean meats, and fiber will Recommends low-GI do not follow with diabetes from a registered
have a positive effect on insulin carbs, monounsaturated current dietitian would be helpful.
and glucagon levels. fats and omega-3 recommended
Recommends 40% carbs, 30% polyunsaturated fats, ADA dietary
protein, 30% fat. and avoidance of trans guidelines.
and saturated fats.
The Okinawa By following the traditional diet, Recommendations appear None noted. Yes. This is one of This appears to be a well-written,
Program exercise and lifestyle of the to be well-grounded in the few diet well-researched book. The
Okinawan elders, one can lose fact and are well books that has data are clearly presented. The
weight and improve his/her health thought-out. long-term diet and lifestyle
and longevity. Recommends 7+ evidence that this recommendations appear
servings of vegetables and diet actually sound. Appears appropriate
fruits/day, 7+ servings of whole promotes health for individuals with diabetes.
grains/day, 3 servings of and longevity.
flavonoid-rich foods, 1–3 soy
products/day, 1–3 omega-3 rich
servings/day, minimal dairy
products and meat, 3 calcium-rich
foods/day. Discusses portion size
and eating only until 80% satiety.
Recommends avoiding saturated
fat and trans fats, and omega-6 to
omega-3 ratio of 3:1 or 4:1.
Recommends green tea
(especially Jasmine tea). Allows
up to 7 servings of high-protein
meats/poultry/eggs per week.
Alcohol in moderation or not at
all. Consider a multivitamin.
Lifestyle considerations include
spiritual life, stress reduction,
learning to manage hostility and
anger, developing a sense of
humor, and practicing conscious
awareness.
NUTRITION
The Omega Diet This is the traditional diet of Crete, Excellent discussion of This appears to be a Appears appropriate for
whose population has been shown fats. This is one of the healthy diet. individuals with diabetes.
to have a significantly decreased few diet books for Additional input from a
CAD and cancer mortality rate. which there is registered dietitian would be
Suggests there is an optimal level long-term evidence that helpful.
of omega-3 PUFAs that people it actually promotes
should consume. One should health and longevity.
enrich the diet with omega-3 fats;
use monounsaturated oils as
primary oils; eat 7+ fruits and
veggies daily; eat more vegetable
proteins: peas, beans, nuts; avoid
saturated fat; avoid oils high in
omega-6 fatty acids, reduce the
intake of trans fatty acids.
(continued)
95
96
TABLE 7.7. (Continued )

The Ultimate To be successful in losing weight He presents a useful We disagree with his assertion that Yes. The behavioral part of his
Weight Solution and maintaining a healthy weight, paradigm, tools, and “BMI is not an accurate method recommendations is excellent
(Dr. Phil one needs to have a realistic goal helpful ideas and for assessing your weight.” Some and appropriate. The actual
MacGraw) weight, and successfully employ instructions for of his diet recommendations diet recommendations appear
positive psychological and behavioral change. He could be argued, such as his reasonable for diabetes.
behavioral strategies which strongly encourages recommendation to eat nuts and Additional input from a
Dr. Phil calls the “7 keys” to exercise. seeds “very sparingly,” but most registered dietitian would be
permanent weight loss: of the recommendations appear to helpful for individuals with
1. “right thinking” be sound. diabetes.
2. “healing feelings”
3. Set up a no-fail environment
4. “habit control”
5. “food control”
6. “intentional exercise”
NUTRITION
7. support system
The South Beach Phase 1 low carb, rapid weight loss. May heighten motivation Claims are made that following this Possibly. Possibly. However, caution is
Diet Phase 2 introduce “good” carbs, due to potential for diet’s recommendations will advised if one has diabetic
slower weight loss Phase 3 weight rapid weight loss in change one’s chemistries and renal disease, because Phase 1
maintenance. Phase 1. insulin resistance. It is not clear could promote metabolic
that data exist to back up this acidosis. Additional input
claim. The reference to “good” from a registered dietitian
and “bad” carbs is simplistic. would be helpful for
Appropriate portion sizes are not individuals with diabetes.
defined. This can be a problem for
individuals who lack a feeling of
satiety to tell them when to quit
eating. No guidelines are given
for Phase 3, except to say that if
you are gaining weight you need
to go back to Phase 1. Lastly, this
book does not place sufficient
emphasis on exercise.
Weight Watcher’s Decrease overall food intake. This program has helped Does not discriminate between the Yes. This appears to be a reasonable
Complete Increase caloric output by many people lose low-GI and high-GI approach. The only suggestion
Cookbook and exercising. Reshape behavior to excess weight, and carbohydrates or the different we could make would be to
Program Basics learn positive attitudes and maintain their kinds of fats. consider more attention to
strategies for dealing with weight appropriate weight. avoiding saturated and trans
loss challenges. Provides a fats.
support group. Recommends
eating a variety of foods; 50–60%
carbohydrates; less than 30% fats,
and eating appropriately to
maintain a healthy weight.
c 2004 by Judith Beck, M.D., and Catherine Robinson, M.Ed., R.D., C.D.E., Tucson, AZ; reprinted with permission.
Source:
Disclaimer: This is our analysis of these books. We neither confirm nor refute the conclusions expressed in these publications.
NUTRITION
97
98 NUTRITION
TABLE 7.8. Kcaloric needs for Weight blood glucose levels. The effect of fat on blood
Maintenance sugar is one-tenth of the effect of carbohy-
drates. (Freeman and Krapeck, 2003). Protein
Obese or very inactive 10–12 kcal/lb (20 kcal/kg)
persons, chronic dieters has minimal effect on blood sugar provided
Individuals >55 years old, 13 kcal/lb (25 kcal/kg) the serving size is not excessive.
active women, sedentary The first and most important step in nutri-
men tion education is for patients with diabetes to
Active men, very active 15 kcal/lb (30 kcal/kg)
recognize which foods contain carbohydrates,
women
Thin or very active men 20 kcal/lb (40 kcal/kg) and to differentiate them from foods contain-
ing fats and proteins. The use of food models
Source: Estimating approximate energy requirements in adults. is helpful in this process.
A core curriculum for Diabetes Management Therapies (2003),
p. 29. After completing an estimation of
kcaloric needs, one needs to consider the num-
In order to calculate macronutrient quan- ber of servings per day required from each
tities for a meal plan, one must recall that 1 g of food group that depends on the kcalorie level
fat equals 9 kcalories, 1 g carbohydrate equals appropriate for each individual as previously
4 kcalories, and 1 g protein equals 4 kcalories. determined (Table 7.11).
Therefore, fat contains twice the number of Various teaching methods may be
kcalories of either protein or carbohydrate. used in meal planning. Some examples
Macronutrient components of one serv- include:
ing of various food groups are listed in r Carbohydrate counting,
Table 7.9. r Exchange method,
Portion size is crucial. Examples of serv- r Plate method, and
ings from each macronutrient group are given r Simple rules of healthy eating.
in Table 7.10.
Of the three macronutrient groups, car- Education material on these methods
bohydrates have the greatest impact upon may be found at the end of this chapter.
TABLE 7.9. Exchange Lists for Meal Planning (American Diabetes Association, 2003)
Carbohydrate Protein
Groups/lists (g/serving) (g/serving) Fat (g/serving) Kcalories
Carbohydrates
Starch 15 3 0–1 80
Fruit 15 – – 60
Milk
Low-fat (skim) 12 8 0–3 90
Reduced fat (2%) 12 8 5 120
Whole 12 8 8 150
Other carbohydrates 15 varies varies varies
Nonstarchy vegetablesa 5 2 – 25
Meat and meat substitutes
Very lean – 7 0–1 35
Lean – 7 3 55
Medium fat – 7 5 75
High fat – 7 8 100
Fat – – 5 45
Some sources feel the following vegetables may be eaten freely: cabbage, celery, cucumber, green onion, hot pepper, mushrooms,
radish, endive, escarole, lettuce, spinach.
NUTRITION 99
TABLE 7.10. Examples of Servings from method must be tailored to meet their individ-
Each Macronutrient Group ual needs.
Food group Portion size
Introduction to Carbohydrate Counting
One starch One slice bread or 1/4 bagel
One fruit One small orange One carbohydrate serving = 15 g = one
One milk One 8-oz glass of low-fat milk starch (one slice bread) = one fruit (one small
One vegetable One cup raw or 1/2 cup cooked orange) = a glass of milk (one 8-oz glass).
One meat One oz (cooked) poultry, fish or Therefore, in this sample meal there are three
(protein) meat carbohydrate servings or 45 g.
One fat One tsp oil or margarine
2 slices of bread = 2 carbohydrate servings
1 egg = 0 carbohydrate servings
1 tsp margarine = 0 carbohydrate servings
People with type 1 diabetes should be 1 glass milk = 1 carbohydrate serving
introduced to carbohydrate counting so pa- Total = 3 carbohydrate servings
tients can learn how to balance insulin dose
As one considers carbohydrates, it is im-
with carbohydrate intake. Patients on multiple
portant to remember that:
daily injections or the insulin pump should un-
derstand carbohydrate-to-insulin ratios. There r Not all starches are equal. Whole grains
are resources to teach these techniques. One are digested and absorbed more slowly than white
example is Complete Guide to Carb Count- flour products including white bread and refined
ing (Warshaw and Kulkami, 2001). Patients cereals. Increased fiber content lowers the rate of
should also learn the principles of healthy absorption.
r Not all fruits are equal. Whole fruits con-
eating.
taining fiber (e.g., strawberries) do not rapidly im-
People with type 2 diabetes can be
pact blood glucose and are recommended over low
taught a combination of carbohydrate count- fiber fruits (e.g., melons), which tend to cause rapid
ing and/or the exchange method. In some pa- blood glucose elevations. Acidic fruits also do not
tients, the plate method with simple rules of rapidly impact blood glucose levels.
healthy eating may be appropriate. r Not all milks are equal. Skim milk has
The technique used will depend upon fewer fat grams and fewer kcalories than whole
many factors including patient understand- milk.
ing, type of medication, and readiness to
Key concepts for nutrition management
change. Each patient differs and the teaching
for all patients with diabetes include:
r Balance, variety, moderation!
TABLE 7.11. Exchange Method— r Take appropriate number of servings at
Portions Needed for a Balanced Diet at a meals and snacks throughout the day.
Given Caloric Intake (The Type 2 r Consume meals and snacks at regular
Diabetes Meal Planner) times throughout the day.
r Drink adequate amount of water every
Kcalories 1,200 1,500 1,800 2,000 2,500
day.
Food group
Starch 5 7 8 9 11
Fruit 3 3 4 4 6
Food Label Reading (See Education
Milk 2 2 3 3 3 Materials in the Appendix)
Vegetables 2 2 3 4 5
Meat (ozs) 4 4 6 6 8 One should follow a step-by-step ap-
Fat 3 4 4 5 6 proach to reading food labels. First, look at
Source: The Type 2 Diabetes Meal Planner, Bristol-Myers
serving size on which all the information
Squibb (1999). printed on the food label is based. Then, look
100 NUTRITION
at total carbohydrate in bold print. Sugar, cigarettes. He has three alcoholic drinks per
starches, and dietary fiber are included in the night on average, and six per night on week-
total carbohydrate. The magic number for to- ends.
tal carbohydrate = 15 g = 1 serving. When His height is 5 8 , and weight is 230 lb,
choosing foods, look for those containing less giving him a BMI of 35.
kcalories, less total fat, less saturated fat, less His current lab profile includes an HbA1 c
trans fat, less cholesterol and sodium, and of 9.0, total cholesterol of 225, HDL of 29,
more dietary fiber. LDL of 141, and TG of 310.
His medications include metformin
(Glucophage) 500 mg twice a day, atorvas-
CASE STUDY tatin (Lipitor) 20 mg at bed time, and quinapril
(Accupril) 20 mg every day.
Now let us put the above recommenda- Mr. Smith states, “I need to control my
tions to use within a case that we invented for diabetes. I don’t want to die like my Mom
you. did.”
John Smith is a 55-year-old male with Mr. Smith’s food recall for one day is
newly diagnosed type 2 diabetes mellitus. He given in Table 7.12.
also has had hyperlipidemia and hypertension He states, “sometimes I eat more; some-
for 4 years. His family history is positive for times I eat less. This was a particularly ‘hun-
type 2 DM in his mother who died from my- gry’ day.”
ocardial infarction at age 48. At the time of
her death, she had end-stage renal failure and Intake Analysis
was on dialysis.
Mr. Smith is married and self-employed. Recall that 1 g of carbohydrate is equal to
His wife works full time. He has a seden- 4 kcal. His total carbohydrates = 395 g. There-
tary lifestyle. He smokes 1 pack/day of fore, 395 g × 4 kcal/g = 1,580 kcal. Thus,
TABLE 7.12. Mr. Smith’s Food Recall

Meal/time (24:00 clock) food Carbohydrate (g) Carbohydrate servings Kcalories
Breakfast 7:30 AM
Orange juice 8 oz 27 2 112
Coffee 12 oz 8
Sugar 4 tsp 16 1 60
Doughnuts (2) 46 3 384
Lunch 12:00 noon
Nachos and cheese 36 2.5 346
Soda 12 oz 38 2.5 152
Snack 3:00 PM
Chocolate cakes 1 individual pack 42 3 243
Soda 12 oz 38 2.5 152
Dinner 6:00 PM
Big Mac 42 3 560
Salad 5.5 oz 5 – 60
Ranch dressing 2 Tbsp 2 – 150
Large fries 46 3 400
Soda 12 oz 38 2.5 152
Evening 9:00 PM
Beer bud light (three 12-oz cans) 19 1 330
Grand total 395 26 3,109
NUTRITION 101
∼50% of his total kcalories come from carbo- decrease his alcohol intake to two drinks or
hydrate, which on first glance appears to fall less per day. He needs to quit smoking, and
within the recommended guidelines. Unfor- he needs to incorporate regular exercise into
tunately, one half of his carbohydrate intake his routine. This means a lot of changes in
consists of empty kcalories from sodas, sugar- his diet and lifestyle, and he might be more
containing foods, and beer. The remaining successful if it is done in a stepwise fashion.
kcalories are derived from fat, protein, and al- Since this gentleman has stated that he does
cohol. His protein intake is adequate, but con- not wish to “die like his mom,” one may hope
tains significant saturated fat. He is also get- that he will be adequately motivated to be suc-
ting saturated and trans fat from the cupcakes, cessful over the long term. However, he will
the French fries, and nachos and cheese. need regular follow-up to help him stay on
He is eating excessive saturated and trans track.
fats, and not ingesting appropriate quantities
of monounsaturated or omega-3 polyunsatu-
rated fats. Therefore, his current intake is not SUMMARY
balanced.
Using the formula given in Table 7.8, Individual meal plans must be tailored
one can estimate his daily kcaloric needs to the needs of each individual with diabetes.
for weight maintenance as follows: 230 (his One size does not fit all. The percentages
weight in pounds) × 10 = 2,300. In order for of carbohydrates, fats, and proteins recom-
him to lose half to one lb per week, he mended by the ADA should be used when cre-
needs to decrease his daily intake by 250–500 ating a meal plan. Regarding carbohydrates,
kcal (2,300 − 250 = 2,050; 2,300 − 500 = the glycemic index (glycemic load) may be
1,800). Therefore, his estimated daily kcaloric important. Since the individual glycemic re-
range for his desired weight is 1,800– sponse to carbohydrate foods varies consid-
2,050. erably, self-monitoring of blood glucose is an
Assuming his daily needs to be 2,000 essential part of the overall care plan. With
kcal, the appropriate number of servings from regard to fats, emphasis should be placed
each food group is listed in Table 7.11. For on decreasing saturated and trans unsatu-
2,000 kcal, the total number of carbohydrate rated fats and increasing monounsaturated
servings would be 16, consisting of 9 starch, and omega-3 polyunsaturated fats. Variety
4 fruit, and 3 milk servings. Nonstarchy in one’s meal plan is crucial, as is the por-
vegetables would be unrestricted. His recom- tion size. One should beware fad diets, es-
mended food intake is approximately two- pecially those that ignore accepted scientific
thirds of his current daily intake of 26 servings studies about physiologic and metabolic pro-
(see Table 7.11). cesses. Remember that change in an indi-
In order to evenly distribute his daily vidual’s lifestyle occurs slowly—backsliding
allowance, one could suggest that he divide will probably occur. Also, for some people,
his total intake from all food groups between their current meal plan is almost as important
three meals and two snacks. A thorough re- to them as their religion. You might walk into
view of his food preferences would assist him a minefield when discussing it. Proceed with
to make appropriate food choices. He should caution!
102 NUTRITION
APPENDIX: TEACHING MATERIALS
Nutrition and Diabetes
• Good nutrition is the key

• You don’t have to buy special foods
• The food that is good for you is good for the whole family
• Try not to think of it as a diet. Instead think “healthy meal plan”
• Variety
• Eat a variety of foods each day
• Well balanced meal plan
• Regular meals
• Eat at least three times each day
• Try not to skip meals
• Eat about the same amount of food each day
• Limit sugar
• Foods that contain a lot of sugar will raise your blood sugar level
• Eat carbohydrate foods in moderation
• These foods affect your blood sugar level
• Try not to eat too much at one time
• Potatoes tortillas bread rice fruit milk
• Eat less fat and salt

• Some foods contain a lot of fat
• Limit the amount of these foods
• Butter margarine cooking oils
• Hot dogs bacon fast food
• Try not to add fat and salt during cooking or at the table
• Increase fiber
• Choose high fiber foods
• Fiber helps to lower your blood sugar level
• Try to eat whole fruits instead of fruit juice
• Whole grains whole fruits and vegetables
NUTRITION 103
• Increase fluid
• Your body needs approximately 6–8 cups fluid daily
• The best fluid is water!
• Healthy body weight
• Try to maintain a healthy weight
• If you need to lose weight, eat smaller portions
• Weight loss – if needed – will help to improve your blood sugar levels
Nutrición y Diabetes
• Buena nutrición es la clave

• La comida que es buena para usted es buena para toda su familia
• No tiene que comprar comidas especiales o de “dieta”
• No trate de pensarlo como una “dieta” Es un plan de comida saludable.
• Variedad
• Coma una variedad de alimentos diarios
• Un plan de comida balanceada
• Coma con regularidad

• Coma por lo menos tres veces al dia
• No deje sus tres comidas
• Limite azúcar
• Los alimentos que contienen mucha azúcar hacen subir el nivel de azúcar en la sangre
• Coma los carbohidratos en moderación
• Estos alimentos afectan al nivel de azúcar en la sangre.
• No coma demasiado a un tiempo
• papas tortillas pan arroz frutas leche
• Coma menos grasa y sal

• Unos alimentos contienen mucha grasa
• Limite la cantidad de estos alimentos
• mantequilla margarina aceite
• salchichas tocino comida “rapida”
• No añada grasa y sal al cocinar
104 NUTRITION
• Mas Fibra
• Escoja los alimentos ricos en fibra
• La fibra le ayuda bajar el nivel de azúcar en la sangre
• Coma fruta entera en vez de jugo de fruta
• Granos integrales tortillas de maiz frutas enteras verduras
• Liquidos
• Su cuerpo necesita 6–8 vasos de lı́quido diario
• Lo mejor es agua
• Peso saludable
• Si usted quiere perder peso, coma porciones más pequeñas
• Si puede perder unas libras, el nivel de azúcar en la sangre va a mejorar
(
C 2004 by Catherine Robinson, M.Ed., R.D., C.D.E., Tucson, AZ; reprinted with permission)
Idaho Plate Method
Breakfast Lunch/Dinner
Fruit Milk Fruit Milk
Optional Bread/
Meat/Protein Starch Meat/Protein
Bread/Starch Vegetable
1-2 Fat Servings 1-2 Fat Servings
(
c 1998 Idaho Plate Method LLC. www.platemethod.com To order, contact (208) 624 7279)
THE TYPE 2 DIABETES MEAL PLANNER
Good Meal Plannig Can Help You Better Control Your Blood Sugar
Eating healthy foods and adding variety to your menus is easier than you think. Your
doctor or healthcare provider can help you develop a meal plan that helps control your blood
sugar. This sheet can help you make that plan more interesting by providing substitution
options, so you don’t have to eat the same foods all the time. It also helps if you eat a balanced
diet, eat meals at the same time every day, avoid skipping meals, and eat food portions that
are indicated by your individual meal plan. The American Diabetes Association recommends
good eating habits along with being physically active as an important part of any good type 2
diabetes self-management plan.
Here’s how you can easily choose foods that fit your type 2 diabetes meal plan:
r Find your total daily kcalorie level on the chart to the right.
r Using the chart, plan your menus for the day with serving amounts from each food group.
NUTRITION 105
r Look at the sample meal plan below to see how you can do this.
r Give your meals variety by choosing other items from the same food groups. See the choices
listed on the other side.
Kcalorie Meal Plans (Daily) 1,200 1,500 1,800 2,000 2,500
Starch 5 7 8 9 11
Fruit 3 3 4 4 6
Milk 2 2 3 3 3
Vegetables 2 2 3 4 5
Meat & Meat Substitutes 4 4 6 6 8
Fat 3 4 4 5 6
Sample Meal Plans
To develop a meal plan at a higher kcalorie level, you can add food-group servings to the
1,200 kcalorie meal plan, as indicated below.
1,200 1,200 Sample 1,500 1,800 2,000 2,500

Kcalories Menu Kcalories kcalories Kcalories Kcalories
Breakfast English muffin 1/2 Add Add Add Add

1 Starch Banana (medium) 1/2 1 Starch 1 Starch 1 Starch 2 Starch
1 Fruit Hot cocoa mix 1 Fat 1 Fat
1 Milk (artificially 1Fruit
sweetened)
1 envelope
Lunch Tortilla (6 across) 1 oz
1 Starch Chicken 1 oz 1 Starch 1 Starch 1 Starch 1 Starch
2 Meat Cheese 1 oz 1 Meat 1 Milk 1 Meat
1 Vegetable Beans 1 Milk 1 Fat 1 Vegetable
1 Fruit Apple (raw—2 1 Vegetable 1 Fat
1 Fat across) 1 Milk
Salad dressing
(reduced-kcalorie)
2 Tbsp
Afternoon
Snack 1 Starch 1 Starch
Nothing 1 Meat
1 Fruit
Dinner Rice 1/3 cup

2 Starch Corn chips 1 oz 1 Fat 1 Starch 1 Starch 2 Starch
2 Meat Chicken 2 oz 1 Meat 2 Meat 2 Meat
1 Vegetable Onions 1 Vegetable 1 Vegetable 2 Vegetable
1 Fruit Butter1 tsp 1 Fat 1 Fat
2 Fat Oil 1 tsp
Canned fruit in juice
1
/2 cup
Evening Low-fat or nonfat
Snack milk 8 oz 1 Fruit 1 Fruit 1 Fruit
1 Starch Popcorn 3 cups
1 Milk
106 NUTRITION
ADD VARIETY TO YOUR TYPE 2 DIABETES MEAL PLAN
Choose Foods You Like that Still Add Up to the Right Kcalorie Count
Starch Low-fat or nonfat milk 8 oz

Low-fat or nonfat buttermilk 8 oz
1 serving = 80 kcalories
Yogurt (nonfat, plain, or artificially sweet-
(each item listed is 1 serving)
ened) 8 oz
Cereal/Beans/Grains/Pasta Hot cocoa mix (artificially sweetened)
Cereal (cooked) 1/2 cup 1 envelope
Beans (cooked or canned) 1/3 cup
Rice (cooked) 1/3 cup Vegetables
Pasta (cooked) 1/2 cup
1 serving = 25 kcalories
Starchy Vegetables (A serving is 1/2 cup of cooked vegetables or
Corn (cooked) 1/2 cup 1 cup of raw vegetables)
Corn on the cob (6 piece) 1
Beets
Peas (cooked) 1/2 cup
Plantain (green, cooked) 1/3 cup Broccoli
Cabbage
Potato (small—3 oz) 1 cup
Carrots
Squash (winter, cooked) 1 cup
Greens
Yam or sweet potato 1/2 cup
Mushrooms
Breads Okra
Bagel or English muffin 1/2 or 1 oz Onions
Bread (slice or roll) 1 oz Pea pods
Crackers, snack 4–5 Peppers
Graham crackers 3 squares Spinach
Hamburger or hot dog bun 1/2 oz or 1 oz Tomatoes
Popcorn (plain, unbuttered) 3 cups Water chestnuts
Tortilla (6 across) 1
Meat and Meat Substitutes
Fruit
Lean Meats
1 serving = 60 kcalories 1 serving = 35–55 kcalories
(each item listed is 1 serving) (each item listed is 1 serving)
Apple (raw—2 across) 1 Cheese (1–3 grams of fat) 1 oz
Banana (medium) 1/2 Chicken (white, no skin) 1 oz
Cherries 12 Cottage cheese 1/4 cup
Dried fruit 1/4 cup Fish (cod, flounder, tuna) 1 oz
Canned fruit in juice or water 1/2 cup Lean beef (flank, round, sirloin) 1 oz
Grapes 12–15 Shellfish (clams, crab, lobster, shrimp) 1 oz
Raisins 2 Tbsp Turkey (white, no skin) 1 oz
Apple, orange, or grapefruit juice 1/2 cup
Cranberry, grape, or prune juice 1/3 cup Medium/High-Fat Meats
1 serving contains 75–100 kcalories
Milk (each item listed is 1 serving)
1 serving = 90–100 kcalories Beef 1 oz
(each item listed is 1 serving) Chitterlings 1 oz
NUTRITION 107
Chicken (dark meat, no skin) 1 oz Broth

Eggs 1 Club soda
Pork (spareribs, barbecue, chops, cutlets) 1 oz Coffee
Sausage 1 oz Drink mixes (sugar-free)
Wieners 1 oz Mineral water
Tea
Fats
Seasonings
1 serving = 5 grams fat, 45 kcalories Flavoring extracts
(each item listed is 1 serving) Garlic or garlic powder
Avocado (4 across) 1/8 Herbs (fresh or dried)
Mustard (prepared)
Bacon 1 slice
Soy sauce
Butter 1 tsp
Vinegar
Cream (light, table, coffee, sour) 2 Tbsp
Cream cheese 1 Tbsp Sweet Substitutes
Margarine 1 tsp Gelatin desserts (sugar-free)
Mayonnaise 1 tsp Gum (sugar-free)
Mayonnaise (reduced-fat) 1 Tbsp Popsicles (sugar-free)
Nondairy creamer (liquid) 2 Tbsp Sugar substitutes
Nondairy creamer (dry) 4 tsp
Oil 1 tsp LIMIT TO 2–3 SERVINGS A DAY
Nuts or seeds 1 Tbsp
Pesto sauce 2 tsp Fruits
Salad dressing (reduced-kcalorie) 2 Tbsp Cranberries (no sugar added) 1/2 cup
Rhubarb (no sugar added) 1/2 cup
Free Foods Sweet Substitutes
Free foods are foods or beverages with less Jam or jelly (sugar-free) 2 tsp
than 20 kcalories. They have little or no Whipped topping 2 Tbsp
effect on blood sugar levels. Spreadable fruit (no sugar added) 1 tsp
Condiments
UNLIMITED SERVINGS
Catsup 1 Tbsp
Beverages Salad dressing (reduced-kcalorie) 2 Tbsp
Bouillon Taco sauce 2 Tbsp
(
c 1999 Bristol-Myers Squibb Company. Reprinted with permission)
108 NUTRITION
EL PLANIFICADOR DE COMIDAS PARA LA DIABETES TIPO 2
La planificación adecuada de sus comidas puede ayudarle a mejorar el control de su

azúcar en la sangre
El comer alimentos sanos dentro de un menú variado, es más fácil de lo que usted piensa.
Su médico o profesional de la atención médica, puede ayudarle a desarrollar un plan de comidas
que le ayude a controlar su nivel de azúcar en la sangre. Esta hoja también puede ayudarle a
preparar un plan más conveniente, ofreciéndole opciones de distintos alimentos para que usted
no tenga que comer siempre lo mismo.
Asimismo, le ayudará a tener una dieta más balanceada, comer a la misma hora todos
los dı́as, evitar el salto de comidas y comer las porciones de alimentos indicadas en su plan
de comidas individual. La Asociación Americana de la Diabetes recomienda observar buenos
hábitos alimenticios junto con la actividad fı́sica, como parte de cualquier plan adecuado para
el control personal de la diabetes tipo 2.
Aquı́ tiene un método fácil para seleccionar los alimentos más apropiados para su plan
de comidas de la diabetes tipo 2.
r Busque su nivel total de calorı́as diarias en la tabla de la derecha.
r Use la tabla para planificar su menú del dı́a con porciones de cada grupo de alimentos.
r Revise el plan de comidas presentado abajo para determinar cómo usted puede seguirlo.
r Añada variedad a sus comidas seleccionando otros alimentos dentro del mismo grupo. Vea las
opciones presentadas en el otro lado.
Planes de Comidas por Calorı́as (Diarias) 1,200 1,500 1,800 2,000 2,500
Almidones 5 7 8 9 11
Frutas 3 3 4 4 6
Leche 2 2 3 3 3
Verduras 2 2 3 4 5
Carnes y Sustitutos de la Carne 4 4 6 6 8
Grasas 3 4 4 5 6
Ejemplos de planes de comidas
Para desarrollar un plan a un nivel más alto de calorı́as, usted puede añadir porciones de
los grupos de alimentos al plan de comidas de 1,200 calorı́as, según se indica abajo.
NUTRITION 109
1,200 Calorı́as Ejemplo de Menú de 1,500 1,800 2,000 2,500

1,200 Calorı́as Calorı́as Calorı́as Calorı́as Calorı́as
Desayuno English muffin 1/2 Añada Añada Añada Añada

1 Almidones Banana (mediana) 1/2 1 Almidones 1 Almidones 1 Almidones 2 Almidones
1 Frutas Mezcla de chocolate 1 Grasas 1 Grasas
1 Leche caliente (endulzada 1Frutas
artificialmente)
1 sobre
Almuerzo Tortilla (6 de
1 Almidones diámetro) 1 oz 1 Almidones 1 Almidones 1 Almidones 1 Almidones
2 Carnes Pollo 1 oz 1 Carnes 1 Leche 1 Carnes
1 Verduras Queso 1 oz 1 Leche 1 Grasas 1 Verduras
1 Frutas Frijoles 1 Verduras 1 Grasas
1 Grasas Manzana (cruda—2 1 Leche
de diámetro)
Aderezo de ensalada
(calorı́as reducidas)
2 cdas
Merienda
por la tarde 1 Almidones 1 Almidones
Nada 1 Carnes
1 Frutas
Cena Arroz 1/3 taza

2 Almidones Chips de maı́z 1 oz 1 Grasas 1 Almidones 1 Almidones 2 Almidones
2 Carnes Pollo 2 oz 1 Carnes 2 Carnes 2 Carnes
1 Verduras Cebollas 1 Verduras 1 Verduras 2 Verduras
1 Frutas Mantequilla 1 cdta 1 Grasas 1 Grasas
2 Grasas Aceite 1 cdta
Fruta enlatada en jugo
1
/2 taza
Merienda por Leche (sin grasa o
la noche grasa reducida) 8 oz 1 Frutas 1 Frutas 1 Frutas
1 Almidones Rositas de maı́z 3 tazas
1 Leche
AÑADA VARIEDAD A SU PLAN DE COMIDAS DE LA DIABETES TIPO 2
Seleccione los alimentos que le gusten hasta el conteo correcto de calorı́as
Almidones Plátano (verde, cocido) 1/3 taza

1 porción = 80 calorı́as Papa (pequeña—3 oz) 1 taza
(cada renglón indicado es 1 porción) Calabaza (cocida) 1 taza
Batata o boniato 1/2 taza
Cereales, Frijoles, Granos, Pastas
Cereal (cocido) 1/2 taza Panes
Frijoles (cocidos o enlatados) 1/3 taza Bagel o English muffin 1/2 o 1 oz
Arroz (cocido) 1/3 tata Pan (rebanada o panecillo) 1 oz
Pasta (cocida) 1/2 taza Galletas de merienda 4–5
Galletas Graham 3
Verduras de Féculas Pan de hamburguesa o perro caliente 1/2 oz or
Maı́z (cocido) 1/2 taza 1 oz
Maı́z en mazorca (pedazo de 6 ) 1 Rositas de maı́z (sin mantequilla) 3 tazas
Guisantes (cocidos) 1/2 taza Tortilla (6 de diámetro) 1
110 NUTRITION
Frutas Queso (1–3 gramos de grasa) 1 oz

Pollo (pechuga sin piel) 1 oz
1 porción = 60 calorı́as
Requesón 1/4 cup
(cada renglón indicado es 1 porción)
Pescado (bacalao, lenguado, atún) 1 oz
Manzana (cruda—2 de diámetro) 1 Carne de res magra (falda, bola, solomillo)
Banana (mediana) 1/2 1 oz
Cerezas 12 Mariscos (almejas, cangrejo, langosta,
Fruta seca 1/4 taza camarones) 1 oz
Fruta enlatada en jugo o agua 1/2 taza Pavo (pechuga sin piel) 1 oz
Uvas 12–15
Pasas 2 cdas Carnes Medianas/Altas en Grasa
Jugo de manzana, naranja o toronja 1/2 taza 1 porción 75–100 calorı́as
Jugo de arándanos, uvas o ciruela 1/3 taza (cada renglón indicado es 1 porción)
Res 1 oz
Leche
Tripas de puerco 1 oz
1 porción = 90–100 calorı́as Pollo (no de pechuga sin piel) 1 oz
(cada renglón indicado es 1 porción) Huevos 1
Puerco (costillas, barbacoa, chuletas)
Leche (sin grasa o grasa reducida) 8 oz
1 oz
Crema (sin grasa o grasa reducida) 8 oz
Salchicha 1 oz
Yogurt (sin grasa, sólo o endulzado artificial-
Perros calientes 1 oz
mente) 8 oz
Mezcla de chocolate caliente (endulzada
Grasas
artificialmente) 1 sobre
1 porción = 5 gramos de grasa, 45 calorı́as
Verduras (cada renglón indicado es 1 porción)
1 porción = 25 calorı́as Aguacate (4 de diámetro) 1/8
(Una porción es 1/2 taza de verduras cocidas Tocino 1 lasca
o 1 taza de verduras crudas) Mantequilla 1 cdta
Remolacha Crema (ligera de mesa, café, agria) 2 cdas
Brecol Queso crema 1 cda
Col Margarina 1 cdta
Zanahorias Mayonesa 1 cdta
Hojas verdes Mayonesa (grasa reducida) 1 cda
Champiñones Crema no láctea para café (lı́quido) 2 cdas
Quingombó Crema no láctea para café (polvo) 4 cdtas
Cebollas Aceite 1 cdta
Vainas de guisantes Nueces o semillas 1 cda
Pimientos Salsa de pesto 2 cdtas
Espinaca Aderezo de ensalada (calorı́as reducidas)
Tomates 2 cdas
Castaña de agua
Alimentos Libres
Carnes y Sustitutos de la Carne
Los alimentos libres son las comidas o
Carnes Magras bebidas que tienen menos de 20 calorı́as.
1 porción = 35–55 calorı́as Tienen poco o ningún efecto en los niveles
(cada renglón indicado es 1 porción) de azúcar en la sangre.
NUTRITION 111
PORCIONES ILIMITADAS Chicle (sin azúcar)

Paleta helada (sin azúcar)
Bebidas
Sustitutos del azúcar
Cubitos de caldo
Caldo
LÍMITE DE 2 A 3 PORCIONES AL DÍA
Agua carbonatada
Café Frutas
Mezcla de refresco (sin azúcar) Arándanos (sin azúcar añadida) 1/2 taza
Agua mineral Ruibarbo (sin azúcar añadida) 1/2 taza
Té
Sustitutos de Dulces
Sazones Mermelada o jalea (sin azúcar) 2 cdtas
Extractos Crema batida artificial 2 cdas
Ajo o ajo en polvo Compota de frutas (sin azúcar añadida)
Especies (frescas o secas) 1 cdta
Mostaza (preparada)
Condimentos
Salsa de soya
Ketchup 1 cda
Vinagre
Aderezo de ensalada (calorı́as reducidas)
Sustitutos de Dulces 2 cdas
Postres de gelatina (sin azúcar) Salsa de taco 2 cdas
(
c 1999 Bristol-Myers Squibb Company. Reprinted with permission)
What To Look For When You Read A Label
1. SERVING SIZE—This is the quantity to 8. SODIUM—Try to consume as little

which all the following nutrients refer. as possible. (READ THE
E.g. if you eat double the serving size, LABELS!) A low sodium diet
you must double the nutrient value contains less than 2,400 mg/day.
(calories, fat grams, etc).
9. CARBOHYDRATES— The total
2. CALORIES—The amount of energy in carbohydrates is most important
one serving size. value to consider. Dietary fiber,
sugars, and other starches are
3. TOTAL FAT—You want to keep the daily included in total carbohydrates.
fat intake to less than or equal to 30% of
the day’s calories. 10. FIBER—In general, the higher the
fiber content, the lower the blood
4. SATURATED FAT—You want this to be glucose spike that results from
minimal. eating this food.
5. MONOUNSATURATED FAT—This 11. PERCENT DAILY VALUE—Don’t

should be the primary kind of fat in your waste your time on this. These
diet. percentages provide some
information, but it’s really not very
6. POLYUNSATURATED FAT—This helpful.
category is of limited value. You want to
maximize consumption of the omega-3 12. INGREDIENTS—The higher the
fats. Therefore, you need to look at the item is on the list, the greater the
ingredients list to see the types of fats amount of it is in this food. Look
included in this food. Please refer to here for specifics on fats, and food
Table 8 for more information on which components that you want to
foods contain omega-3 polyunsaturated avoid, such as high fructose corn
fats. syrup.
7. TRANS FAT—You want this to be as

close to ZERO as possible
(© 2004 by Catherine Robinson, M.Ed., R.D., C.D.E., and Judith Beck, M.D., Tucson, AZ; reprinted with permission.)
112 NUTRITION
LIFESKILLSTM TEACHING GUIDE
How to Get a
“Hand” Le on Serving Sizes
You’re trying harder than ever to manage your diabetes. You take your medicine on time,
exercise regularly and even eat right. Still your blood sugars are all over the place! The problem
might be the serving size of your food. One key to more consistent blood sugars is consistent
food intake especially carbohydrates (sugars and starches).
For example, if one day you eat one cup of cereal and the next day you eat 11/2 cups
because you ate from a larger bowl, you will get more carbohydrate and a higher a blood sugar.
Keeping the serving size the same helps keep the grams of carbohydrate the same and blood
sugars more consistent.
Weighing and measuring your food and determining the sizes of your dishes at home will
help. The difference in your dishes and glasses will surprise you.
How can you measure food when you are eating out? Try the Hand Method.
3 oz.
r your palm is about three ounces of cooked meat (four ounces for a man’s palm)
r your fist is eight ounces of liquid

r your fist is also about the size of a piece of fruit, 3 knuckles are one small potato
NUTRITION 113
r your thumb nail is one teaspoon
r your cupped hand is 1/2 cup
Use your hand to determine the serving sizes of foods served in restaurants. Try pasta
with marinara sauce, French bread and salad with dressing.
Does the pasta look like one handful, two or more? Most likely 2–3 handfuls. Two handfuls
(1 cup) is 3 servings of carbohydrate. The bread is one serving per slice (hand size). One fist
of marinara sauce is also one carbohydrate. The salad is free but not the salad dressing.
By our calculations we have determined that your dinner has five (5) carbohydrate choices.
You may have more if you eat more than one slice of bread or 1 cup pasta.
How does this compare to your meal plan? If your plan only allows three carbohydrate
choices, you have gone over and can expect a high blood sugar. If you take insulin you can
adjust your dose to cover the extra carbohydrate. But, if you are taking diabetes pills it would
be best to stick to your plan.
Either eat less of the pasta or skip the bread. You might also ask for an appetizer size if
you have a hard time leaving food on your plate or share the entree with a friend.
114 NUTRITION
Your Special Nutrition Needs for Diabetes
Food provides energy or “fuel” for your body. This is measured in kcalories. These
kcalories come from carbohydrates, protein, fat and alcohol. Each plays a specific role in the
body.
Carbohydrates come from breads, grains, cereals, some vegetables, fruit & juice, sugar and
milk. Carbohydrates are an important source of energy and B vitamins. They also have the
greatest effect on your blood sugar.
You may have been asked to count carbohydrate grams or choices. Keeping the carbohy-
drate content of your meals the same from day to day helps in blood sugar control.
If you are using the Food Guide Pyramid for meal planning, the carbohydrate food groups
are: bread, grains & starchy vegetables, fruit, milk and sugars. Most meal plans consider one
serving from each of these groups to be a carbohydrate (carb) choice. Each choice is 15 grams
of carbohydrate.
Your Meal Plan may allow 3–4 carbs per meal depending on your kcalories. Four carb
choices would be 2 slices of bread, 1 cup of milk and 1 small piece of fruit. It could also be 1
medium potato and 2 cookies.
Try to keep your carbohydrate foods consistent in total choices or grams from day to
day. Most older adults should have 10–14 carbohydrate choices per day depending on their
kcalories. Lower kcalories use 10 choices, higher kcalories use 14 choices. Spread the choices
throughout the day and the food groups. Carbohydrates should be 40 to 50% of your total
kcalories.
Protein is our building block that preserves and repairs body tissue. It also helps antibodies
fight infection. The best choices are lean meats like skinless chicken, trimmed round or flank
steak, lean pork chops and fish. Cheese, cottage cheese, eggs and beans are also good protein
foods. Limit eggs to 3 per week and use low fat cheese. Protein should be about 15–20% of
your total kcalories.
Fat comes from animal and vegetable sources. Animal sources are mostly saturated fat which
should be limited. This is the type of fat that clogs arteries. Unsaturated fats (poly and mono) are
the fats of choice. These come from vegetable sources. Monounsaturated fats when substituted
for saturated fat can help lower blood cholesterol. Rich sources are olive, canola and peanut
oil. Total fat should about 30% of your daily kcalories. Some physicians and dietitians allow
more fat if it is from monounsaturated foods.
Cholesterol is a waxy, fat-like substance. It is part of the plaque that clogs arteries. Limit
cholesterol to 300 mg/day. A 3 ounce serving of lean meat or chicken has about 75 mg of
cholesterol. One egg has about 280 mg.
Alcohol should only be used in moderation (≤2 drinks/day men, ≤1 drink/day women) and
NUTRITION 115
with physician permission. If you take insulin, always eat when drinking alcohol. Alcohol
contains 7 kcalories per gram.
Other Issues
Sodium should be limited to 2400 to 3000 mg/day. If you have high blood pressure, limit
sodium to <2400 mg/day. Do not use salt in cooking. Use herbs and spices. Also, limit
processed foods, canned vegetables, soups and fast foods. These are high in sodium.
Fiber (found in many fruits and vegetables) helps the digestive tract run smoothly and prevents
constipation. Some fibers also may help lower blood cholesterol. Goal is 25–35 gm per day.
Water is important to keeping you hydrated. Water helps keep your kidneys healthy. Be sure
to drink 6–8 glasses of water daily.
116 NUTRITION
Vitamins & Minerals
Each vitamin and mineral plays an important role in maintaining lifelong healthy bodies.
Some of the more important are included here. The Recommended Daily Allowance (RDA)
or Recommended Dietary Intake (DRI) is given. Try to include sources of these vitamins and
minerals daily. If you cannot include all sources you may need a supplement.
Vitamin A: important for healthy eyes, skin and to help fight disease. Good sources include
bright orange and dark green leafy vegetables∗ , bok choy∗ , cantaloupe, pumpkin, dairy products
and fortified margarine. RDA is 5000 IU/day.
B vitamins: the B-complex group aids in carbohydrate metabolism, promotes appetite and
nerve function. Good sources include whole grains, legumes, dairy products, nuts, pork and
other lean meats. RDA and RDI vary for the B vitamins.
Vitamin C: helps fight disease and reduce risk of heart disease. Good sources include citrus
fruits, broccoli∗ , cantaloupe, papaya, strawberries, and spinach. RDA is 90 mg/day for males
and females, and 35 mg/day extra for smokers.
Vitamin D: helps bones and teeth harden and increases calcium and phosphorus absorption.
Good sources include vitamin D enriched dairy foods, fish oils and sunlight. RDA is 400
IU/day.
Vitamin E: antioxidant vitamin which helps in fighting disease. Good sources include veg-
etable oils, margarine, eggs, whole grains, wheat germ and leafy greens. RDA is 15 mg/day or
22 IU natural Vit E. Estimated safe daily intake is 800–1000 mg/day.
Minerals
Calcium: critical to strong bones and teeth. Good sources include all dairy products, dried
peas and beans, and most dark leafy greens. RDI for adults ranges from 1000–1300 mg/day.
The body can’t absorb calcium without vitamin D.
Chromium: may have an effect on lowering blood sugar in chromium deficient people. Pa-
tients getting total parenteral nutrition may experience improvement in peripheral neuropathy
after chromium replacement. Sources are brewer’s yeast, liver, kidney, wheat germ, corn oil,
whole grains, meats and cheese. RDI is 25–30 mcg/day. Estimated safe daily intake 50–200
mcg/day.
Iron: helps carry oxygen in the blood. Good sources are red meat, liver, molasses, dried beans
and enriched whole grains. Animal sources are better than plant sources. RDA range for adults
is 8–15 mg/day.
Magnesium: used by bones and teeth. It is vital to carbohydrate metabolism by activating
different enzymes. Good sources include green vegetables, avocados, bananas, whole grains,
NUTRITION 117
peanut butter and nuts. RDA range for adults is 320–420 mg/day. Estimated safe daily intake
is 350 mg/dl.
Potassium: works in concert with sodium to maintain the body’s fluid balance. It is also
involved in carbohydrate and protein metabolism. Good sources include most fruits, vegetables
and low fat yogurt. RDA is not established. Safe levels are between 1875–5625 mg/day.
Zinc: strengthens your immune system. Also important in metabolism of carbohydrates, fats
and proteins. Good sources include meat, dark poultry, shellfish, legumes and whole grains.
RDA is 15 mg/day. Safe levels are 40 mg/day.
If you feel you can’t get all your needed nutrients, consider a multivitamin. Chose a
supplement that contains a broad spectrum of vitamins and minerals.
∗ cruciferous (cabbage vegetables) which may help reduce the risk of some cancers
(Diabetes Education Society, 535 Detroit St, Denver, CO 80206 Telephone: (303) 670 7310 or (800) 659 5808
Web page: www.diabetesedu.org E mail: diabetes@diabetesedu.org)
118 NUTRITION
INTRODUCTION TO CARBOHYDRATE COUNTING
Why count carbohydrates or “carbs”?
Carbs raise your blood sugar so you need to know:

r Which foods contain carbs.
r How many carbs are in these foods.
r How many carbs you usually consume each day.
r How many carbs you need each day.
r How to check your blood sugar so you can balance your meals with medication and exercise
and achieve good control of your diabetes!
This packet provides information about foods that do and foods that do not contain carbs. You
will find a sample meal plan and a guide to reading food labels. To help figure out how many
carbs you need each day, it’s a good idea to talk to a Registered Dietitian. You should also
learn how to check your blood sugar.
r Knowledge and understanding are keys to your success.
Let’s start by looking at the foods you can eat freely.

Low or no carb vegetables !
Low or no carb vegetables are: Examples include

Low kcalorie and great sources of Asparagus, Broccoli, Carrots, Peppers, Cabbage,
vitamins, minerals, and fiber. Cauliflower, Green beans, Celery, Cucumber,
Try to eat veggies at least 2 or 3 Mushrooms, Onions, Romaine Scallions,
times a day. Summer squash, Zucchini
On the following page you will find out which vegetables you need to include in your carb
counting meal plan.
Which foods contain carbs? They are found in three main groups of foods:
r Starches including breads, grains, cereals, crackers, starchy vegetables
r Fruits all varieties
r Milks including milk, yogurt
You can either count carbs in grams or servings. Whichever way you choose, it’s a good idea
to remember the number fifteen because
r One carb serving equals 15 grams
NUTRITION 119
Each of the following carb servings contains approximately 15 grams

Breads Cereals and Grains Milk and Yogurt
Bagel, 1/4 of 1 whole Bran cereal, 1/2 cup Milk Skim, 1%, 2% 1 cup
Bread, 1 slice or 1 oz Bran flakes, 3/4 cup Dry milk powder, 1/3 cup
English muffin, 1/2 of 1 whole Oatmeal, cooked 1/2 cup Evaporated milk, 1/2 cup
Pancake or waffle, 1–4 inch Flour, 3 Tbsp Yogurt plain, 1 cup*
Tortilla corn / flour, 1–6 inch Rice cooked 1/3 cup Yogurt, sweetened, 1/2 cup
Pasta cooked 1/3 cup Soy milk, 1 cup
Crackers and Snacks Starchy Vegetables Fruits
Graham Crackers, 3 squares Beans, pinto 1/2 cup Apple or orange, 1 small
cooked
Popcorn, 3 cups Peas, 1/2 cup Banana, 1/2 medium
Rice cakes, 2–4 inch Lentils, 1/2 cup cooked Canned fruit, 1/2 cup**
Saltine—type crackers, 6 Corn or Hominy, 1/2 cup Grapes, 17 small
Potato, 1 small or 3 oz Juice orange, apple, 1/2 cup
Sweet potato, 1/2 cup Strawberries 11/4 cup whole
* artificially sweetened
** unsweetened
Other foods containing carbohydrate
Sweets Combination foods

They are of poor nutritional value so its best The following foods contain a variety of
to choose them occasionally for a treat! ingredients
Each of the following is approximately 1 Each of the following is approximately 1
carbohydrate (15 gram) serving:* carbohydrate (15 gram) serving:*
Cake (no icing), 2 inch sq Bean soup, 1/2 cup
Chocolate milk, 1/2 cup Beef stew, 1 cup
Jelly /Jam, 1 Tbsp Chili with beans, 1 cup
Gingersnaps, 3 Lasagna, 1 cup or 8 oz
Ice cream no sugar added, 1/2 cup Macaroni and Cheese, 3/4 cup or 3 oz
Pudding sugar free, 1/2 cup Pizza cheese thin crust, 1/8 of 10 inch pie
Pudding regular, 1/4 cup Spaghetti with tomato sauce, 1/2 cup
Sugar table or powdered, 1 Tbsp Combination/Fast Foods
Syrup light, 2 Tbsp
Big Mac, ® 1/3 of 1 whole
Syrup regular, 1 Tbsp
Cheeseburger, 1/2 burger
Vanilla wafers, 5
Subway sandwich, ® 1/3 of 6 inch sub
Most fast foods are high in kcalories,
sodium and fat
* Please read the food label on all prepared products for exact information on the total number of carbohydrate
grams contained in 1 serving.
120 NUTRITION
How do you figure out your daily carbohydrate consumption? A good start is to keep records
of your daily meals and snacks. Include all food and beverages and record portion sizes, e.g.,
1 cup, 1/2 cup, 2 slices, etc. This will help when working out the number of carbohydrates you
need each day
Foods that do not contain carbohydrates:
Meats, meat substitutes

Meats and meat substitutes are rich in protein. If you don’t exceed the recommended portion
size, they have very little effect on your blood sugar levels. Choose lean meats to cut down on
saturated fat and kcalories.
Recommended types and serving sizes are listed below:
Meats Meat Substitutes
One serving = 3 oz cooked: Serving sizes are listed below:
Chicken, Turkey breast no skin Low fat cheese, e.g. Mozzarella 3 oz
Fish or Shellfish Cottage cheese, 3/4 cup
Beef eye of round *Eggs (1–2) or egg whites (3)
Tuna fresh or canned in water Tofu non fat, 1/2 cup
*Eggs yolks are high in cholesterol. Limit 3 per week.
Fats
Like meats, fats have very little effect on your blood sugar levels. However, if you eat
excessive amounts, you will likely gain weight. Also, saturated fats may raise your blood
cholesterol levels. Try to limit saturated fats and instead use healthier unsaturated fats.
Recommended types and serving sizes are listed below
Unsaturated Fats Saturated Fats
Oils: canola, olive, peanut, 1 tsp Butter, Lard, 1 tsp
∗
Soft margarine / Mayonnaise, 1 tsp Bacon, 1 slice
Nuts, 6–10 Cream cheese, 1 Tbsp
Avocado, 1/8 of 1 whole Sour cream, 2 Tbsp
*Look for margarines labeled “No Trans Fat”
How much protein and fat do you need per day? Each person has different needs!
An approximate recommendation is:
r 2 servings of meat or meat substitute per day.
r 2–3 servings of fat per day.
Sample Meal Plan for carbohydrate counting
Please note that each person has individual needs. This is purely an example!
NUTRITION 121
Breakfast Food / Beverage Carb Grams Carb Servings

3
/4 cup Branflakes 15 1
1
/2 banana 15 1
1 cup 1% milk 15 1
Tea or coffee 0 0
Total 45 3
Lunch Food / Beverage
2 slices wholegrain bread 30 2
1 tsp mayonnaise 0 0
Lettuce, tomato, celery 0 0
3 oz tuna canned in water 0 0
1 small orange 15 1
Total 45 3
Evening Meal Food / Beverage
3 oz grilled chicken 0 0
1
/2 cup pinto beans 15 1
1/3 cup cooked rice 15 1
Large mixed salad 0 0
1 Tbsp oil / vinegar 0 0
1 1/4 cup strawberries 15 1
Total 45 3
Snack Food / Beverage
1 cup 1% milk 15 1
3 Graham crackers 15 1
Total 30 2
Daily Total Carb grams Carb servings
Meals 135 9
Snack 30 2
Grand Total 165 11
FOOD LABELS
When carb counting, take a step by step approach to reading labels

Make a note of:
r Serving size
r Total carbohydrate grams All carbs including sugar, other starches, and dietary fiber, are
contained in total carbohydrate grams.
When label reading, 12–18 grams carbohydrate counts as 1 carb serving

In each of the following examples, the total carbohydrate grams counts as 1 serving:
122 NUTRITION
Wholegrain bread
Nutrition Facts
Serving size: 1 slice
Kcalories: 70
Total fat 1 g
Sat fat 0 g
Total carbohydrate 13 g
Dietary fiber 2 g
Sugar 1 g
Protein 3 g
Unsweetened frozen pineapple

Nutrition Facts
Serving size: 1/2 cup
Kcalories: 70
Total fat 0 g
Cholesterol 0 mg
Dietary fiber 1 g
Sugar 13 g
Protein less than 1 g
Skim milk
Nutrition Facts
Serving size: 1 cup
Kcalories: 86
Total fat 0 g
Cholesterol 4 mg
Dietary fiber 0 g
Sugar 11 g
Protein 8 g
Please continue reading for information on the fiber rule! This shows how you can reduce
your total carbohydrate intake by eating high fiber foods!
The Fiber Rule

r As previously mentioned, all carbs including sugar, other starches, and dietary fiber, are
contained in total carbohydrate grams.
r Sugar and other starches convert to glucose in your body and will raise your blood sugar
levels.
r Fiber is not digested in your body so it will not raise your blood sugar levels.
r If the fiber content of the food is greater than 5 grams, you may deduct this amount from
the total carbohydrate grams.
NUTRITION 123
r The following example shows you how to use the fiber rule
High Fiber Cereal
Nutrition Facts
Serving size: 2/3 cup
Kcalories: 90
Total fat 1 g
Saturated fat 0 g
Cholesterol 70 mg
Dietary fiber 9 g
Sugar 6 g
Protein 2 g
r Subtract the dietary fiber from the total carbohydrate to find out how many carbs are in
this product. See below:
Total Carbohydrate 25
−9
Fiber
16
Total carbohydrate = 16 grams for 2/3 cup of this cereal.

16 grams = 1 carbohydrate serving
Check out the labels and choose high fiber foods!
(
c 2004 by Catherine Robinson, M.Ed., R.D., C.D.E., Tucson, AZ; reprinted with permission)
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8
Diabetes and Exercise

Scott Going1 and Betsy Dokken2
1 Departments of Nutritional Sciences and Physiology, University of Arizona, Tucson, Arizona
2 Department of Physiology, University of Arizona, and University Physicians, Healthcare, Tucson, Arizona
INTRODUCTION to improve diabetes control in people who al-

ready have the disease. These mechanisms are
While everyone can benefit from exer- reviewed below.
cise, those who have diabetes derive even
more benefit than most other people. Many Blood Glucose Control
people are aware of the benefits of exer-
cise, but have difficulty incorporating phys- One goal of diabetes management is to
ical activity into their lifestyles. The goal of control the blood glucose level, which will
this chapter is to review and discuss the prac- help to prevent or delay long-term complica-
tical aspects of using exercise to prevent and tions such as blindness, neuropathy, and kid-
manage diabetes. ney failure, and will decrease cardiovascular
risk. Exercise has been shown to be as ef-
fective at lowering the blood glucose level
BENEFITS OF EXERCISE as many oral hypoglycemic medications. The
IN PEOPLE WITH OR AT RISK reason that exercise is such an effective tool
FOR DIABETES in the management of diabetes is that it can
lower blood glucose in the absence of in-
Diabetes Prevention sulin action. Those who are insulin resistant,
such as the vast majority of people with type
Lack of exercise is one of the strongest 2 diabetes, have a decreased response to in-
predictors of the development of type 2 dia- sulin action, thus the ability to lower blood
betes. Many studies have shown a protective glucose independent of insulin is important.
effect of physical activity, and this protec- At the cellular and molecular level, defective
tion appears to be stronger in those at high- insulin signaling causes insulin resistance.
est risk: individuals who are obese and have a In other words, insulin resistance is the re-
strong family history of diabetes. The mech- sult of defects in the way certain molecules
anisms of diabetes prevention through exer- communicate to enable glucose uptake into
cise are thought to be similar to those at work muscle and fat cells via glucose transporter
125
126 DIABETES AND EXERCISE
proteins. Exercise is an effective treatment that it is more difficult. Exercise increases the
for insulin resistance because muscle con- body’s energy expenditure, and may help to
traction enables the signaling molecules to prevent the decreased metabolic rate that of-
communicate properly and cause glucose up- ten accompanies weight loss, which can lead
take into muscle cells without insulin action. to regain of lost weight.
Thus, a person with type 2 diabetes, who
has poor insulin action due to insulin resis- Blood Pressure
tance, can lower his/her blood glucose level by
exercising. About 70% of people with all types of
The acute effects of exercise can result diabetes have hypertension, and blood pres-
in lower blood glucose levels for up to 48– sure can be a stronger risk factor than blood
72 hours after the bout of exercise is com- glucose level for some of the major diabetes
pleted. Although these are short-term effects, complications (such as cardiovascular dis-
regular physical activity can result in an over- ease). Blood pressure control must be one of
all decrease in the insulin-resistant state—the the priorities for diabetes management. Reg-
earliest major metabolic defect in type 2 dia- ular exercise is associated with lower systolic
betes. Those with type 1 diabetes benefit from and diastolic blood pressures, independent of
glucose lowering ability as well, although other effects of training, such as weight loss.
in general the risks of hypoglycemia are in- According to the National Institutes of Health,
creased relative to those with type 2 diabetes regular aerobic exercise has been shown to
(see “Risks of Exercise” section). reduce resting blood pressure in people who
have hypertension by an average of 11 points
Insulin Sensitivity (systolic) and 9 points (diastolic).
Type 2 diabetes accounts for the vast ma- Depression

jority of all diabetes cases worldwide. By def-
inition, people with this disease are insulin Research suggests that over 50% of peo-
resistant, meaning that insulin action is in- ple with diabetes also suffer from depres-
efficient. Physical training (regular exercise) sion, although it is not yet known whether
has been shown to decrease body fat, fat cell this comorbidity is related to biochemical or
size, and blood insulin levels. Regular exer- psychosocial issues. Depression can severely
cise also results in higher levels of the glucose interfere with the multiple self-management
transporter proteins in muscle cells, without aspects of a diabetes treatment regimen; there-
which glucose is unable to enter cells to be fore, controlling depression is critical to the
metabolized. All of these mechanisms act to control of diabetes in patients who suffer from
improve the body’s sensitivity to insulin, and both. Studies have demonstrated that regular
these benefits persist as long as exercise is physical activity can work at least as well
performed regularly. Because of these effects, as any other treatment for mild to moder-
regular exercise can result in a decreased re- ate depression. Research in animals and hu-
quirement for exogenous insulin or other dia- mans indicate that exercise alters neurotrans-
betes medication. mitters that control emotion, can stimulate
the parasympathetic nervous system, and im-
Weight Control prove the ability of the body to tolerate stress
and to meet changing demands. Exercise also
Most people with type 2 diabetes are has definite cognitive effects; it has been
overweight, and weight loss and/or preven- shown to improve self-perception, provid-
tion of weight gain is important for long-term ing a sense of personal mastery and positive
diabetes management. Although it is possible self-regard. It also reduces negative thinking.
to lose weight without exercise, studies show These cognitive changes can be critical to a
DIABETES AND EXERCISE 127
person’s ability to control a chronic disease of life, and contributing to health outcomes.
such as diabetes. A program that encourages improvement in
each of these areas is generally recommended.
Lipids As noted above, research has shown that dis-
ease risk factors, e.g., fasting glucose, insulin,
Since diabetes is a disease of not lipids, and blood pressure, can be improved
only carbohydrate, but also fat and protein with moderate amounts of exercise. Achiev-
metabolism, it is not surprising that the ma- ing an adequate level of weekly energy ex-
jority of people with diabetes have distur- penditure is key and has led to public health
bances in lipid metabolism that result in dys- recommendations for weekly levels of exer-
lipidemia. Because dyslipidemia is a strong cise. Any physical activity that contributes
risk factor for the development of cardiovas- to increased daily energy expenditure can be
cular disease, and because people with dia- beneficial for weight control, lowering body
betes are already at very high risk, every ef- fat, and improving glucose regulation. Im-
fort must be made to normalize serum lipids. provements in other fitness components, such
Although most people will likely require med- as flexibility, muscular strength, and aerobic
ication to treat dyslipidemia to target levels, endurance, require more specific types and in-
exercise can be a useful adjunct to medica- tensity of exercise.
tions along with proper adjustments in nu-
tritional intake. Studies have shown that ex- Public Health Recommendations
ercise can help to lower triglyceride levels
and raise high-density lipoproteins (HDL— Research has shown that even modest
cholesterol), two changes that are necessary levels of physical activity have significant
in most patients with type 2 diabetes. Exercise health benefits if done on a regular basis.
has also been shown to change body com- Guidelines from the U.S. Centers for Dis-
position, so that visceral fat stores (“central ease Control and Prevention, endorsed by the
adiposity”) are decreased relative to subcuta- American College of Sports Medicine and
neous fat. Visceral fat has been implicated as the American Heart Association recommend
a major cause of the metabolic syndrome, and 30 minutes or more of moderate intensity ex-
therefore decreasing the depot of this type of ercise accumulated on most days of the week
fat results not only in improved insulin sensi- (Pate et al., 1995, pp. 402–407). Moderate in-
tivity, but also might decrease cardiovascular tensity is defined as an exercise heart rate in
risk in a number of other ways, such as by im- the range of 45–85% of maximum heart rate.
proving lipid profiles and prothrombotic char- This level of exercise corresponds to about
acteristics of the metabolic syndrome. 150 minutes per week and 700–1,000 cal of
energy expenditure per week depending on
frequency and intensity of exertion. Recent re-
GOALS OF EXERCISE search suggests that several short bouts (∼10
minutes) of exercise spaced throughout the
The overall goal of an exercise pro- day may be as beneficial as one sustained
gram is to achieve the health benefits de- bout, as long as ∼30 minutes of exercise is
scribed above. Other goals include improv- accumulated over the course of the day (Pate
ing flexibility, increasing muscular strength et al., 1995; DeBusk et al., 1990). Thus, the
and endurance, improving cardiorespiratory guidelines emphasize accumulating the rec-
function and aerobic endurance, and reduc- ommended minutes of exercise most days.
ing or maintaining body weight with appro- Physical activity in chores such as sweeping,
priate levels of bone, muscle, and body fat. raking, shoveling, and similar activities is also
These are all important goals, leading to in- beneficial, adding to daily energy expenditure,
creased functional capacity, improved quality as does other strategies like taking the stairs
rather than the elevator and parking a few the CDC guidelines and represents a useful
blocks from one’s destination and walking the long-term goal as fitness improves. This level
final distance. However, they can be difficult of exercise represents roughly 15–20 miles
to track and are recommended as an adjunct, of walking per week for an average weight
not a replacement, for planned exercise. individual.
Planned Exercise
Aerobic Endurance
Planned exercise is any physical activ-
Aerobic endurance supports the ability
ity done explicitly for the purpose of achiev-
to sustain repetitive dynamic activities that
ing a given health and fitness objective. The
require large muscle group involvement and
type, intensity, duration, and location of ac-
elevated breathing and heart rates, such as
tivity are planned to contribute to the desired
brisk walking, jogging, swimming, rowing,
results. The range of activities is broad, from
and cycling. Also referred to as cardiovascu-
a 30-minute walk with a friend to increase
lar fitness and aerobic fitness, it relates to the
energy expenditure, to a bout of weight lift-
ability of the circulatory and respiratory sys-
ing to improve muscular strength. We dis-
tems to supply oxygen during sustained phys-
tinguish planned activity from more informal
ical activity. A treadmill or cycle ergometer
strategies since planning, scheduling, and log-
exercise test of maximum oxygen consump-
ging activity improves awareness and ensures
tion (max V̇O2 test) is considered the best
progress toward exercise goals. Sample phys-
measure of cardiovascular fitness, although
ical activity planners and a log are given in the
field tests such as the 1-mile run or walk
Appendix.
reflect aerobic fitness. Moderate intensity aer-
obic activities require significant energy ex-
Weight Control penditure, contribute to weight management,
improve cardiac function and cardiovascular
While both moderate caloric restriction
and muscular efficiency, lower blood pres-
and increased energy expenditure are recom-
sure, and improve glucose metabolism.
mended for weight loss, an increased level
of daily physical activity is the best predic-
tor of sustained weight loss. Rhythmical aero- Muscle Strength
bic activities that engage large muscle groups,
such as walking, rowing, cycling, and swim- Adequate levels of muscle strength are
ming, and that can be sustained for several important for daily function. Muscle loss with
minutes or more are generally best suited for aging and reduced muscle strength contribute
increasing energy expenditure. These repre- to inactivity, physical impairment, lower
sent the most common activities prescribed resting energy expenditure, risk of weight
for improving aerobic capacity and metabolic gain, impaired glucose tolerance, and bone
risk factors. The CDC guidelines represent an loss. While walking, swimming, and simi-
ideal goal for overweight individuals begin- lar aerobic activities are essential for enhanc-
ning an exercise program. For some obese in- ing cardiorespiratory endurance, they have a
dividuals, this level of activity can be quite modest effect at best on lean mass and mus-
challenging, although it is more tolerable if cle strength. Muscle strength is best improved
shorter more frequent bouts of exercise are through weight lifting and other types of
prescribed. Research has shown that individ- resistance exercise. Persons with hyperten-
uals who are most successful at losing weight sion, nephropathy, neuropathy, or retinopa-
and keeping it off expend 1,500–2,000 cal thy should consult their physician before
or more in weekly exercise (Wing and Hill, beginning resistance exercise since elevations
2001). This is more than recommended in in blood pressure may put them at risk.
Flexibility edge that this high-risk population requires

careful screening for the presence of compli-
Poor flexibility is associated with joint cations that may be worsened by the exercise
stiffness and low back pain. Flexibility can program. In patients planning to participate in
be readily improved with a regular routine low-intensity forms of physical activity such
of static stretches. Improving flexibility may as walking, clinical judgment may be used in
help with stiffness and protect against injury deciding whether to recommend an exercise
during exercise. stress test.
Complications in addition to cardiovas-
cular disease that are potentially worsened by
RISKS OF EXERCISE IN PEOPLE exercise include (and are not limited to) di-
WITH DIABETES abetic retinopathy and neuropathy. Patients
who have proliferative diabetic retinopathy
For most people with diabetes, or at should avoid weight lifting and other phys-
risk for the development of the disease, the ical activity that involves straining, jarring,
benefits of exercise far outweigh the risks. or Valsalva-like maneuvers. Patients with di-
However, some precautions must be taken abetes who are interested in strength training
when making exercise recommendations in or body building programs must receive ap-
this high-risk population. proval from their eye care professional prior
to their participation.
Exercise Assessments
Prior to recommending exercise to a pa- Hypoglycemia

tient with diabetes, a careful medical history
It is important for the clinician to realize
and physical examination should be done with
that not all patients with diabetes are at risk
a focus on the symptoms and signs of disease
for hypoglycemia (low blood glucose). Many
affecting the heart and blood vessels, eyes,
patients with type 2 diabetes are able to con-
kidneys, feet, and nervous system.
trol blood glucose levels without the use of
According to the American Diabetes
medications that increase insulin levels, and
Association’s 2004 Clinical Practice Recom-
thus do not experience insulin-induced hypo-
mendations, an exercise stress test is recom-
glycemia. In contrast, patients with type 1 di-
mended for people who meet the following
abetes must rely on exogenous insulin, and
criteria:
therefore are by definition at risk for hypo-
r Age >35 years, glycemia.
r Age >25 years, and Hypoglycemia occurs in people with di-
◦ Type 2 diabetes of >10 years’ du- abetes as a result of a mismatch between the
ration amount of insulin required to promote ade-
◦ Type 1 diabetes of >15 years’ du- quate glucose uptake into cells (under present
ration. and potentially changing conditions) and the
r Presence of any additional risk factor for
amount of insulin action during the same
coronary artery disease, time period. Because sulfonylurea medica-
r Presence of microvascular disease (pro-
tions act by increasing insulin release from
liferative retinopathy or nephropathy, including mi-
the pancreas, patients taking these drugs can
croalbuminuria),
r Peripheral vascular disease, and experience the same mismatch of insulin need
r Autonomic neuropathy. and insulin availability. Patients with diabetes
are often in the difficult situation of wanting
Although these criteria may seem con- to normalize their glucose levels for preven-
servative, and most adults with diabetes would tion of complications and experiencing more
meet at least one, it is important to acknowl- hypoglycemia when they improve glycemic
control. Hypoglycemia is very common in TABLE 8.2. Medications that

such situations. Increase Pancreatic Insulin Release
In part, it is difficult to predict and “stan-
Generic name Brand name
dardize” the amount of glucose entering the
bloodstream (dietary carbohydrate, endoge- Repaglinide Prandin
nous glucose production) and the amount ex- Miglitol Glyset
iting the bloodstream by means other than
insulin (exercise). As discussed earlier, exer- In addition to sulfonylureas, other drugs
cise promotes the transport of glucose out of work by increasing insulin release from the
the bloodstream and into muscle cells aside pancreas and also can potentially cause hy-
from insulin action, thus resulting in a low- poglycemia. However, these drugs are very
ering of blood glucose levels in addition to short-acting and should be taken only with
that caused by insulin. The amount of glucose carbohydrate-containing meals. Patient edu-
lowering depends upon not only the duration cation regarding the actions of medications
of the activity, but also on the intensity. The should significantly reduce the side effect of
timing of physical activity also may be impor- hypoglycemia (Table 8.2)
tant in those who use medications that have a
“peak action” such as intermediate-acting in-
sulin. Because of the many variables involved, EXERCISE RECOMMENDATIONS
exercise-induced hypoglycemia can be a com-
mon, unpredictable, and dangerous complica- Exercise prescriptions consider fre-
tion of their diabetes. quency, duration, intensity, and types of exer-
As mentioned earlier, all types of insulin cise (Table 8.3). Together, these variables de-
have the potential to cause the side effect of termine total energy expenditure and the type
hypoglycemia. In addition, all medications of adaptation (e.g., muscle strength versus en-
that act to increase blood insulin levels can durance) that can be expected.
also cause hypoglycemia. These include sul-
Frequency
fonylureas and combination medications con-
taining sulfonylureas (Table 8.1). Some form of exercise can be done on
most if not all days of the week. Low-to-
moderate intensity aerobic exercise can be
TABLE 8.1. Medications that Increase
done on a daily basis without undue stress.
Blood Insulin Levels
More intense aerobic activity should be fol-
Generic name Brand name lowed by less intense exercise or a rest day
to ensure adequate recovery. Stretching exer-
Newer (second generation),
more likely used
cises are safe to do every day. Strengthening
Glyburide Diaβeta, Micronase, exercises require a rest day between workouts.
Glynase Research has shown significant improvements
Glipizide Glucotrol XL in muscle strength and bone mineral density
Glimepiride Amaryl with two days of weight training per week.
Older (first generation),
less likely used
Thus, two and not more than three weight
Chlorpropamide Diabenese training sessions per week are recommended.
Tolazamide Tolinase
Tolbutamide Orinase Intensity
Combination drugs containing
sulfonylureas Moderate intensity aerobic exercise is
Glyburide and Metformin Glucovance defined as an aerobic activity that elicits
Glipizide and Metformin Metaglip
a heart rate of approximately 45–85% of
TABLE 8.3. Example of Exercise Prescription Focused on Major Fitness Components

Goals Improve major fitness components: aerobic endurance, muscular strength and endurance,
flexibility, body weight and composition.
Energy expenditure: ≥700–1,500 cal per week
Mode Matched to goal (fitness component) and participant interest
Aerobic endurance → rhythmical, large muscle group activity that elevates heart rate and
respiration.
Muscle strength and endurance → resistance exercise
Flexibility → static stretching
Body weight/composition → energy expenditure
Frequency Overall: 5–7 days per week
Aerobic endurance → 4–7 days per week
Muscle strength and endurance → 2–3 days per week
Flexibility → 5–7 days per week
Body weight/composition → 5–7 days per week
Intensity Aerobic endurance → 50–85% of max HR
Muscle strength endurance → loads that allow 8–12 repetitions; final rep is challenging to complete
Flexibility → hold for 15–30 seconds, at point just before discomfort
Duration Overall: accumulate ≥30 minutes per day; 10–60 minutes per session, depending on goal, mode
and fitness level.
Aerobic endurance → 10–60 minutes per session
Muscle strength and endurance → 30–60 minutes per session
Flexibility → 10–15 minutes per session
Body weight/composition → ≥30 minutes per day
maximum heart rate. This is roughly equiv- musculature, such as walking, jogging, swim-
alent to brisk walking or easy jogging (4– ming, and cycling, and which can be sus-
6 mph). Most individuals are able to carry on tained for at least several minutes, generally
a conversation during moderate intensity ex- elicit the greatest energy expenditure. Reg-
ercise, which is a good practical guide. Loads ular aerobic activity improves cardiorespira-
that can be lifted 8–12 times are considered tory function, muscular endurance, and con-
moderate loads during weight lifting exercise. tributes to weight reduction and reduced body
fat. Weight training and other forms of re-
Duration sistance exercise (e.g., cycle ergometers and
rowing machines with adjustable levels of
Total exercise of 30–60 minutes per day
resistance) are necessary to improve muscle
is sufficient to achieve most exercise goals.
strength. Resistance exercise also contributes
Shorter bouts of 10 minutes each have been
to energy expenditure, although potentially
shown to have substantial benefit, as long as
less than aerobic activity because of its inter-
about 30 minutes are accumulated over the
mittent nature with frequent rest intervals be-
course of the day. Weight training sessions
tween sets. Stretching exercises must be per-
typically last 30–60 minutes. This amount of
formed to improve flexibility.
time is needed to exercise all major muscle
groups and for adequate rest between sets.
Only active time should be counted toward Energy Expenditure
the weekly minute’s goal.
The Diabetes Prevention Program’s
Type (DPP), Lifestyle Change Program, clearly
showed exercise, along with healthy eating
It is important to match the type of ac- and modest weight reduction (∼7% of body
tivity with the desired goal. Rhythmical aero- weight), can dramatically reduce the risk of
bic activities, which engage large amounts of type 2 diabetes in individuals with impaired
glucose tolerance (DPP, 2002). The DPP ex- Progression

ercise goal of 700 cal of energy expenditure
in moderate intensity exercise was chosen be- A conservative progression encourages
cause it is feasible for most individuals to at- increasing frequency followed by duration
tain. This goal corresponds to approximately and intensity. For previously inactive individ-
150 minutes of physical activity similar in in- uals, 3 days of exercise per week, of up to
tensity to brisk walking. Participants were en- 30 minutes per day, is a good beginning. A
couraged to distribute their activity through- minimum of 10 minutes per session is recom-
out the week with a minimum frequency of mended. An additional day per week is added
three times per week, with at least 10 min- until the participant is exercising 5 or more
utes per session. A maximum of 75 minutes days per week. Once the exercise “habit” is es-
of strength training could be applied toward tablished, increasing duration in not more than
the total 150 minutes weekly activity goal. 30 minutes increments per week over 5 weeks
is recommended until the 150 minutes per
week goal is reached. A total weekly energy
Walking versus Other Activities
expenditure of 700 cal, roughly equivalent to
Many adults choose walking as their pri- 150 minutes per week of moderate intensity
mary mode of exercise because it requires no exercise, is considered feasible and sustain-
special equipment, other than a good pair of able, and has been shown to be sufficient to
walking shoes, and can be done just about any- produce improvements in weight, glucose, in-
where. A beginner’s walking plan is given in sulin sensitivity, and overall health. This is
the Appendix. Other activities, equivalent to considered the minimum amount of weekly
brisk walking, such as aerobic dance, bicy- exercise. Successful long-term maintenance
cle riding, swimming (laps), and skating, can of weight loss has been associated with ap-
be equally effective for increasing weekly en- proximately 1,500–2,000 cal of energy expen-
ergy expenditure. Any safe, enjoyable activity diture per week, or roughly 15–20 miles of
that requires large muscle activity should be brisk walking (or the equivalent activity) per
encouraged. week. This level of exercise represents a long-
term goal, to be undertaken once the min-
imum has been successfully maintained for
Flexibility
∼3 months. This gives adequate time to im-
Approximately 10 minutes of static prove fitness and establish a base from which
stretching exercises are recommended 3– more intense exercise can be safely under-
7 days per week. Stretching is best done after taken. The increased energy expenditure can
light-to-moderate aerobic activity when the be accomplished by gradually increasing du-
body temperature is slightly increased and ration or intensity of exercise. For many indi-
the muscles are warmed. Stretching during viduals, there is limited time for exercise, so
cooldown is the recommended time. Upper gradually increasing intensity (speed of walk-
and lower body stretches of all major mus- ing for jogging) becomes the most feasible
cle groups should be done. Static stretches way to increase energy expenditure for indi-
that slowly elongate the muscle are recom- viduals who are willing and able, without ex-
mended, along with holding the stretched cessive time demands.
position just before the point of discomfort. Static stretching can be done every day.
Specific stretches should be chosen in collab- No more than 5–10 minutes is needed to per-
oration with a physical therapist or exercise form 4–5 stretches that stretch each major
specialist, considering past injury, joint lax- muscle group. Each stretch should be held
ity, or other imbalances, so as to not exacer- for 15–30 seconds. Assisted stretching pro-
bate existing conditions. Ballistic movements cedures like proprioceptive neuromuscular fa-
should be avoided. cilitation may facilitate greater improvements
in flexibility, but should be performed with advantage, so participants may be grouped by

care by trained partners, physical therapists, fitness and experience.
or sports medicine personnel. Health and fitness facilities often offer a
Strength training is recommended 2– menu of classes that emphasize a particular
3 days per week. No more than 2–3 sets of 8– fitness component, e.g., traditional aerobics
12 repetitions with the major muscle groups classes, and aerobics classes that use equip-
are needed to increase muscle strength and ment such as steps and bikes designed to im-
muscle mass. A typical progression is to be- prove cardiovascular fitness; weight training
gin with loads that can be lifted 8 times and classes to improve muscle strength; and yoga
increase repetitions over several sessions until and stretching classes to improve flexibility.
12 repetitions are achieved. The load is then For individuals without medical contraindica-
increased by 2–10 lbs (depending on the mus- tions and who are interested, enrolling in “spe-
cle group), repetitions decreased to 8, and the cialty” classes is enjoyable, motivating, and
cycle repeated. beneficial. Alternatively, classes can be struc-
tured to improve multiple fitness components.
Group Exercise Classes Typically, light-to-moderate aerobic activity
for warm-up is followed by more vigorous
Group exercise classes are beneficial for aerobic and resistance exercise for improv-
individuals who enjoy the camaraderie of ex- ing aerobic endurance and muscle strength.
ercising with other individuals, and they pro- Stretching for flexibility is done during a
vide an opportunity for persons with lower cooldown period following the more vigor-
self-efficacy to learn from leaders and more ous portion of the session. In the group setting
experienced classmates. Group classes allow when all individuals are performing the same
facilities to provide instruction, motivation, exercise, caution in selecting appropriate ex-
and guidance to participants at a relatively ercises for all ages, disabilities, and skill levels
low cost. However, they must be designed is crucial. When selecting exercises appropri-
in a manner that is consistent with the spe- ate for the group, the following evaluation is
cific goals and objectives of the participants, recommended; a yes answer to all questions
which can be challenging if the group is very is required to maximize participants’ safety.
diverse. Instructors must be knowledgeable
r Is the exercise safe for all participants
about health risk factors, be able to conduct
appropriate screenings, and modify programs based on age and health status?
r If the exercise is safe, are the participants
for special needs. Instructors must hold ap-
able to perform the exercise properly?
propriate certifications from nationally rec- r Is this exercise an effective way to in-
ognized organizations, such as the American crease flexibility, strength, coordination, balance,
College of Sports Medicine’s Group Exercise or cardiovascular endurance?
Leader Certification.
Participants must have undergone appro- ACSM’s Resource Manual for Guide-
priate screening and instructors must review lines for Exercise Testing and Prescription
and consider screening results for all class contains a detailed list of common high-risk
members when designing the class. Ideally, exercises and recommendations for alterna-
a group of individuals would start the class tive exercises (American College of Sports
and progress together, although in commu- Medicine, 2001). Finally, all facilities should
nity and clinical settings, this is often not fea- have a written emergency plan for medical
sible. The leader must be aware of each par- complications, and exercise class leaders must
ticipant’s fitness level, and the class must be be familiar with them and certified in CPR and
structured so that participants can exercise at first aid. The Active Living Leadership, a na-
an appropriate intensity. Offering beginning, tional project supported by the Robert Wood
intermediate, and more advanced classes is an Johnson Foundation, has recently launched
an online calculator (see “Resources” sec- barriers to exercise must be identified and
tion) that can be used to estimate the financial addressed, and the importance of planning,
cost of physical inactivity. This tool is useful scheduling, and monitoring activity must be
for demonstrating to individuals and employ- discussed. Appropriate forms for planning
ers the costs of inactivity, the savings associ- and logging activity should be given to the
ated with becoming more active, and may be participant.
motivational. These issues can best be addressed one-
on-one with a counselor or any other trained
personnel. They also can be addressed in a
MOTIVATING PEOPLE group setting, led by a facilitator, as long as
TO EXERCISE a nonjudgmental, supportive environment is
maintained. The key is for individuals to self-
The greatest challenge of any behavioral identify challenges and personal solutions,
intervention is supporting patients in their although hearing other people’s challenges
goal of sustaining the new behavior until it is and solutions can be insightful, and problem-
incorporated into their daily routine and be- solving with the group is often helpful. Indi-
comes a way of life. According to the CDC, vidualization and enjoyment are keys to long-
fewer than 50% of adults engage in the recom- term motivation.
mended amount of exercise, and about 25% of Participating in a variety of fun activi-
adults report no leisure time physical activity. ties is motivational for many individuals; oth-
In today’s hectic world, with the demands of ers are creatures of habit and prefer to stick
job, spouse, children, friends, and other obli- with one activity. Finally, an appropriate sup-
gations, there is little time left for exercise port system is essential. For some persons,
and other leisure pursuits, or so it seems. Per- the opportunity for social interaction is attrac-
ceived time constraints are probably the most tive, and exercising with a buddy or group
cited barrier to regular activity, and inactive is motivational. Others view exercise as an
individuals need help restructuring their pri- opportunity for much-needed “solitude,” and
orities. Frequent stress may contribute to de- need understanding and support from others
pression, lethargy, and little enthusiasm for to reprioritize and take personal time. Some
physical activity. Others may lack confidence people need help in identifying their interests
that they can exercise or be fearful of injury, and exercise “personalities,” and encourage-
and some confuse fatigue with pain and in- ment to ask for the support they need from
jury. Still others set unrealistic goals and be- friends and family. It is important to recog-
come discouraged when they are not met, or nize that life challenges are constantly chang-
take on “too much too soon”, and experience ing. Thus, psychosocial issues impacting on
excessive soreness or injury. Even before an exercise and other healthful lifestyle behav-
exercise program is begun, it is imperative that iors should be revisited often and strategies
these issues be addressed. Too often, patients revised right along with traditional prescrip-
are told they should get more activity without tion variables such as frequency, intensity, du-
instruction on how, or are given a prescription ration, and mode of exercise.
or sent to a gym without addressing psychoso-
cial concerns. Lacking an adequate support Creating Readiness and Stages of Change
system, it is understandable why they fail.
Participants need to know what they can People are more likely to adopt and sus-
and cannot safely do, and they need to be tain healthy behavior when they are ready to
taught the difference between fatigue and un- change. The Transtheoretical Model of Be-
due soreness. Realistic goals (short- and long- havior Change (Prochaska and DiClementi)
term) and a realistic progression linked to postulates people move through a series of
those goals must be established. Perceived stages while adopting and sustaining a new
behavior. The stages are precontemplation (no signals for relapse, such as actual or antici-
intent and no exercise), contemplation (intent, pated reduction frequency, and develop writ-
but no exercise), preparation (intent and oc- ten strategies to deal with situations that in-
casional exercise), action (regular exercise), terrupt exercise, such as illness, injury, and
and maintenance (exercising for 6 months or changes in schedule.
more). Progression through these stages can
be facilitated by targeted strategies. For ex-
ample, individuals in precontemplation and ASSESSMENT
contemplation may be helped by receiving in-
formation on the health benefits of exercise, The recommended screening procedures
instructions from a person of authority (health before beginning exercise in patients at risk or
care provider), interactions with role models with diabetes are given below. In addition to
(in person, or through audio or videotapes), the usual medical screening, evaluation of ac-
and through examination of previous attempts tivity history, self-efficacy for exercise, exer-
that may reveal ways to encourage adoption in cise barriers, motivation, social support, and
a future attempt. Incentives and disincentives readiness for activity are useful for develop-
are important antecedents for health behav- ing strategies for adoption and maintenance
ior change. Incentives should be built into the of exercise.
program and outweigh disincentives. Reduc-
ing disincentives, such as exercising at an in- Medical Screening
convenient time, an unappealing place, or an
unenjoyable activity, is very important. Goal Screening is required prior to recom-
setting is also an important part of the adop- mending individual exercise programs. For
tion phase. Asking participants to list goals newly diagnosed patients or those without
and identify areas where assistance is needed up-to-date medical records, a history and
may be effective in encouraging change. physical examination are required, including
Once a behavior is adopted, other factors diabetes evaluation, evaluation of retinopathy,
determine maintenance. Behavior that is sat- neuropathy, and nephropathy, cardiovascular
isfying (reinforcing) or reduces discomfort is evaluation, serum lipid profile, and an exer-
likely to be maintained. Four strategies have cise ECG in patients with known or suspected
proved useful in enhancing maintenance: (1) CAD. Specific recommendations are given in
monitoring (e.g., keeping logs) and feedback Table 8.4.
of change; (2) reinforcement—making the ac-
tivity as satisfying as possible; (3) anticipat- The Physical Activity Readiness
ing relapse or interruptions (relapse preven- Questionnaire (PAR-Q)
tion); and (4) making a formal commitment
(contract). Monitoring may take the form The PAR-Q was developed to identify
of self-reports, diaries, or physiological test- people who may need a medical evaluation
ing. Monitoring forms can be used together prior to beginning an exercise program.
with exercise staff to determine progress and This questionnaire would be appropriate for
for problem-solving. Reinforcement may take community prevention programs that include
many forms—social and symbolic reinforcers healthy people as well as those with chronic
include attention, praise, money, and awards. health challenges. “Translation, reproduction,
It is important to recognize that reinforcers are and use in its entirety” are encouraged by the
idiosyncratic, and the particular reinforcers developers, the British Columbia Ministry of
must be appealing to the participant. Relapse Health. The document can be found online
prevention may be especially important. Upon at: http://www.nsa-norva.navy.mil/mwr/Phy
initiation of a program, participants should be sical%20Activity%20Readiness%20Questio
encouraged to monitor exercise, identify clear nnaire.pdf.
TABLE 8.4. Recommended Screening Procedures Before Beginning Exercisea

History of physical examination for those new diagnosed or without up-to-date records
Review all systems
Identification of medical problems (e.g., asthma, arthritis, and orthopedic limitations)
Diabetes evaluation
Glycosylated hemoglobin (HbA1 )
Ophthalmoscopic examination (retinopathy)
Neurological examination (neuropathy)
Nephrological evaluation (microalbumin or protein in urine)
Nutritional status evaluation (underweight, overweight)
Cardiovascular evaluation
Blood pressure
Peripheral pulses
Bruits
12-lead electrocardiogram
Serum lipid profile (total cholesterol, triglycerides, HDL, and LDL cholesterol)
Exercise ECG in patients with known or suspected CAD (for IDDM, those over 30 years of age or diabetes of
longer than 15 years’ duration; for NIDDM, those over 35 years of age)
a
From Campaigne (2001, pp. 227–284).
Physical Activity History Change questionnaire can be administered.

The participants are asked to consider five
Knowing a person’s activity history, in- statements regarding their exercise intent and
cluding their activity successes and failures, recent history, and indicate which statement is
is helpful in planning their activity program. true for them. Knowledge of the participant’s
This can be assessed informally by asking readiness can help focus efforts designed to
what activities they enjoy, whether they pre- encourage behavior change. For more infor-
fer group or individual activities, team, dual mation on the Transtheoretical Model and
or individual sports, their skill level and con- Stages of Change, see the article by Marcus
fidence, and frequency of participation. It is and Simkin (1994).
useful to assess at least the past 6–12 months
history. A number of physical activity ques- Exercise Perceived Barriers
tionnaires have been developed, and many
are reviewed in A Collection of Physical Ac- Perceived barriers to exercise are as-
tivity Questionnaires for Health-Related Re- sessed with questions surveying the demands
search (Pereira et al., 1997). The book by on the participant’s time, motivation, family
Montoye and colleagues is another helpful re- obligations, health, and interest in exercise.
source (Montoye et al., 1996). A checklist of Identification of potential barriers is the first
common activities, which assesses typical fre- step in developing a plan for removing barri-
quency and duration of participation is useful ers and sustaining compliance. The question-
for the purpose described. naire is available in the article by Steinhardt
and Dishman (1989).
Readiness for Change Exercise Intrinsic Motivation

Informally, a participant’s readiness to The Exercise Intrinsic Motivation ques-
undertake an exercise program can be as- tionnaire addresses interest in physical activ-
sessed by asking him/her to rate on a 10-point ity, enjoyment, perceived skill, and anxiety
scale his/her readiness to adopt and sustain an during physical activity. Along with per-
exercise program (1 = not ready, 10 = very ceived barriers, knowledge of intrinsic mo-
ready). More formally, the Exercise Stages of tivation aids in planning programs to enhance
compliance. The questionnaire can be found so they experience early success and build
in the article by McAuley et al. (1989). confidence. Exercising with a more experi-
enced “buddy” also may help them build
Exercise Self-efficacy confidence (Sallis et al., 1988; Sallis et al.,
1987).
The exercise self-efficacy question- A flow chart summarizing steps for
naire assesses a person’s confidence that screening, exercise prescription, and promot-
they can stick with an exercise program ing adoption and maintenance of regular ac-
when confronted with various situations and tivity is given in Figure 8.1. Exercise prescrip-
challenges. Individuals with low self-efficacy tion guidelines are summarized in Table 8.3
are at risk for poor compliance and may and recommended screening procedures be-
benefit from more frequent monitoring and fore beginning exercise are summarized in
social support. Realistic goals must be set, Table 8.4.
Readiness?
Stage appropriate counseling
PA readiness questionnaire No and encouragement
PA history questionnaire
Attitudes, values, barriers
Physician reinforce
Yes PA messages
Medical Contraindications?
Medical history
PARQ No Age ≥ 35 yr No
Physical examination
Yes Exercise
prescription
Goals
Yes
Mode
Cardiovascular disease?
Orthopedic Frequency
Hypertension?
limitations?
Retinopathy?
Intensity
Nephropathy?
Duration
Yes No
See Table 8.3
Yes
Avoid moderate to high

intensity weight lifting, other Cycle or arm Treadmill GXT (if any
forms of resistance exercise, ergometer additional risk factors)
and intense aerobic activity GXT
unless cleared by a patient's
health care provider Symptom-limited: HR,
BP, ECG, VO2
FIGURE 8.1. Steps for promoting and prescribing exercise. PA = physical activity, PAR-Q = physical activity
readiness-questionnaire, GXT = graded exercise test.
APPENDICES
Walking Planner
Weekly goals: minutes/ steps
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Duration Duration Duration Duration Duration Duration Duration

1 Location Location Location Location Location Location Location
Time Time Time Time Time Time Time
# Steps # Steps # Steps # Steps # Steps # Steps # Steps



Daily
Total
Min
Daily
Total
Minutes Steps
Steps Week’s
totals
Note. In the Total steps boxes, write steps for the entire day.
Physical Activity Planner

Name: No
Month:
Week’s goals: Time Minutes
Calories cal
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Activity 1 Activity 1 Activity 1 Activity 1 Activity 1 Activity 1 Activity 1

AM
Location Location Location Location Location Location Location
Calories Calories Calories Calories Calories Calories Calories

AM

AM
PM
TOTALS
(CAL)
Week’s
total
Important questions to consider while building your physical activity plan:
What physical activities do I enjoy?

What physical activities can I realistically engage in this week?
Can I engage in those activities safely (e.g., right shoes, hydration, etc.)?
How much activity do I need to meet my energy expenditure goal for this week?
How much rest should I get between activity days/sessions?
Can I involve anyone else in my physical activity Action Plan? Do I want to?
Physical Activity Log
Name:
Date Time of Day Description of Physical Duration Comments

Activity (type, intensity, (minutes)
etc.)
8/16/00 7:30 AM Brisk walk, 3.5 mph 40 Felt great; try some
jogging next time
8/17/00 4:00 PM Swimming, leisurely 30 With Janet, bring water
bottle
Notes:
Beginner’s Twelve Week Walking Schedule
This beginner’s program is designed to get previously inactive persons in the habit and walking
60 minutes in 12 weeks. Warm-up and cooldown are included in the scheduled minutes.
Consistency is the key to creating a new habit, even if initially the minutes must be reduced.
Listen to your body and adjust accordingly. This schedule is meant as a guide. The starting
point may be too strenuous or too light. Try to keep your easy and harder days in the same order.
It is natural to feel a little tired or have a few aches when beginning a fitness program. However,
if you are “worn out” or have pain, add a rest day. If the pain continues, see a physician.
Sun Mon Tue Wed Thu Fri Sat
Week 1 15 min 15 20 15 20 15 20
Week 2 15 min 20 20 15 20 15 25
Week 3 15 min 25 20 15 25 20 25
Week 4 20 min 30 20 20 25 20 30
Week 5 20 min 30 30 20 30 20 35
Week 6 25 min 30 30 25 30 25 40
Week 7 25 min 30 40 30 30 30 40
Week 8 25 min 30 40 30 30 30 40
Week 9 30 min 40 40 30 40 40 50
Week 10 30 min 40 50 30 50 40 50
Week 11 40 min 40 50 40 50 40 50
Week 12 40 min 40 60 40 60 40 60
Resources
1. American Diabetes Association (ADA): web site: http://store.diabetes.org/adabooks/

The ADA provides information to people with di- product.asp?pfid=922&WTLPromo
abetes, health care professionals, and the general =EXERCISE book smallsteps
public. A variety of programs targeted to prevent- d. [d.] Diabetes Risk Test: A question-
ing diabetes and its complications in high-risk pop- naire developed to evaluate the risk of hav-
ulations are available for implementation in coming or developing Type 2 Diabetes. Use-
munities. ful for health fairs or community health
a. Home page: www.diabetes.org screenings.
b. Exercise information for pa- e. African American Programs:
tients: http://www.diabetes.org/weightloss- http://www.diabetes.org/community
and-exercise/exercise/overview.jsp programs-and-localevents/africanamericans
c. Small Steps, Big Rewards Program: .jsp
The ADA and the National Diabetes Educa- f. Latino Programs: http://www.
tion Program (NDEP) have designed a na- diabetes.org/communityprograms-and-
tional awareness campaign to target people localevents/latinos.jsp
at risk for type 2 diabetes. The campaign will g. Native American Programs:
create awareness that type 2 diabetes can be http://www.diabetes.org/community
prevented through modest lifestyle changes programs-and-localevents/ nativeamericans
and losing about 5–7% of body weight (trans- .jsp
lation of the DPP results into practice). A 2. Diabetes Exercise and Sports As-
walking kit with pedometer (step counter) is sociation: http://www.diabetes-exercise.org/
available for purchase through the following index.asp
3. National Center for Bicycling and Walk- Marcus, B.H., and Simkin, L.R. (1994). The transtheoret-
ing: The mission of this organization is to create ical model: Applications to exercise behavior. Med
bicycle-friendly and walkable communities. The Sci Sports Exerc 26(11):1400–1404.
website includes valuable information that can be McAuley, E., Duncan, T., and Tammen, V.V. (1989).
Psychometric properties of the Intrinsic Motivation
applied to any community, including assessment
Inventory in a competitive sport setting: A confir-
tools: http://www.bikewalk.org/index.htm
matory factor analysis. Res Q Exerc Sport 60(1):
4. Centers For Disease Control Exercise 48–58.
Recommendations: http://www.cdc.gov/nccdphp/ Montoye, H.J., Kemper, H.C.G., Sarris, W.H.M., and
dnpa/ physical/recommendations Washburn, R.A. (1996). Measuring Physical Activ-
5. NIDDK: Information on Physical Activ- ity and Energy Expenditure. Champaign, IL: Human
ity and Weight Control: http://www.niddk.nih.gov/ Kinetics.
health/nutrit/pubs/physact.htm Pate, R.R., Pratt, M., Blair, S.N., Haskell, W.L., Macera,
6. Active Living Leadership (http://www C.A., Bouchard, C., Buchner, D., Ettinger, W.,
.activelivingleadership.org), physical in- Heath, G.W., and King, A.C. (1995). Physical ac-
tivity and public health. A recommendation from
activity cost calculator (http://www
the Centers for Disease Control and Prevention and
.activelivingleadership.org/ costcalc.htm)
the American College of Sports Medicine. JAMA
273(5):402–407.
Pereira, M.A., FitzerGerald, S.J., Gregg, E.W., Joswiak,
M.L., Ryan, W.J., Suminski, R.R., Utter, A.C., and
REFERENCES Zmuda, J.M. (1997). A collection of physical activ-
ity questionnaires for health-related research. Med
American College of Sports Medicine. (2001). ACSM’s Sci Sports Exerc 29(6):S5–205.
Resource Manual for Guidelines for Exercise Test- Sallis, J.F., Grossman, R.M., Pinski, R.B., Patterson, T.L.,
ing and Prescription, 4th ed. Baltimore, MD: and Nader, P.R. (1987). The development of scales
Lippincott, Williams & Wilkins. to measure social support for diet and exercise be-
Campaigne, B.N. (2001). Exercise and diabetes mellitus. haviors. Prev Med 16(6):825–836.
In ACSM’s Resource Manual for Guidelines for Ex- Sallis, J.F., Pinski, M.A., Grossman, R.B., Patterson, T.L.,
ercise Testing and Prescription, 4th ed. Baltimore, and Nader, P.R. (1988). The development of self-
MD: Lippincott, Williams & Wilkins, pp. 227–284. efficacy scales for health-related diet and exercise
DeBusk, R.F., Stenestrand, U., Sheehan, M., and Haskell, behaviors. Health Edu Res 3:283–292.
W.L. (1990). Training effects of long versus short Steinhardt, M.A., and Dishman, R.K. (1989). Reliability
bouts of exercise in healthy subjects. Am J Cardiol and validity of expected outcomes and barriers for
65(15):1010–1013. habitual physical activity. J Occup Med 31(6):536–
DPP. (2002). Description of lifestyle intervention, from 546.
the Diabetes Prevention Program (DPP) Research Wing, R.R., and Hill, J.O. (2001). Successful weight loss
Group. Diabetes Care 25:2165–2171. maintenance. Annu Rev Nutr 21:323–341.
9
Living Well with Diabetes

An Approach to Behavioral Health Issues
Tim Moore
Marana Health Center, Marana, Arizona
INTRODUCTION Medical Management
Effective management is critical when The first leg of the stool is effective med-
you are living with a chronic condition like ical management. Most patients think that
diabetes, a condition for the most part that is effective medical management means taking
not curable. In order for this management to medications as prescribed, seeing a physician
be effective, it needs to be as comprehensive or provider regularly, and perhaps, having a
as possible. This chapter will offer health care quality relationship with their physician or
providers a comprehensive approach to help- provider that allows them to ask questions
ing individuals cope with chronic illnesses and get the information they need. They are
such as diabetes. correct in thinking that these are essential as-
pects of effective medical management. But
some people try to manage their diabetes with
just medical management. This dimension of
management is critically important but if it is
A THREE-PRONGED APPROACH the only way that a patient tries to manage
TO COMPREHENSIVE their diabetes, then it is like having a one-
MANAGEMENT legged stool. A one-legged stool can be ef-
fective, such as one used for milking cows,
Sotile (1996) describes three main however, it does not offer solid support and,
components for overall chronic care self- therefore, its effectiveness is limited.
management: medical, behavioral, and emo-
tional. To help remember this comprehen- Behavioral Management
sive approach to managing diabetes, it is
helpful to think of a three-legged stool The second leg of the stool is ef-
metaphor. fective behavioral management. Behavioral
143
144 BEHAVIORAL HEALTH ISSUES
management includes diet patterns, physical process what their initial reactions were to the
activity levels, compliance, whether or not diagnosis. The patient’s initial reaction will al-
the patient tests and documents blood glucose low the health care provider to learn about the
levels regularly, whether or not they smoke, patient’s understanding of diabetes, what their
how well they understand and use diabetic perspective of diabetes is, and whether or not
equipment, whether or not they check their they have had any family member or friends
feet daily, etc. People with diabetes who take who have had diabetes. It is especially im-
into consideration effective behavioral man- portant in the Hispanic or Mexican American
agement along with effective medical man- cultures to ask whether any relatives or friends
agement do much better than those who just have had it. They almost always will have rela-
try to manage their diabetes medically. tives or friends who have diabetes and, based
on this experience, they will have a certain
perspective about the disease. Some of these
Emotional Management
perspectives will be positive or contribute pos-
The third leg of the stool is effective itively toward their self-management of the
emotional management, which involves un- diabetes. For example, a patient might talk
derstanding and being able to deal effectively about an aunt who lost her leg and is now on
with the most common emotional reactions of dialysis and that what they learned from this
living with diabetes. was that it is important to manage diabetes
well to avoid such complications. These pa-
tients might, therefore, be more motivated to
COMMON EMOTIONAL control their blood glucose levels.
REACTIONS Other perspectives might make it more
difficult for patients to learn to cope with their
A common emotional reaction when first diabetes. Another patient might describe sim-
diagnosed with diabetes is shock. Even pa- ilar kind of concerns (i.e., a relative dealing
tients whose entire family has diabetes react with complications) and see that as the in-
with shock when they are diagnosed with di- evitable road that they will have to travel.
abetes because they felt immune to getting Often when patients are initially diag-
it or they thought they were living a healthy nosed with diabetes, health care profession-
lifestyle that would prevent them from getting als overwhelm them with information about
it. monitoring blood sugars, diet and exercise, or
Another initial emotional response can about lifestyle changes they have to make. Not
be fear or uncertainty. When first diagnosed, enough time is dedicated to finding out their
patients will often feel very uncertain about view of the illness, which ultimately shapes
their future. They ask themselves what the dis- their response to self-management issues. Re-
ease means to them and wonder what changes viewing these common emotional reactions
they will have to make or how else it will affect provides an opportunity to hear about the pa-
them. Combined with these questions, there tient’s individual perspective. These early dis-
also might be a lot of fear, both of the un- cussions also can be very effective in a group
known and of what will happen to them. Some context. As one patient describes their emo-
will face their own mortality or the prospect tions, other patients identify with them, which
of dealing with complications. Perhaps they can lead to a useful discussion about emo-
will think about their relatives or friends who tions and reactions that is really initiated and
have lost limbs or have gone blind. sustained by the patients themselves. During
When working with a patient who has these discussions, patients practice skills that
been recently diagnosed with diabetes, it is ultimately will contribute to their effective
important to ask them sometime early in the management of the chronic condition.
BEHAVIORAL HEALTH ISSUES 145
Another common emotional reaction at small amount of frustration with the lifestyle
diagnosis and in the continuing struggle to live changes that are needed to a paralyzing anger
well with diabetes is anger. The answers of or bitterness toward these changes and an out-
patients or group of patients as to why they right refusal to make them. The depression
are angry will usually go in one of two direc- continuum can range from feeling down or
tions. Patients might say that they are angry at discouraged at certain times to being clini-
themselves because they knew that they were cally depressed.
at risk for diabetes but they did not do the Continuum
things that they knew they should have done to Fear
prevent it. Or they might be angry at the real-
Anxiety Paralyzing fear
ity of getting the diagnosis because they feel
Anger
they had been doing the right things to avoid
diabetes. There is often a high level of frus- Frustration Bitterness
tration simply with the fact of having to learn Depression
so much new information and having to make Sadness, Clinically
adjustments in so many areas. discouragement depressed
The reactions of family members also
should be discussed. Often family members Depression
will not have an initial reaction of anger but
as the situation progresses, they too can expe- It seems that no matter how hopeful and
rience frustration, anger, and fear as they have optimistic a patient is when they begin the trek
to make changes too. For example, a spouse of dealing with diabetes, eventually everyone
who does all the cooking and grocery shop- gets discouraged at some point in managing
ping and who does not have diabetes might and controlling it because it is a chronic con-
feel frustrated at having to make significant dition and has to be dealt with over time. It
changes for the person who has diabetes. is important to introduce patients to this fact
Another common emotion is anxiety. Of- fairly early in the process just to help them
ten people are very anxious about whether normalize this reaction. Knowing that depres-
they will be able to make the needed adjust- sion is a natural reaction to diabetes will help
ments in their lifestyles. They will also have some get through it.
anxiety about being able to continue the type Other patients may need additional help
of work that they are doing or whether they getting out of a depression. It is important
will be able to afford the medical costs related to address depression because there is really
to controlling their diabetes. good evidence that people with chronic condi-
Another common emotional reaction tions, such as diabetes, who also get clinically
that typically occurs further down the road depressed, have a much harder time control-
after initial diagnosis is depression. We will ling and managing their diabetes.
elaborate on depression further in this chapter. At Marana Health Center, we routinely
screen for depression. Any patient with di-
abetes is given a PHQ-9 depression screen
EMOTIONAL CONTINUUM (Spitzer, Kroenke and Williams, 1999), a
widely used depression screening in primary
Although these emotional reactions are care.
present initially, many of these emotions ac- If depression is diagnosed, then we fol-
tually manifest themselves on a continuum. low the guidelines established for treating de-
The fear continuum can range from a small pression in primary care that were part of the
amount of anxiety to being paralyzed with the McArthur study (The Macarthur Initiative on
fear. The anger continuum can range from a depression & Primary Care at Dartmouth &
Duke, 2003). Depending on the PHQ-9 score, Both patients and health providers who
we might decide to follow a watchful wait- work with patients with diabetes should con-
ing protocol to see how the patient responds, sider the three-legged stool metaphor and at
adjusts, and deals with it and then reassess in every opportunity bring up questions or of-
a month. Or we may decide to start the pa- fer information related to each leg of the
tient on antidepressant medications immedi- stool: effective medical, behavioral, and emo-
ately with frequent follow-up. It is important tional management. These three legs are al-
to realize that some level of depression or de- ways interacting and the people who live well
pressive feelings is common and to manage with diabetes over the long haul have learned
this along with the diabetes is crucial. to manage diabetes in each of these three
In addition, there needs to be ongoing as- ways.
sessment of both depressive feelings and the
other common emotions because a patient can Building a Foundation
do very well managing the emotions at one
point in living with their diabetes but experi- In addition to the three types of effec-
ence significant problems with these emotions tive management of diabetes, there are the
at another point in their lives. For example, I three foundation stones for living well with
worked with a 46-year-old Hispanic female a chronic illness, such as diabetes. This is an-
who had diabetes for about 18 years. She had other discussion that is often very effective in
worked very hard to manage her diabetes well a group context because of the interaction that
and not let it interfere in her life in any way. it sparks among patients with diabetes. This
She got an infection in her foot and was hospi- discussion is most effective in a group where
talized for 1 week. After returning home, the there is a range of patients in terms of the
infection got worse, she had to be rehospital- amount of time that they have been dealing
ized and ended up spending another 5 weeks with their diabetes.
in the hospital. She almost lost her leg and did
loose her job. She was completely recovered Awareness, Acceptance, and Action
by the time I saw her at Marana Health Cen-
ter but was now struggling with emotions she The three foundation stones that are use-
had never experienced before related to her ful in living well with diabetes are (three A’s):
diabetes—fear and discouragement. Patients awareness, acceptance, and action. First of all,
need to be aware that managing the emotional patients with diabetes need to be aware of as
part is just as important as managing the med- much information as possible regarding di-
ical part of diabetes. abetes. Normally providers are very good at
giving the patient information. This should in-
Managing Stress clude information about the chronic quality of
diabetes and how that affects a person differ-
Other aspects of effective emotional ently than a disease that is curable. At this
management include understanding and man- point, it is important to get the patient’s per-
aging stress, learning how to relax and refuel, spective on what chronic means and how the
managing personality based coping patterns, chronic quality of the illness affects a person
nurturing family teamwork, and controlling physically, emotionally, mentally, and in rela-
cognitions or thought patterns. These five tionships. It is also important for patients to
components of effective emotional manage- have awareness about the uncertain quality of
ment come from Dr. Wayne Sotile and are diabetes and to know that, even when it is man-
explained more fully and completely in his aged well, certain things beyond their control
book, Psychosocial Interventions for Car- can happen. They also need to have awareness
diopulmonary Patients (1996). of the healing systems of the human body and
how it functions as an integrated system in disease, and that the information they have re-
which you cannot separate the mind from the ceived is relevant to them. They then put this
body in terms of dealing with a chronic dis- information into action. They are now will-
ease. Patients tend to be very open to receiving ing to start making changes in the way they
information, but as health providers we often eat and are willing to start monitoring their
feel that by giving the information we have blood sugars regularly. They are also willing
done enough. However, the reality is that in- to muster all of their personal resources and to
formation does not change anyone by itself. start doing things in all of the realms of what
It can be the beginning of a change, but it is it means to be a human being. These realms
also important to talk about acceptance, the include the mental, emotional, and spiritual
second foundation stone. aspects of a person. They are willing to start
When asking patients how they react to taking action to add to the body’s natural re-
the word “acceptance,” a health care profes- sources and responses by doing things that
sional will usually get a few different reac- increase the healing response and encourage
tions. Some can be very negative. For exam- wholeness.
ple, some patients might say that they will
never accept having this illness. Upon fur- Building a Framework
ther exploration, the health professional might
learn that, for this person, acceptance means A foundation is not a house, so the next
“giving into it” or “giving up.” Acceptance step is to talk to patients about building a
would contradict their personal goal of over- framework on the foundation. The discussion
coming the disease. Other reactions include about the foundation stones and the frame-
trying to live like they do not have diabetes work can also be done effectively in a group
(i.e., pretending to not have it) or denying that context. Group sizes can range from three to
they have it. Denial eventually is very prob- eight people in order to be effective in deal-
lematic for the patient because diabetes can- ing with the issues that come up with emo-
not be beat simply by force of will. Usually, tional management. More and more commu-
the person who tries to live like they do not nity health centers are using group classes for
have it crashes hard. Eventually they get to the patients with diabetes, during which time they
point, they have a melt down, or get extremely discuss effective emotional management.
sick and then are faced with dealing with the As the discussion of building a frame-
reality of the illness. work on the foundation stones unfolds, pa-
Two types of people who do not do well tients are encouraged to cultivate certain
with diabetes are those who give up when they senses or states. When asking patients what
get the diagnosis and those who try to live the word “cultivates” means, the responses
like it really is not true. An approach is to usually have an agricultural connotation. For
talk them about acceptance as a victory that example, they will use terms like “to turn up
has two parts. The first part is accepting the the soil,” “to expose to light,” “to irrigate,” “to
reality of the illness. The patient says to them- weed,” and so on. Many descriptions imply a
selves “all this information I’ve gotten applies very active process. To cultivate is a very ac-
to me and it is true for me.” The second part is tive ongoing process, and the process and end
accepting that they have power to respond to result is very helpful, which is a perfect de-
the information and to make a difference with scription of what a patient with diabetes wants
the disease. to do with certain states or senses.
Awareness and acceptance leads to ac- Patients are encouraged to cultivate a
tion, the third foundation stone. At this point, greater sense of relaxation. And for most pa-
patients have the information available to tients, this is a difficult one to incorporate into
them, they have accepted the reality of the their lives especially because for many with
diabetes their lives get busier as they do the start experiencing or exploring new things to
things necessary to manage the illness. Dis- broaden their experiences. Patients are also
cussing ways to include and cultivate a greater encouraged to cultivate the spiritual aspects
ability to relax physiologically also will cul- of what it means to be fully human and
tivate more peace of mind. Since there seems this might include seeking God or develop-
to be an increased level of anxiety associ- ing faith. Some patients pray or have others
ated with living with diabetes or other chronic pray for them. Others find ways to serve oth-
illnesses, cultivating peace of mind becomes ers even in the midst of their struggles with
important. diabetes.
Cultivating a greater sense of control is Spirituality may be about finding ways
important especially for the patients who ex- to love others. An older Mexican American
perience living with diabetes feel like their life woman, who comes to the Marana Health
is starting to spin out of their control. Any- Center, lives alone and feels that attitude is
thing that can give them a greater sense of one of the most crucial aspects in managing
control will help them manage their diabetes her diabetes. What helps her continue to have
and control their emotional reactions of living a positive attitude about her own health is vol-
with it. Patients also are encouraged to culti- unteering three to five times a week at the se-
vate hope and joy. Often when a person starts nior center in Marana. Helping others takes
dealing with a chronic illness, it is an oppor- her mind off herself. It also made her realize
tunity to start discussing some of the larger that many people have it worse than she does.
issues in life. Spiritual issues might become Doing this motivates her to continue to take
more important with patients. Patients are es- good care of her diabetes. She also finds real
pecially encouraged to continue to do things pleasure and enjoyment in taking care of her
that are fun for them and make them laugh. dogs, and that motivates her to do the things
Often people have to stop doing things, espe- that she needs to do for herself so that she
cially around food, that were pleasurable to will be able to be with them and take care of
them and it is important to find other ways to them.
experience joy. As mentioned earlier, these issues can be
Patients are also encouraged to cultivate dealt very effectively in a group context, but
connections. Dealing with diabetes can often most patients with diabetes probably will not
narrow a person’s involvement with others. spend a lot time within a group context. It
Perhaps they stop going out to eat or to have is possible to bring these issues up in small
pizza and beer with a group of friends because ways as health providers have an ongoing
they do not want to deal with the issues affect- relationship with their patients. Over time,
ing their blood sugars or having to explain to discussions with patients are opportunities to
them about their newly diagnosed condition. bring up the three types of effective manage-
As a result of diabetes, their lives can become ment, the foundation stones, and the states
more confined or restricted. Patients need to to cultivate. Patients are encouraged to con-
know that it is important to continue cultivat- tinue on a path of managing and controlling
ing connections with others. One of the ad- their diabetes when health care providers tie
vantages of discussing this in a group context together medical, behavioral, and emotional
is the new friendships that can develop. management.
Creativity is another topic that patients As a health care professional contin-
are encouraged to cultivate. When they are ues to work with patients with diabetes, they
faced with doing new things and thinking can provide them with incremental informa-
about things in new ways, they can use this tion about effective emotional management.
as an opportunity to do things they have This can happen either in a group context or
never done before. Patients are encouraged to individually.
The next component of effective emo- are doing things to make sure that this does
tional management includes providing the pa- not happen. The tearing down of relationships
tient with information about understanding can happen in small increments, but because
and managing stress, making a connection the condition is chronic, over time these small
between stress and physiology. When they get separations can result in a large separation
this connection, they can then see how it re- between family members or the people with
lates to their blood sugars or their blood pres- which they are most intimately involved.
sure and the other issues that affect diabetes. It is basically true that the more con-
Health care professionals should also nected, understood, and supported a person
show the connection between stress and cop- feels, the better they do in managing their
ing energy, describing the warning signs they diabetes. So it is important to acknowledge
should see when their coping energy is get- and identify the types of support needed for
ting low. This energy is the one they need encouragement and to practice openness and
to cope well with things including their di- intimacy. These issues certainly include the
abetes and the other issues that are ongoing in issue of independence versus dependence, of
their life. At the same time, patients should be change of roles, of change of lifestyles, and
shown that to understand and manage stress, of uncertain future. Often, it is important for
they need to learn to relax and refuel. the health care provider to bring up these is-
Another dimension that becomes critical sues as family members might be reluctant to
in effective emotional management and can bring them up because they do not want the
be seen over time when working with patients patient with the diabetes to feel guilty or get
with diabetes is their personality-based cop- angry with them. Sometimes family members
ing pattern or style. This style will have a ma- and friends are afraid if they bring up certain
jor impact on the way they approach the man- issues about living with diabetes and how it
agement of their diabetes and how effective affects them that it might look like they do not
they are with managing their diabetes. It is im- really care about the patient.
portant for patients to be more aware of their
particular pattern and to recognize the pitfalls
associated with that pattern when they are liv- CONCLUSION
ing with a chronic condition. They should also
begin to work on changing parts of their pat- The most effective management of dia-
tern. Dr. Wayne Sotile gives detailed informa- betes will always involve medical, behavioral,
tion on these coping styles and describes the and emotional components—a three-legged
most common coping styles and the pitfalls of stool. Health care providers have a crucial
each style when living with a chronic illness. role in helping patients with diabetes man-
This information is useful for framing how to age the emotional component. From dealing
make suggestions to patients with diabetes in with common emotions to managing stress
terms of certain behavioral changes, and how and nurturing family teamwork, the health
to support them in the changes that they are care provider can consistently and gently help
making. the patient along the path of living well with
Discussing these coping styles or pat- their diabetes.
terns can lead naturally to a discussion of
nurturing family teamwork. It is important to
emphasize with patients having diabetes that REFERENCES
diabetes is not just an individual disease, it af-
fects the entire family. And like any chronic Sotile, W. (1996). Psychosocial Interventions for
condition it can tear down relationships over Cardiopulmonary Patients. Champaign: Human
time unless individuals and family members Kinetic.
Spitzer, R., Kroenke, K., Williams, J. (1999). Validation The Macarthur Initiative on Depression & Primary Care
and utility of a self-report version of PRIME-MD: at Dartmouth & Duke (2004). Depression Manage-
the PHQ Primary Care Study. Journal of the Amer- ment Tool Kit c 2004 Trustees of Dartmouth Col-
ican Medical Association. (282) 1737–1744. lege VI.3 June 7, 2004.
10
Planning for Sick Days,

Surgery, and Travel
Betsy Dokken
Department of Physiology, University of Arizona, and University Physicians Healthcare, Tucson, Arizona
Diabetes control can be adversely affected by was once thought in younger people and in
stressful situations related to physical or emo- people of color who have type 2 diabetes.
tional distress. Health care providers must be DKA is present in the patient who is produc-
able to advise patients with diabetes who being ketones and has a blood pH below normal.
come ill with infections, injuries, or other ail- Ketones are produced when the body is unable
ments that complicate their diabetes manage- to metabolize carbohydrate for energy. This
ment routine and cause hyperglycemia. situation is caused by insulin levels that are in-
Definition of a sick day: A sick day could sufficient to promote glucose transport inside
be caused by a variety of situations, from a cells where its metabolism occurs. Therefore,
common cold to a broken bone to a death in the since DKA is caused by insulin deficiency, it
family. If the patient is thrown off of his/her can usually be prevented by adequate insulin
usual diabetes management routine, or expe- administration.
riences persistent hyperglycemia despite self- Another life-threatening complication is
management techniques that usually maintain called hyperglycemic hyperosmolar nonke-
glucose control, he or she is having a sick day. totic syndrome (HHNK), also called hyperos-
molar nonketotic hyperglycemia (HONK). In
this situation, which is most commonly found
RISKS ASSOCIATED WITH in elderly people with type 2 diabetes, severe
CONCURRENT ILLNESS hyperglycemia and dehydration occur in the
absence of ketone production.
The most critical complication of con- Both DKA and HHNK are life-
current illness is diabetic ketoacidosis (DKA). threatening situations. Preparing patients to
Although DKA usually does not occur in safely and effectively manage sick days ahead
those with type 2 diabetes, studies in recent of time can mean the difference between life
years indicate that it does occur more than and death.
151
152 PLANNING FOR SICK DAYS, SURGERY, AND TRAVEL
PATIENT RECOMMENDATIONS it is crucial to attempt to prevent or stop

FOR NUTRITIONAL INTAKE AND vomiting in patients with diabetes. Antiemetic
MEDICATION ADJUSTMENT suppositories are a practical treatment for nau-
sea, and can be called in to the pharmacy if
Type 1 Diabetes the patient complains of nausea and/or vom-
iting. Patients who have had recurring DKA
Insulin Adjustment associated with vomiting should have an ac-
tive prescription for antiemetics at all times.
The most common trigger for DKA is
the omission of insulin. Health care providers Nutritional Recommendations
have consistently taught patients that they
must eat after taking their insulin. Patients To prevent or limit dehydration and elec-
can misinterpret this information, and omit trolyte imbalance, it is important for food
their insulin if they know they are unable to and/or fluid intake to continue. In general,
eat due to illness. It is important to explain patients should be encouraged to drink 4–6
to patients that their long-acting (basal) in- ounces of noncaloric fluids every 30 minutes.
sulin is required even if they are not eating. Carbohydrate (sugar) intake is also important,
Most patients with type 1 diabetes are now on and a goal of 50 g every 4 hours will simulate
peakless basal insulin analogs (such as insulin typical meals. Foods and fluids that may be
glargine) that do not cause hypoglycemia dur- used to replace usual meals include:
ing fasting (if appropriately dosed). Those pa- r Sports drinks
tients who are on a basal/bolus insulin regi- r Crackers
men should understand that the basal insulin r Jell-o (not sugar-free)
r Soup
has no relationship to food intake, and their
r Applesauce
bolus (short-acting) insulin is meant to cover r Bananas
meals and to correct hyperglycemia when it r Fruit juice
occurs. Patients who are taking older basal in- r Soft drinks (not sugar-free)
sulins may experience hypoglycemia during
the insulin’s peak time when they are fasting
or unable to eat. Regular insulin, which is still Type 2 Diabetes
used by some patients to cover meals, is ac-
Medication Adjustment
tually closer to an intermediate-acting than a
short-acting insulin. The short-acting insulin Patient taking oral medications to treat
analogs (such as lispro or aspart) are more ef- diabetes should continue to take them. If they
fective for meal coverage and for correcting are nauseated and unable to eat solid food,
hyperglycemia than is regular insulin. In the they may have to temporarily omit their met-
event that patients are not eating, basal insulin formin, since it can exacerbate nausea if taken
should be continued, and regular insulin and on an empty stomach. Insulin secretagogues
the short-acting analogs should be used only such as glyburide and glipizide should be
to correct hyperglycemia. taken to maximize the patient’s ability to se-
crete insulin during the illness. This insulin
Other Medications production is necessary and is similar to the
exogenous basal insulin discussed in type 1
Antiemetics. Vomiting is a very potent diabetes. Therefore, patients should not omit
trigger for DKA, and can also be a symp- these medications even if they are not eating.
tom of DKA. In any case, if vomiting persists Patients with type 2 diabetes who are tak-
the patient will almost certainly decompen- ing insulin should be advised as if they have
sate and require a hospital admission. Thus, type 1 diabetes—always take the basal insulin
PLANNING FOR SICK DAYS, SURGERY, AND TRAVEL 153
even if unable to eat; take extra short-acting perioperative management with the diabetes
insulin if necessary. care provider prior to the surgical prepara-
tion. Often, patients receive insufficient or in-
Nutritional Recommendations accurate recommendations from the anesthe-
sia and/or operative team. Many times older
Nutritional recommendations during patients with type 1 diabetes are assumed
sick days for those with type 2 diabetes are to have type 2, and are thought to be safe
similar to those for type 1. temporarily without basal insulin. Iatrogenic
DKA is fairly common due to omission of
insulin during the perioperative period. In
SURGERY AND OTHER MEDICAL contrast, if hospital professionals have a poor
PROCEDURES understanding of the differences in insulin re-
quirements between insulin-resistant patients
Surgery certainly qualifies as extreme with type 2 diabetes (very large doses) and
stress, and as such promotes a physiologi- insulin-sensitive type 1 patients (sometimes
cal response similar to a sick day, and usu- very small doses), all patients with diabetes
ally more extreme. Medical procedures such might receive similar insulin doses for the
as vascular studies or endoscopies usually re- same blood sugar level. This is seen in the
quire special preparations that disrupt the pa- outmoded “sliding scale” insulin orders us-
tient’s usual routine and may or may not al- ing regular insulin, which is not recomm-
ter medication requirements. Risks of surgery ended.
include severe hyperglycemia, fluid and elec-
trolyte imbalance, hypoglycemia, and DKA.
Patients with diabetes should also be pre-
pared for other challenges associated with Type 1 Diabetes
hospitalization, such as receiving appropri- r Patients should never be advised to omit a
ate nutrition. Despite current, evidence-based dose of basal insulin. If the basal insulin is NPH or
of nutritional recommendations for patients Lente, due to the potential for hypoglycemia during
with diabetes provided by the American the peak action, the dose may be adjusted:
Diabetes Association and others, most hospi- ◦ If NPO:
tal food service departments continue to pro- If basal insulin is glargine or an-
vide meals according to calorie level, or “no other peakless insulin, do not change the
sugar (sucrose) added” limits, not carbohy- dose. This insulin should already be ad-
drate content. Patients who are managing their justed to fasting glucose levels.
If basal insulin is NPH or Lente,
total carbohydrate intake may be frustrated
give the usual night time dose; decrease
with the high carbohydrate meals they receive the morning dose by 30%.
in the hospital. In some situations, a regular Use short-acting insulin only to
diet would be more beneficial to patients who correct hyperglycemia (if the patient does
know how to estimate their own carbohydrate not have individualized instructions, 15%
intake. of total daily dose 4 to 6 hours apart is a
good starting point).
◦ If on clear liquids:
PATIENT RECOMMENDATIONS No change in the basal insulin.

Use short-acting insulin to correct
FOR THE PERIOPERATIVE hyperglycemia (as above).
PERIOD Recommend a combination of
carbohydrate-free and carbohydrate-
Ideally, a patient with diabetes who is containing beverages, aiming for 50 g to
scheduled for surgery should discuss their replace one meal.
Type 2 Diabetes Packing
If the patient takes oral diabetes medi- Regardless of the mode of travel, peo-
cation, they should continue to take it until ple with diabetes should have the follow-
a strict NPO situation is necessary. If a po- ing items in a “carry-on” bag, easily access-
tential exists for renal compromise during or ible:
after the procedure, metformin should be dis- r all the insulin and syringes you will need
continued until after a postprocedure creati-
for the trip
nine level less than 1.4 mg/dl. Patients who r all oral medications (an extra supply is a
take insulin should be given the same insulin- good idea)
adjustment guidelines as type 1 patients (dis- r blood glucose testing supplies (include
cussed above). extra batteries for your glucose meter)
r urine ketone strips if using an insulin
Travel pump or history of DKA
r other medications or medical sup-
Patients with diabetes are able to safely plies, such as glucagon, antidiarrhea med-
travel as long as a few precautions are taken. ication, antibiotic ointment, antinausea
drugs
High and low blood sugars can occur due to r personal ID and diabetes identity card
changes in meal timing and content. Medi- r a well-wrapped, air-tight snack pack of
cation adjustments may be necessary for a crackers with cheese or peanut butter, a juice box,
minority of travelers. In order to control di- and some form of sugar (hard candy or glucose
abetes during travel, patients must have ade- tablets) to treat low blood glucose.
quate monitoring supplies, medications, and
knowledge regarding the foods that will be
available and a method of estimating carbo- Airline Security
hydrate content.
The American Diabetes Association has
worked closely with the Transportation Se-
Foot Care curity Administration to ensure that people
with diabetes are treated fairly in light of
Travel often includes using public trans- recent increases in airport security. A full
portation, sightseeing, and other activities that set of recommendations can be found at
cause more wear and tear than usual on al- www.diabetes.org. In general:
ready vulnerable feet. Foot problems during
travel are so common that a new term has r Notify the security screener that you
been coined by the podiatry community— have diabetes and are carrying your supplies with
“Diabetic Holiday Foot Syndrome.” Patients you.
with diabetes should be prepared to walk more r Make sure your insulin vials, insulin pens,
than they usually do in a typical day. Encour- jet injectors, and insulin pump are accompanied by
age travelers to wear athletic or other walking a professionally printed pharmaceutical label iden-
shoes, to limit friction on skin by wearing tifying the medication (insulin), which is usually on
the outside of the box.
socks, to examine feet frequently (especially r Lancets, blood glucose meters, blood glu-
in the middle of the day to detect early prob- cose test strips can be carried through the security
lems), and to carry supplies for minor foot checkpoint.
problems such as blisters or abrasions. Pa- r Notify screeners if you are wearing an
tients with neuropathy will not be able to de- insulin pump, and request that they visually in-
tect early skin problems and must actively spect the pump rather than removing it from your
seek them by examining their feet frequently. body.
r Advise screeners if you experience symp- syringe at the bedside, set an alarm and take
toms of a low blood glucose level and are in need the injection at the same time as at home.
of medical assistance. Short-acting insulin should be taken to cover
r The above protocol applies only to travel
meals and correct hyperglycemia as usual.
within the 50 United States and is subject to change. Older basal and premixed insulins are
International passengers should consult their indi-
more difficult to adjust, since they do influ-
vidual air carriers for applicable international reg-
ulations.
ence meal times. The more time zones the
patient crosses, the more complicated the ad-
justment will be. In general, traveling East
Dealing with Time Zone Changes
shortens the day, and less insulin may be
Time zone changes are not usually prob- needed. Traveling West lengthens the day, and
lematic unless the change increases the risk more insulin (additional injections) may be
of hypoglycemia. The risk of hypoglycemia needed. In general, patients will be safe tak-
is increased if insulin is taken and carbo- ing the usual dose the morning of travel, if
hydrate is not consumed during the time two daily injections are taken, the larger dose
the insulin peaks. People taking oral agents, is usually (not always) taken in the morning, to
basal/bolus insulin, or using insulin pumps control meal-related glucose excursions dur-
typically do not need to make major adjusting the day. When traveling to another time
ments during travel. Those who take pre- zone, the patient should be advised to take the
mixed insulin, intermediate-acting insulin, usual dose the morning of travel, and to ad-
or a combination of intermediate-acting and just amounts the rest of the day. For example,
short-acting insulins may need to make some if traveling West, take half the evening dose
adjustments. with a meal at the usual (home) time, and the
remaining half with another meal at the local
dinner time.
Adjusting Insulin for Travel
It should be apparent that the basal/bolus
Newer insulins have made travel much regimen is less complicated and people who
less of a burden for insulin-treated diabetes. travel extensively should be offered this regi-
If a peakless basal insulin is used, the timing men if they are still taking intermediate-acting
of the injection need not be changed since it or premixed insulin.
has no relationship to food intake. If the pa-
tient expects to be asleep during the time of the
usual injection, the time could safely be ad- SUMMARY
justed by up to 2 hours per day until reaching
a convenient local time to take the injection. Sick days, surgery, and travel are situa-
Depending on the length of the trip and the tions in which routines are disrupted. Careful
difference in time zone, another option would planning can help avoid diabetes complica-
be to premeasure the insulin and keep the tions during these challenging times.
PATIENT GUIDE TO SICK DAY MANAGEMENT
Type 1 Diabetes
What is a sick day? Any day that you are not feeling well, having trouble eating your
usual meals, or are experiencing a medical procedure or extreme emotional upset.
Why are sick days important? Diabetes is affected not only by what you eat and the
insulin you take, but also by other hormones in the body. Hormones that work against in-
sulin usually increase during illness or stress, causing the insulin you take to work less ef-
fectively. This is why illness and stress cause the blood sugar to rise. Diabetic ketoacidosis
is a severe, life-threatening complication of diabetes that commonly occurs during illness
or severe stress. This develops due to a lack of adequate insulin to fight the stress-related
hormones.
What can I do? The MOST important thing you can do during a sick day is to take your
insulin. Even if you cannot eat, your body needs at least the insulin you take during a usual
day, maybe even more. You should adjust your insulin as follows:
r Identify your longest-acting insulin. This is probably either glargine (Lantus), NPH, or Lente.
Take your usual dose of this insulin, the same number of times during the day.
r Identify your shortest-acting insulin. This is probably lispro (Humalog), aspart (Novolog), or
regular insulin. If you are not eating, do not take your usual doses of the short-acting insulin. Take the
short-acting insulin as follows:
◦ Add together your total daily dose of all insulin.
◦ How many units of long-acting and short-acting insulin do I take in a typical
day? units
◦ Figure out 15% of this number (with a calculator, multiply your total daily dose ×
0.15). If the result is a fraction, round up to the nearest unit. This is your “sick day dose”.
◦ My “sick day dose” is: units of short-acting insulin.
◦ When blood sugar is over 150 mg/dl, take this dose of short-acting insulin, at least
4 hours apart.
What should I eat? If you are able to, eat the way you usually do. If you are unable to eat
normally, it is important to make sure you get enough fluid and carbohydrate (sugar).
◦ Drink 4–6 ounces (4 ounces is half a cup) of fluid without calories every 30 minutes.
This fluid could include water, unsweetened hot or cold tea, or diet soft-drinks. This fluid is
important to prevent dehydration.
◦ Eat or drink 50 g of carbohydrate every 4 hours. To find the carbohydrate content
in food/fluids, look at the nutritional label. Note the serving size, and the total carbohydrate.
For example, one can of (non-diet) soda contains 12 ounces and 43 g of carbohydrate. This
carbohydrate (sugar) will provide you with energy to fight your illness, and help to prevent
low blood sugar.
What else should I do during a sick day?
r Check your urine for ketones. When the body produces ketones (detectable in the urine) and
your blood sugar is high, it means you are not taking enough insulin to stay in control during your illness.
◦ If you have ketone strips, make sure they are not expired
◦ If you do not have ketone strips, get some at the pharmacy (available without a
prescription)
◦ Check your urine for ketones several times daily while you are sick. If you are taking
enough insulin and fluids, ketone levels should not be more than “small”
r Call your diabetes care provider (primary care physician, nurse practitioner, or diabetes educator)
if:
◦ You vomit (throw up) even once; ask for an antinausea medication. Suppositories
work best if you are having trouble keeping food down. A prescription may need to be called
in to your pharmacy. This could prevent a hospital stay.
◦ You have an obvious infection. You may need an antibiotic.
◦ Your illness lasts longer than 2 days
◦ Your blood sugar is over 400 mg/dl, two times in a row, after you have taken your
sick day dose of insulin and it should have had an effect.
◦ You have “moderate” to “large” amounts of ketones in your urine and a blood sugar
over 200 mg/dl for more than 8 hours, even after taking your sick day dose of insulin.
◦ You feel very sick or are in pain.
◦ You have abdominal pain, shortness of breath or trouble breathing, your family
notices a fruity odor in your breath, or you become extremely sleepy or woozy.
Your diabetes care provider is:

Name:
Office number:
Emergency contact information:
PATIENT GUIDE TO SICK DAY MANAGEMENT
Type 2 Diabetes
What is a sick day? Any day that you are not feeling well, having trouble eating your
usual meals, or are experiencing a medical procedure or extreme emotional upset.
Why are sick days important? Diabetes is affected not only by what you eat and the
insulin you take, but also by other hormones in the body. Hormones that work against insulin
usually increase during illness or stress, causing the insulin you take to work less effectively.
This is why illness and stress cause the blood sugar to rise. Severe high blood sugar requiring
hospitalization can occur if proper care is not taken during illness.
What can I do? When you are sick, even if you are unable to eat normally, you must
take your diabetes medication. If you take only pills for your diabetes, you need these even
if you are unable to eat. Metformin (Glucophage), a common diabetes medication, can cause
stomach upset if not taken with meals. If this happens to you, stop taking the metformin until
you are able to eat again.
If you take insulin (either alone or in combination with diabetes pills), you still need to
take it while you are sick. Even if you can not eat, your body needs at least the insulin you
take during a usual day, maybe even more. You should adjust your insulin as follows:
r Identify your longest-acting insulin. This is probably either glargine (Lantus), NPH, or Lente.
Take your usual dose of this insulin, the same number of times during the day.
r Identify your shortest-acting insulin. This is probably either lispro (Humalog), aspart (Novolog),
or regular insulin. If you are not eating, do not take your usual doses of the short-acting insulin. Take the
short-acting insulin as follows:
◦ Add together your total daily dose of all insulin.
◦ How many units of long-acting and short-acting insulin do I take in a typical
day? units
◦ Figure out 15% of this number (with a calculator, multiply your total daily dose ×
0.15). If the result is a fraction, round up to the nearest unit. This is your “sick day dose”.
◦ My “sick day dose” is: units of short-acting insulin.
◦ When blood sugar is over 150 mg/dl, take this dose of short-acting insulin, at least
4 hours apart.
What should I eat? If you are able to, eat the way you usually do. If you are unable to eat
normally, it is important to make sure you get enough fluid and carbohydrate (sugar).
r Drink 4–6 ounces (4 ounces is half a cup) of fluid without calories every 30 minutes. This fluid
could include water, unsweetened hot or cold tea, or diet soft-drinks. This fluid is important to prevent
dehydration.
r Eat or drink 50 g of carbohydrate every 4 hours. To find the carbohydrate content in food/fluids,
look at the nutritional label. Note the serving size, and the total carbohydrate. For example, one can of
(non-diet) soda contains 12 ounces and 43 g of carbohydrate. This carbohydrate (sugar) will provide you
with energy to fight your illness, and help to prevent low blood sugar.
What else should I do during a sick day?

r If you normally take insulin, check your urine for ketones. When the body produces ketones
(detectable in the urine) and your blood sugar is high, it means you are not taking enough insulin to stay
in control during your illness.
◦ If you have ketone strips, make sure they are not expired
◦ If you do not have ketone strips, get some at the pharmacy (available without a
prescription)
◦ Check your urine for ketones several times daily while you are sick. If you are taking
enough insulin and fluids, ketone levels should not be more than “small”
r Call your diabetes care provider (primary care physician, nurse practitioner, or diabetes educator)
if:
◦ You vomit (throw up) even once; ask for an antinausea medication. Suppositories
work best if you are having trouble keeping food down. A prescription may need to be called
in to your pharmacy. This could prevent a hospital stay.
◦ You have an obvious infection. You may need an antibiotic.
◦ Your illness lasts longer than 2 days
◦ Your blood sugar is over 400 mg/dl, two times in a row, after you have taken your
sick day dose of insulin and it should have had an effect.
◦ You have ”moderate” to ”large” amounts of ketones in your urine and a blood sugar
over 200 mg/dl for more than 8 hours, even after taking your sick day dose of insulin.
◦ You feel very sick or are in pain.
◦ You have abdominal pain, shortness of breath or trouble breathing, your family
notices a fruity odor in your breath, or you become extremely sleepy or woozy.
Your diabetes care provider is:

Name:
Office number:
Emergency contact information:
11
Self-Management
Donna Zazworsky1 and Lynda Juall Carpenito-Moyet2
1 Carondelet
Health Network, Tucson, Arizona; St. Elizabeth of Hungary Clinic, Tucson, Arizona; and Case
Manager Solutions, LLC, Tucson, Arizona
2 LJC Consultants, Inc. Mickleton, New Jersey and ChesPenn Health Services, Chester, Pennsylvania
INTRODUCTION projects funded by the Center for Medicare

and Medicaid (CMS) have turned their ef-
Never before have health care profes- forts to a “pay for performance” strategy
sionals had at their disposal the variety and rewarding providers with higher reimburse-
efficacy of medications. Sulfonylureas, once ments for achieving positive health outcomes
the mainstay of type 2 diabetes mellitus man- in chronic care management. In the managed
agement, have now been joined by many new care arena, pay-for-performance models have
medications that reduce insulin resistance and been launched in several of the Blue Cross
inhibit hepatic glucose production. Today’s plans in California and Michigan and also
glucose monitoring systems are less painful within Aetna. “Rather than monitoring physi-
and patients have an endless choice of foods cian groups on the basis of traditional cost
specifically produced for people with dia- controls and utilization management, Pay for
betes. Insurance companies even will reim- Performance (P4P), the revised bonus eval-
burse patients who regularly exercise by of- uation process, monitors for improving the
fering discount memberships to health clubs. quality of care given to HMO patients using
Despite the advances in medicine and tech- health outcomes and patient satisfaction in-
nology, too many patients have HbA1cs over formation from a number of clinical and ser-
8%. Complications of renal failure, amputa- vice categories, according to the Blue Cross of
tions, and vascular diseases continue to plague California” (www.healthsourcesonline.com/
persons with diabetes. Regardless of how ad- edu/payper.htm, 2004).
vanced the science of diabetes management is, In order to move to this next level of
positive health outcomes will not occur with- health care reimbursement, health care team
out effective strategies to encourage patients members must prepare themselves to not only
to self-manage more effectively. know how to measure their outcomes but
Self-management efforts are a priority they also must learn new skills. Health care
for today’s health care team. Demonstration providers should ask themselves . . .
161
162 SELF-MANAGEMENT
– How do I motivate patients to be “self- 5. Problem solving especially for blood glu-
managers?” cose and low levels, and sick days
– What kind of skills do I, as a health care 6. Reducing risks of diabetes complications
provider, need to learn so that I can teach and em- 7. Living with diabetes (psychosocial adap-
power my patients to become “self-managers?” tation) (Mulcahy et al., 2003, p. 768).
– How do I do this in my 12-minute office
visit? Any type of diabetes program should
– Can I do it more efficiently as a team? weave these seven behaviors into individ-
ual and group self-management efforts. The
These are not easy questions to answer. AADE offers a comprehensive framework for
Empowering patients to be in charge of their the diabetes educator to assess, intervene, and
health is a complex process of knowledge and evaluate these behaviors. For a complete tech-
skill-building coupled with problem solving nical review, the reader can obtain a copy of
and coping skills to deal with day-to-day is- the standards from The Diabetes Educator,
sues. Even more challenging is that in order to September/October 2003 issue authored by
motivate a person to self-manage his diabetes Mulcahy et al. (2003)
mellitus effectively, the provider must know
the patient as an individual. What motivates
one person may not motivate another. This ADULT LEARNING PRINCIPLES
can be a baffling challenge for both patients
and providers. In essence, the health care team To begin a self-management program,
and patient must be armed with a “menu” of the basics of adult learning must be reviewed.
strategies to approach self-management. Beebe and O’Donnell identify five principles
This chapter will identify elements that are applied to diabetes self-management
of self-management behavior goals recom- education:
mended by the American Association of Di-
abetes Educators (AADE) and provide an – Self-directed learning enhances auton-
overview of adult learning principles, key the- omy
oretical perspectives, and application mod- – Adults must feel a need to know
els being utilized in today’s chronic care – Problem-oriented learning is more ac-
self-management frameworks. This chapter ceptable
– Incorporating life experiences enhances
also will offer the reader a number of self-
motivation
management tools that can be adapted to any – Active participation is essential for be-
setting. havior change (Beebe and O’Donnell, 2001,
p. 381).
Example. Utilization of these five princi-

DIABETES SELF-MANAGEMENT
ples can be exemplified through the ongoing
EDUCATION GOALS
relationship of one particular patient, Mr. J.L.,
a 45-year-old Hispanic man with type 2 dia-
The American Association of Diabetes
betes. Mr. L’s HbA1c is 8.7%. He lives alone
Educators has outlined seven self-care behav-
and eats all of his meals at three different
iors as the Diabetes Self-Management Edu-
church base shelters everyday. He is asked to
cation Core Outcomes Measurements. These
come in weekly to the clinic and see the nurse
behaviors are:
practitioner to review the type of food he has
1. Being active: physical activity (exercise) eaten at the shelters. He and his nurse prac-
2. Eating titioner together identify the foods and fluids
3. Medication taking he eats. They talk about food choices in food
4. Monitoring blood glucose quality and quantity, such as choosing a small
SELF-MANAGEMENT 163
glass of orange juice instead of a fruit drink, through their Levels of Patient Education Out-
using a small quantity of pancake syrup only, come Attainment (Henry and Zander, 2001).
and a pass up on the toast and jam are also of- In this model, the educator identifies a pa-
fered. In addition, he is advised to walk after tient’s educational competency level by cog-
every meal to increase carbohydrate utiliza- nitive, psychomotor, and belief domains. This
tion. Further insight is encouraged by asking model integrates Lamb and Stempel’s (1994)
him how much fatigue he had the day when case management work on “insider–expert”
he ate excess of carbohydrates. with the educator role and defines the teach-
Beebe and O’Donnell add that these prin- ing/helping process in three steps:
ciples regarding self-management education
1. As an educator, you bond with the patient
are also applicable to children with diabetes.
around the crises (such as newly diagnosed with
However, they note that additional interven- diabetes or having to start on insulin injections).
tions on coping skills and decreasing parent– The educator helps the patient to learn the meaning
child conflict also must be incorporated. of the illness and their hope.
Another aspect to consider is that adult 2. The educator begins to work with the pa-
learners have different learning styles. Hart- tient, helping them think differently about them-
man (1995) identifies four major styles: selves and their situation.
3. Eventually, the educator assists the pa-
Concrete. This is an individual who wants
tient in changing by experimenting with new be-
things presented in a clear, structural, and orderly
haviors, accepting help, and moving into self-care
sequence. This person wants to know what is ex-
as much as possible.
pected and what are the goals and objectives.
Experiential. This individual learns through This model opens the health care
direct practical instructions. This person learns by provider to a different relationship with the
doing—physical objects are important. patient, in some cases, the educator/provider
Abstract. This individual is the most chal-
serves as an “expert” for the patient when the
lenging, because they want to know “why” about
patient needs new information and, at other
everything. They need other references/research.
Cooperative. This individual learns best in times, the educator is an “insider” for the pa-
groups. tient when they need support and encourage-
ment. Table 11.1 illustrates how a provider can
While applying diabetes self-manage- evaluate their success in being the “insider–
ment education to the adult learner, the educa- expert” with their patients’ achievement with
tor must be creative and able to assess quickly self-management.
what type of learner the person is and what
tools can be utilized to meet his/her learning
style. For example, the concrete learners will LITERACY
benefit with the patient diabetes MAP (see
Figure 11.1) and pocket passport. They can Literacy is another aspect to consider
see exactly what is expected of them in their when addressing self-management. Too of-
self-management process. ten, providers assume that the patient can read
The experiential learners will learn by and/or write, or are medically literate. There-
monitoring their blood sugar levels and seeing fore, assessing literacy is critical but diffi-
the changes over time. The abstract learners cult. In most cases, patients are embarrassed
may need a textbook and web sites to satisfy to admit they cannot read or write. Or they
their need for more information. The cooper- nod their head when the provider is explain-
ative learners will learn better in a group class ing about laboratory results in medical ter-
where they can participate with others. minology. In some cases, patients may bring
The Center for Case Management ex- someone else with them to the visit to mask
pands on the Adult Learning principles their literacy. In order to address these literacy
164 SELF-MANAGEMENT
Patient Diabetes MAP

Patient Name:_______________________________________ Date:_________________
Primary Care Provider:_____________________________ Phone:________________
Diabetes Nurse Educator:__________________________ Phone:________________
Dietician:_______________________________________ Phone:________________
Your Health Care Team A team of doctors, nurses and dieticians are working together to evaluate and treat your
diabetes.
Self-Management: The following activities are important for you to do as part of your own are
management:
Blood Sugar Check your blood sugar ____________ times a day before meals and
record the results.
Meal Plan Follow the individual meal plan that has been developed by you and
dietician. Please make appointment with Dietician.
Appointment Time:___________________________
Exercise Follow the exercise prescription given to you.
_______________________________________________________
Take your diabetes medicine regularly as prescribed.
Medication
Testing: You and your health care team will work together to keep your:
Weight Weight near the target weight decided on by you and your dietician.
Goals sets: _____________________________________________
Blood Sugar Blood Sugar between 80 and 120 before meals and 2 hrs after
meals below 145.
HgbAlc HgbAlc checked every three months.
HgbAlc at or below 7%.
Blood Pressure
Blood pressure at or below 130/80.
Cholesterol
LDL Cholesterol at or below 100 mg/dl
Urine Protein
Urine for protein annually
Prevention: In order to notice any important changes in your condition:
Have an annual dilated eye exam.
Check your feet daily and have them checked regularly by your physician.
Report any infection or illness for prompt treatment.
Do not smoke. If you are smoking start a smoking cessation plan.
Control stress in whatever healthy ways work best for you (no drugs or
alcohol please).
Others: ___________________________________________________
Education: 1. type of Diabetes ___________________________
2. Glucose monitor given _______________________
3. Patient given instruction on how to use glucose monitor.
4. Patient able to demonstrate
Finger stick technique and Blood testing.
5. Hyperglycemia, causes, and treatments.
6. Hypoglycemia, causes, and treatments.
7. See a diabetes educator (nurse and/or dietician) for basic
diabetes education. ________________________________________
8. After that initial visit, follow-up education will be scheduled as needed
Signature of Educator ________________________________Date: _______________________
Source: St. Elizabeth of Hungary Clinic, 2002
FIGURE 11.1. Patient Diabetes MAP.
issues, Schillinger (2000) suggests the follow- careful not to use the words “good” or “bad” with-
ing methods for providers and health educa- out qualifying. For example, when discussing diet
tors to work with their patients: with a patient who had high cholesterol, the patient
said that he had heard that peanuts and walnuts
(1) Use qualitative jargon rather than tech- were a good fat, so he ate them regularly and in
nical or lay jargon. In other words, describe a mea- large quantities. The patient truly believed that he
surement in terms of how much or how often. Be was making a healthy choice. When the provider
SELF-MANAGEMENT 165
TABLE 11.1. Levels of Patient Education Outcome Attainment Model

Competency level Cognitive domain Psychomotor domain Value/Belief
Beginner Knowledge Perceptions and set Receives

Repeats Reads Pays attention
Intermediate Comprehension Guided Response Responds
Defines Reviews with Comments
Advanced Application Mechanistic Values
Describes Uses Plans
Performs
Completes
Expert Analysis Complex Overt Organizes
Evaluates Adjusts, Adapts Commits
Source: Used with permission: The Center for Case Management, Inc. 1991.
explained that nuts are still a fat and must be eaten in relation to the person’s willingness to com-
in limited quantities, the patient was surprised, but ply or adhere to self-care advice given. But it
very willing to reduce his intake before starting on is not that easy. Kristeller and Rodin (1984)
medications. This patient was a high school math differentiate between a three-staged model of
teacher, but had limited medical literacy. treatment: compliance, adherence, and main-
(2) Use the interactive communication
tenance (self-management). They summarize
loop. Schillinger (2000) describes a circular
methodology that asks patients to repeat the in-
that compliance is the greatest level of depen-
structions or have them explain their disease pro- dency on the health care system, adherence
cess or health problem back to the provider or edu- is an intermittent dependency, while self-
cator. This gives the provider a better understanding management is the demonstration of maxi-
of what area needs to be restated or explained. After mum of independence on the system.
the provider evaluates where the patient is in their Theoretical models approach self-
level of recall and understanding, then the provider management through constructs that inves-
offers another explanation and has the patient again tigate cognitive capabilities, literacy levels,
recall the instructions or explain. gender differences, cultural belief systems,
Example. Mr. J.L., who was previously men- attitudes, behavioral change components,
tioned, is illiterate but can copy numbers from and social support systems. Not only is it
his glucometer to his log book. He cannot an issue of learning new behaviors, but in
write down his food intake but can understand many cases, old patterns must be unlearned
pictures of food and beverages, which he cir- (Beebe and O’Donnell, 2001). This section
cles on a picture log. He then can visibly see describes common models that are currently
the relationship of the foods he ate with subse- being applied in adult self-management
quent blood sugar readings. The practitioner training and what has been shown to work.
reviews the log and assesses the patient’s level One thing for sure, it is not an easy issue of
of comprehension from both the qualitative just compliance to advice.
and disease integration standpoint.
Health Belief Model
THEORETICAL PERSPECTIVES The Health Belief Model (Becker, 1974)
ON BEHAVIOR CHANGE offers a framework for the health care team
to gain an all encompassing perspective re-
When looking at self-management, lated to the individual’s perceptions, sociode-
many health care team members lump success mographics, external cues, and likelihood to
166 SELF-MANAGEMENT
take action. This model discusses the inter- TABLE 11.2. Cues to Action
relationship that occurs in a person’s health
Family members Most cultures
belief and how the provider must take into ac- Church bulletins, clergy Most cultures
count when assessing these multidimensional Community Health Mexican American, Native
aspects needed for a patient to become a “self- Workers: promotoras Americans, African
manager.” The following description of each and community health Americans
representativesa
component is described with examples.
TV advertisements on Mexican American
Individual perceptions address two con- language specific
cepts: (1) susceptibility and (2) seriousness. stations
Assessing how a person views their own level Radio stations for specific Mexican American,
of susceptibility to an illness, and their own cultures Asian-Pacific,
Newspapers for specific Most cultures
lived experience with the seriousness of the
cultures
illness helps shape the person’s willingness Grocery store flyers
and readiness to take action of some type. For (language specific)
example, a patient who has had a family mem- Workplace flyers
ber with diabetes and renal complications or a (paycheck stuffers)
serious infection on their foot that eventually a
Community Health Workers have become more and more im-
lead to an amputation will help enhance the portant in the areas of self-management.
Source: Please refer to “Chapter 20” for a more comprehensive
individual’s perception of seriousness. If they discussion on the background, training, and utilization of the
have had several close family members with CHW.
diabetes, they most likely will perceive their
own risk of getting diabetes some day.
Sociodemographics are another critical uals who have a higher educational level
feature of this model. Lower income individ- tend to have a greater rate of health in-
uals do not seek preventive health care and surance (www.covertheuninsuredweek.org).
tend to have a higher rate of chronic illnesses, This translates into better practices for health
such as diabetes, high blood pressure, etc. Cul- prevention and early detection for those with
tural influences and beliefs also play an im- health insurance.
portant role in prevention and chronic illness Cues to action portray a multitude of
actions. It is important to assess the person’s cultural vehicles related to their values and
cultural beliefs and actions and understand belief systems. For example, in the Mexican
how to adapt interventions into the person’s American culture, novellas (soap operas) are
belief systems. For example, the diabetes team a popular form of entertainment and can be
considered combining a nutrition group class used as an educational vehicle. Other popu-
for Asian Pacific patients. However, when it lar forms of cues to action are provided in
was explored more thoroughly, it was iden- Table 11.2.
tified that each culture holds very separate Likelihood to take action weighs the ben-
food preferences, which may be contradictory efits to the barriers while adapting a self-
to the other and insulting. For example, one management practice. In other words, is the
from Asian Pacific culture may eat red meat cost or time to perform a new behavior per-
while another may not. Therefore, trying to ceived as more of a barrier or a benefit for that
encourage this patient to attend a group nutri- individual and/or their family. For example,
tion class will only distance the person from if a person is asked to start monitoring their
care. Instead, a more personalized approach blood glucose daily, it is important to assess
through a one-on-one format may be more if the patient has the financial means to pay
appropriate. for the glucometer strips and whether the per-
Finally, other demographics such as ed- son has the time to perform the test as rec-
ucational level must be recognized. Individ- ommended by the provider. The skill-building
SELF-MANAGEMENT 167
effort also may be looked at as a barrier and change efforts, such as weight management,
not a benefit. smoking cessation, and chronic care manage-
Example. One nurse practitioner (NP) ment.
teaches her patients who do not have insurance The success of this model is threefold:
to test daily as follows: First day, the patient
1. The health care provider can easily assess
will do a prebreakfast measurement. The next
the person’s level of readiness by identifying their
day, the patient will check their blood sugar stage of change.
2 hours after lunch. The third day, the patient 2. The health care provider can then match
will do a reading before bedtime. Of course, an intervention modality keeping in mind the per-
the NP instructs the person to take a reading son’s culture and literacy level.
if they experience unusual symptoms. 3. The health care provider engages in a
collaborative process with the person to identify
barriers and level of confidence to begin a self-
Transtheoretical Theory (Readiness management practice.
for Change)
The stages of change and typical character-
One of the more widely applied models istics are illustrated in Table 11.3. Suggested
today is Prochaska and DeClementi’s Readi- interventions are offered with each stage.
ness for Change Model (1992). Initially ap- Here are a few examples of applying the
plied to addictive behaviors, this model has stages of change theory to patients with dia-
been utilized with many other behavioral betes.
TABLE 11.3. Motivating Behavior Change

Stage Attitude Typical characteristics Intervention tools
Precontemplation “Never” Not planning to change in the near Build awareness

future. Screenings for blood Sugar
Uninformed or under-informed about Health fairs
the risks; often labeled as resistant or Computerized health
unmotivated Risk appraisals
Contemplation “Someday” Consider changing their habits in the Give more information
near future. through brochures,
Some awareness of risks; often labeled books, web sites
as procrastinators or ambivalent.
Preparation “Soon” Planning to take action within the next Set Goals
30 days. Develop a wellness plan
May have made unsuccessful attempts
to change.
Action “Now” Actively changing their habits. Give logs such as blood
May not consistently carry out new sugar logs, diet logs,
behaviors. exercise logs
Health care provider must
give review and give
feedbacka
Maintenance “Forever” Have maintained new behaviors for Refer to support groups
6 months. Not tempted to return to Have patient return for
old habits. regular (i.e., monthly,
quarterly, etc.) check ups
Develop relapse
Prevention plan
a
Motivating Behavior Change: Modified from Take the First Step Heart Health Resource. General Mills Bell Institute of Health and
Nutrition.
168 SELF-MANAGEMENT
– Precontemplation stage: Elicit from them 2 weeks. Using a scale of 1–10, with 1 being
symptoms like blurred vision or fatigue and dis- not very confident and 10 being very confi-
cuss the relationship of these symptoms to hyper- dent, ask the patient how they would rate their
glycemia. level of confidence or capability in accom-
– Contemplation stage: Discuss how el- plishing these goals. If the patient says 4, ask
evated blood glucose levels damage the lining
what would help them raise it to a 7 or 8. As the
of small blood vessels and utilize props from
brochures or a video.
provider, you may need to help the patient re-
– Preparation stage: Set a goal of two serv- define the goal to achieve a higher level of con-
ings of fresh vegetables and two servings of fresh fidence. Figure 11.4 is an example of a self-
fruit per day. management tool that providers can use with
– Action: Ask the patient to fax or call the patients (www.improvingchroniccare.org).
provider with their weekly blood sugar log.
– Maintenance: Set a goal with the patient Putting Theory into Practice
to come for quarterly diabetes visits to review
HbA1c results, weight, blood sugar, and exercise Chronic Care Model: Self-Management
logs. Component
Dr. Scott Gee, a pediatrician and med-
Putting these theories into practice is
ical director for Prevention and Health
a process of integrating many of the con-
Information in Kaiser’s in Oakland, CA, sug-
structs described here and fitting them into
gests two tools: communication guidelines to
a working rubric. Without question, there are
promote health behavior change, and talking
a number of internal and external variables
with patients about diabetes management key
that must be considered. The Chronic Care
strategies: patient choice, matching readiness,
Model discussed in Chapter 6 offers a method-
and promoting self-care. Providers and edu-
ology to assess an organization’s ability to
cators can use these tools as guides to assess
effectively manage chronic care. The model
individuals and families based on their level
addresses six elements for chronic care man-
of readiness plan and help them develop a
agement: community linkages, health sys-
plan to move in self-management adherence
tem, self-management support, clinical in-
(Figures 11.2 and 11.3).
formation systems, delivery system design,
and decision support (Wagner, 1998). The
Self-Efficacy 2002 Health Disparities Collaborative Train-
ing Manual provides a checklist for health
Self-efficacy is a theory that describes
care organizations in relation to examining
a person’s evaluation of his or her capac-
the six elements of the Chronic Care Model.
ity to manage stressful or problematic sit-
The manual recommends the following self-
uations (Bandura, 1982). Successful self-
management review. Does your organization:
management depends on the person believing
that the behavior change will improve the situ- r Use diabetes self-management tools that
ation (outcome expectancy). The person also are based on evidence of effectiveness.
r Set and document self-management goals
must believe that he can make the behavior
change (Bandura, 1982). When working with collaboratively with patients.
r Train providers on how to help patients
a patient with diabetes mellitus, help him set
with self-management goals.
realistic goals. r Follow-up and monitor self-management
For example, discuss the goals of in- goals.
creasing the intake of three vegetables serv- r Use group visits to support self-
ings a day and decreasing 1–2 servings of management.
starch each day. Then ask the patient if they r Tap community resources to achieve self-
feel this is possible for them to do for the next management goals.
SELF-MANAGEMENT 169
Developing a program that incorpo- CHRONIC DISEASE SELF-

rates these self-management objectives into MANAGEMENT PROGRAM
practice will begin to address the patient–
provider interaction. Effectiveness will then The Chronic Disease Self-Management
be measured through health status changes Program (CDSMP) was designed at the
and satisfaction rates of patients and pro- Stanford Patient Education Research Center
viders. (Sobel & Lorig, 2002). This program utilizes
BRIEF NEGOTIATION
Behavior Change Counseling for Diabetes Management
Communication Guidelines to Promote Health Behavior Change
Ask Permission
- Would you be willing to spend a few minutes discussing your diabetes management?
- Would you be interested in discussing ways to manage your diabetes?
Share Clinical Results (optional)

- I have your recent test results, would you like to look at them together?
- What is your understanding of A1C? (educate as needed)
- Your A1C is 8.9%.
- The target A1C for diabetes control is 7.0%.
- Ask for the patient’s interpretation: What do you make of this?
- Add your own interpretation or advice as needed AFTER eliciting the patient’s/parent’s
response
Offer Options
- There are a number of ways to manage your diabetes. They include:
♦ Healthy Eating
♦ Physical Activity
♦ Medication
♦ Home Blood Sugar Monitoring
- Is there one of these you’d like to discuss further today? Or perhaps you have another
idea that isn’t listed here.
Assess Readiness
0 1 2 3 4 5 6 7 8 9 10
- On a scale from 0 to 10, how ready are you to consider [option chosen above]
- Straight question: Why a 5?
- Backward question: Why a 5 and not a 3?
- Forward question: What would it take to move you from a 5 to a 7?
FIGURE 11.2. Communication guidelines to promote health behavior change. (Source: Used with permission, Kaiser
Permanente, Oakland, CA 2003.)
BRIEF NEGOTIATION
Behavior Change Counseling for Diabetes Management
Explore Ambivalence
Step 1: Ask a pair of questions to help the patient explore the pros and cons of the issue
- What are the things you like about____? AND:
- What are the things you don’t like about______?
OR
- What are the advantages of keeping things just as they are_____? AND:
- What are the advantages of making a change_____?
Step 2:
- Summarize Ambivalence
- Ask: Did I get it all? / Did I get it right?
Tailor the Invention
Stage of Readiness Key Questions
Not Ready 0 – 3 • Would you be interested

in knowing more about
• Raise Awareness
managing your
• Elicit Change Talk diabetes?
• Advise and Encourage • How can I help?
• What might need to be
different for you to
consider a change in
the future?
Unsure 4 – 6 • Where does that leave

you now?
• Evaluate Ambivalence
• What do you see as
• Elicit Change Talk your next steps?
• Build Readiness • What are you thinking/
feeling at this point?
• Where does
________fit into your
future?
Ready 7 – 10 • Why is this important to

you now?
• Strengthen • What are your ideas for
Commitment making this work?
• Elicit Change Talk • What might get in the
way?
• Facilitate Action • How might you work
Planning around the barriers?
• How confident are you
in your ability to carry
out your plan?
• How will you know
you’ve reached your
goal?
• How might you reward
yourself along the way?
Close
♦ Summarize
♦ Show Appreciation/Acknowledge willingness to discuss change
♦ Offer advice, emphasize choice, express confidence
♦ Confirm next steps
♦ Arrange for follow up
FIGURE 11.2. (continued)

SELF-MANAGEMENT 171
Talking with Patients About Diabetes Management

Key Strategies: patient choice, matching readiness and promoting self care
Research supports that patient choice and matching your intervention with patient readiness promotes successful self care.
Eliciting patient perspectives highlights strengths and barriers that allow you to swiftly focus on what is most important to
the patient. “Matching” your intervention can decrease frustration in talking about behavior change.
Invest in the Beginning

• Ask Permission
“Would you be willing to spend a few minutes discussing your diabetes management?”
• Assess Readiness
“We’ve talked a little about your diabetes and how important healthy eating can be. On a scale from 0 to 10, how
ready are you to begin making some changes in how you eat?”
• Customize Your Approach Based on Readiness
Not Ready Ready
0 1 2 3 4 5 6 7 8 9 10
Unsure
Stage of Key Questions

Readiness/Goals
Not Ready 0 – 3
• Raise Awareness Would you be interested in knowing more about diabetes and
• Advise and Encourage your health?
How can I help?
Unsure 4 – 6
• Evaluate Ambivalence What might be the pros and cons of making a change?
• Build Readiness What do you see as your next steps?
What are you thinking/feeling at this point?
Ready 7 – 10
• Strengthen Commitment What are your ideas for increasing physical activity?
• Facilitate Action Planning What might get in the way?
How might you work around the barriers?
How confident are you in your ability to carry out your plan?
Invest in the End

• Show appreciation for patient’s willingness to discuss diabetes
• Express Confidence
“I strongly encourage you to begin a regular exercise program. Physical activity is one of the best things you can do
to successfully manage your diabetes. I recognize that the choice to exercise is entirely yours. I am confident that if
you decide to begin a physical activity program, you can find a way to do it.”
• Confirm next steps
• Arrange for Follow Up
FIGURE 11.3. Key strategies while talking with patients about diabetes management. (Source: Used with permission,
Kaiser Permanente, Oakland, CA 2003.)
172 SELF-MANAGEMENT
Self-Management Support Tool

Health Changes Plan
Organization:
Name: Date:
Phone:
The health change I want to make is (be very specific: What, When, How, Where, How
Often):
My goal for the next month is:
The steps I will take to achieve my goal are:
The things that could make it difficult to achieve my goal include:
My plan for overcoming these difficulties includes:
Support/resources I will need to achieve my goal include:
My confidence that I can achieve my goal: (scale of 1–10 with 1 being not confident at
all, 10 being extremely confident)
1 2 3 4 5 6 7 8 9 10
Review Data: with
Source: www.improvingchroniccare.org
FIGURE 11.4. Self-management support tool.
lay leaders to facilitate weekly programs that vouchers on services, food or supplies to “give
train others on how to live with a chronic aways” such as water bottles, pedometers, or
illness, regardless of the disease. This pro- T-shirts. These tend to be successful when
gram has been very successful throughout matching them appropriately with the patient
the country and is being quickly adopted. population. For example, one clinic received
The topics cover a wide range of behavioral, a grant and funded a glucometer strip incen-
informational, and knowledge components, tive program for their patients who were unin-
such as an overview of self-management, re- sured. Patients were enrolled into an incentive
laxation and cognitive symptom management, program when they agreed to participate by
fatigue management, advanced directives, designing a self-management agreement to test
pression, informing the health care team. their blood sugars at least three times a week
These are just a few, for more information and bring their logs in monthly and review
on the CDSMP, visit the Stanford Univer- them with the nurse. In return they would pay
sity Web site at www.stanford.edu/group/ only $5/bottle for their strips every month.
perc/cdsmp.html. Over 80 people enrolled, but less than
half participated regularly. The program was
successful for those who were ready (in the
INCENTIVE PROGRAMS action stage) and/or had a good handle on
monitoring and recording their blood sugar
Incentives are a method to motivate peo- levels. However, many patients did not return
ple to improve adherence to self-management monthly because they were at different stages
behaviors. Incentives range from discount of readiness. Patients either did not feel they
SELF-MANAGEMENT 173
needed to check their blood sugars because Special note. Diabetes education can be
they were feeling fine, or they needed more provided by a variety of people, in a va-
intensive follow-up on how to complete the riety of settings. Explaining a nutrition la-
blood sugar logs. The greatest level of adher- bel to someone with diabetes, regardless of
ence in performing regular blood sugars was the credentials of the person teaching or the
seen in the gestational diabetes group. This location of the encounter, is diabetes edu-
was expected since they were motivated to cation. Comprehensive diabetes education is
have a healthy baby and scheduled for regular typically provided by formal programs em-
weekly or biweekly visits. ploying certified diabetes educators (CDEs).
Other incentive programs that have been Health care professionals experienced in di-
received positively focus on coupons to abetes education may be eligible to become
grocery stores or health clubs for regular certified as diabetes educators through the
attendance to diabetes education classes. To- National Certification Board for Diabetes
day, many diabetes self-management pro- Educators (NCBDE—see www.ncbde.org).
grams provide an incentive program in the Comprehensive diabetes education programs
initial stages. It is when the more intensive may be eligible for recognition by the Amer-
education program ends and the patient must ican Diabetes Association (required by some
then transition to the long-term regime of reg- payors for reimbursement). ADA-recognized
ular follow-up visits with the provider—the programs must meet the National Standards
desire is that the patient and the provider will for Diabetes Self-Management Education,
be able to maintain an incentive-driven inter- published in Diabetes Care, 27:S143, 2004,
action. At these visits, it is critical that the and available at www.diabetes.org. Diabetes
provider review the self-management logs and is a worldwide epidemic and education is a
provide feedback. That feedback will lead the key component to its management. Education
provider to help the patient develop new self- that provides accurate and useful information
management goals that can then be the inter- to people affected by diabetes is extremely
nalized incentive for the patient. This is the valuable, and should be provided by all who
direction of proactive health care. are willing and able to reach communities
at-risk.
CONCLUSION REFERENCES
Self-management abilities are constantly Bandura, A. (1982). Self efficacy mechanism in human
agency. Am Psychol 37(3):122–127.
being challenged by internal and external
Becker, M.H. (1974). The Health Belief Model and Per-
forces. This chapter gives the health care sonal Health Behavior. Thorofare, NJ: Charles B
team a number of evidence-based options that Slack, Inc.
can be applied within individual or group Beebe, C., and O’Donnell, M. (2001). Educating pa-
interactions. With the onset of the pay-for- tients with type 2 diabetes. Nurs Clin N Am 36(2):
375–385.
performance models, self-management skills
Hartman, V.F. (1995). Teaching and learning style pref-
cannot be viewed as a one-time approach— erences: Transitions through technology. VCCA J
it is an ongoing process of trial and learning 9(2):18–20.
among providers, patients, and families. Just Henry, S., and Zander, K. (2001). Improving patient ad-
as patients are learning new ways of living herence. Care Manag 13–17.
Kristeller, J.L., and Roden, J. (1984). A three-stage model
through better self-management—so must the
of treatment continuity: Compliance, adherence, and
health care providers learn new ways of mo- maintenance. In Baum A., et al. (eds), Handbook of
tivating and teaching their patients how to be Psychology and Health, Vol. 4. Hillsdale, NJ: Social
better self-managers. Psychological Aspects of Health. p. 86.
174 SELF-MANAGEMENT
Lamb, G., and Stempel, J. (1994). Nurse case man- and Bindman, A.B. (2002). Association of health lit-
agement from the client’s view: Growing as in- eracy with diabetic outcomes. JAMA 288:475–482.
sider/expert.Nurs Outlook 42:7–13. Schillinger, D., Piette, J., Grumbach, K., Wang, F.,
Mulcahy, K., Maryniuk, M., Peeples, M., Peyrot, M., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C.,
Tomky, D., Weaver, T., and Yarborough, P. (2003). and Bindman, A.B. (2003). Closing the loop: Physi-
Diabetes self-management education core out- cian communication with diabetic patients who have
comes measures. The Diabetes Educator 29(5): low health literacy. Arch Intern Med 163:83–90.
768–803. Sobel, D.S., Lorig, K.R., and Hobbs, M. (2002). Chronic
Prochaska, J.O., DiClemente, C.C., and Norcross, J.C. condition self-management program: from devel-
(1992). In search of how people change, applica- opment to dissimination. Permanente Journal 6(2):
tions to addictive behaviors. Am Psychol September: 11–18.
47(9):1102–1114. Wagner, E.H. (1998). Chronic disease management:
Schillinger, D., Griumbach, K., Piette, J., Wang, F., What will it take to improve care for chronic illness?
Osmond, D., Daher, C., Palacios, J., Sullivan, G.D., Effective Clin Pract 1:2–4.
12
The Diabetic Foot

Barbara J. Aung
Aung FootHealth Clinics and Wound Management Center, Tucson, Arizona
INTRODUCTION joint mobility, and a history of past ulceration

and/or amputation, which have shown to be
The diabetic foot and its associated pedal related in the repetitive minor trauma associ-
manifestations have been well documented ated with a diabetic foot ulceration (Frykberg
and, when left untreated, pose potentially et al., 1998).
limb-threatening complications. Foot ulcer- Figure 12.1 represents an illustration
ations in people with diabetes represent the summarizing the various pathways, contribut-
most common cause of nontraumatic lower ing factors, and a cycle of occurrence leading
extremity amputation in the industrialized to a diabetic foot ulceration most often seen
world. Individuals with diabetes mellitus run in this patient population.
a 15–46 times higher risk of a lower extrem-
ity amputation than those without diabetes
(Harris, 1998). Likewise, complications as- DIABETIC AMPUTATION AT
sociated with the foot account for the most
A GLANCE
frequent reason for hospitalization in the pa-
tients with diabetes, and account for up to r Amputation is 15 times more likely in
25% of all diabetic admissions in the United people with diabetes.
States (Harris, 1998). A number of studies r 50% have contra-lateral amputation
have shown that the vast majority of diabetic within 3–5 years.
foot complications resulting in an amputa- r 3-year mortality rate of 20–50%.
tion begin with the formation of a skin ul-
cer. Among the many risk factors identified The foot is often thought of as a mirror
as reasons for foot ulcerations, the most com- of systemic disease and, in diabetes, it is the
mon single precursor to lower extremity (foot place where early manifestations of the dis-
and/or leg) amputation are reduced/impaired ease may be initially present. Not all diabetic
response to infection(s), peripheral neuropa- foot complications can be prevented, but it
thy, vascular disease, abnormal foot pres- may be possible to reduce their incidence with
sures, minor trauma, foot deformity, limited a program designed with a multidisciplinary
175
176 THE DIABETIC FOOT
missed opportunity to address patients’ foot

care needs.
Family physicians, their staff, and addi-
Impaired tional medical care providers who come in
Response Trauma
contact with a patient with diabetes can and
to Infection Minor,
repeated should play a pivotal role in early diagnosis
of complications associated with the lower ex-
tremity and feet. What are the components of a
comprehensive foot examination? In response
to this question, the following suggestions
are proposed, based on possible roles each
member of the multidisciplinary team may
Neuropathy play.
First, there are a number of terms and/or
FIGURE 12.1. Cycle of pathways leading to ulceration. definitions mentioned during the course of the
forthcoming discussion that one should be-
team to manage the disease itself. The pro- come familiar with for both the examination
gram should combine the management and and treatment aspects to care.
then prevention of the complications, a pro- Diabetic foot. The foot of a patient
gram of early detection of risk factors, and a with diabetes, which has the potential risk
course of appropriate treatment. When imple- of pathologic consequences, including infec-
mented, many of these ulcers and perhaps up tion, ulceration, and/or destruction of deep
to 85% of amputations may be prevented. tissues associated with neurological abnor-
The goal of this chapter is to review, dis- malities, various degrees of peripheral vas-
cuss, and provide guidelines for a comprehen- cular disease, and/or metabolic complications
sive foot exam and to manage the diabetic foot of diabetes in the lower limb (based upon
in diverse clinical settings. the World Health Organization [WHO] def-
inition) (Alberti et al., 1999).
Diabetes type 1. Formerly called insulin-
BEGINNING WITH A dependent diabetes mellitus (IDDM). This
COMPREHENSIVE FOOT describes an autoimmune disease of younger
EXAMINATION patients with a lack of insulin production caus-
ing hyperglycemia and a tendency toward
The importance of building a strong ketosis.
foundation of care for a patient with diabetes Diabetes type 2. A metabolic disorder re-
begins with a comprehensive foot and lower sulting from the body’s inability to produce
extremity examination. Several studies have enough or properly utilize insulin. Formally
found that in a primary care clinic setting, called noninsulin-dependent diabetes melli-
foot examinations are infrequently performed tus (NIDDM), these patients also have hyper-
during a patient’s routine office visit, and, if glycemia but are not as prone to ketosis.
performed, these examinations are often not Epidemiology. The study of occurrence
documented well (Pham et al., 2000). In the and distribution of disease.
case of hospitalized patients with diabetes, Incidence. The rate at which new cases
their feet also may be inadequately evaluated of disease occur with a specific time period.
(Pham et al., 2000). There is not just one LEAP. Lower Extremity Amputation
aspect of the care being rendered that result Prevention program.
in these statistics; unfortunately, there may Neuropathy. Nerve dysfunction affect-
be a number of factors, all contributing to a ing sensory, motor, and/or autonomic fibers
THE DIABETIC FOOT 177
with varying degrees of impairment, symp- The many and common risk factors for
toms, and/or signs. amputation can be identified based on spe-
Diabetic peripheral neuropathy. Pres- cific aspects of the history of the patient and
ence of symptoms and/or signs of peripheral a systematic examination of the foot. Those
nerve dysfunction in people with diabetes af- risk factors for lower extremity amputation
ter the exclusion of other causes. include peripheral neuropathy, structural foot
LOPS. Loss of protective sensation de- deformity, ulceration, infection, and periph-
scribes the progression of neuropathy in the eral vascular disease.
diabetic foot to the point that the foot is at risk All patients with diabetes who seek treat-
for ulceration. ment with any health care practitioner re-
Intrinsic minus foot. A neuropathic foot quire inspection of both feet at each visit and
with intrinsic muscle wasting and associated should receive a comprehensive examination
claw toe deformities. no less than once a year. For those patients
Ischemia. The impairment of blood flow who demonstrate diabetic foot-related com-
secondary to an obstruction or constriction of plaints, a detailed evaluation should be per-
arterial inflow. formed more frequently.
Infection. Invasion and multiplication
within body tissues by organisms such as bac-
teria, fungi, or yeast, with or without the clin- DIAGNOSIS AND EVALUATION
ical manifestation of disease.
Ulceration (ulcer). A partial or full- In evaluating the diabetic foot, a workup
thickness defect in the skin that may extend of the patient’s general medical history
to subcuticular tissue, tendon, muscle, bone, (Abbott et al., 1998), physical findings, and
or joint. any results from necessary diagnostic testing
Amputation. The complete or partial re- and/or procedures coupled with a thorough
moval of a limb or body appendage by surgical medical and foot history and examination
or traumatic means. should be performed.
Charcot foot (Arthropathy, osteo-
arthropathy, neuroarthropathy). Noninfec-
tious destruction of bone and joint associated PATIENT HISTORY
with neuropathy.
The foot examination is initiated by in-
terviewing the patient and reviewing both
A PROCESS OF CARE their past medical and specific diabetic foot
conditions. The collection of this medical his-
When a patient with diabetes arrives for tory should consist of the information offered
examination, there are a number of diagno- in Table 12.1.
sis and treatment objectives that a multidisci-
plinary team should achieve. These include:
(1) appropriate screening and examination, CLINICAL EXAMINATION
(2) early recognition and treatment of diabetic
foot complications, (3) prevention of ulcera- A clinical examination should be per-
tion and recurrence (particularly if the patient formed systematically so as not to overlook
has a past history), and (4) most importantly, any significant and important aspects of an
patient self-management education. The goal active medical condition. After the patient
of treatment should be to maintain the pa- and his or her extremities have been acutely
tient as an ambulatory, productive member of evaluated, key components of the foot ex-
society. amination should be performed. Many of the
TABLE 12.1. Diabetic Patient History Checklist

Patient’s general history Foot-specific history Wound/ulcer history
Diabetes disease duration General Location

Glycemic control and management Daily activity Duration of wound/ulcer
Cardiovascular, renal and ophthalmic, Current footwear Inciting event or trauma
dental evaluations
Other co-morbidities Any chemical exposures Recurrences
Current treating physicians Callus formation Infections
Social habits such as alcohol/tobacco Deformities Hospitalizations
Current medications Previous foot surgery Wound care/off loading methods
Allergies Neuropathy symptoms Patient’s compliance/wound response
Previous hospitalizations and surgeries Ischemic symptoms Interference with wound care/family or social
problems for patient
Previous medical treatments to the feet Previous foot trauma or surgery
Previous or most recent laboratory Edema—unilateral versus Bilateral
studies, vascular, radiological Previous or active Charcot joint treatment to date
studies . . .
possible conditions to examine are presented ◆ Semmes–Weinstein 10 g monofilament

in a bulleted format below. Each bulleted ◆ Light touch: cotton wool
item represents an important component of ◆ Two-point discrimination
what should be included in a comprehensive ◆ Pain: pinprick
foot examination or a significant finding that ◆ Temperature perception: hot and cold
◆ Deep tendon reflexes ankle, knee
should be noted, based on evidence that indi-
◆ Babinski test
cates likely predictors for ulceration.
Musculoskeletal Examination
Vascular Examination
◆ Biomechanical abnormalities: foot defor-
◆ Palpation of pulses (dorsalis pedis, pos- mities
terior tibial, popliteal, femoral) r
Hammertoes
◆ Subpapillary venous plexus filling time r
Bunion (s) or Tailor’s Bunion(s)
(normal ≤3 seconds) r
Flat or high-arched feet
◆ Venous filling time (normal ≤20 seconds) r
Charcot deformities
◆ Color changes: r
Amputations
r Cyanosis r
r Dependent rubor Limited joint motion
◆ Gait evaluation
r Erythema
◆ Muscle strength testing:
◆ Presence of edema r Passive and active, nonweight-
◆ Temperature gradient bearing and weight-bearing
◆ Changes to the skin possibly indicating r Foot drop
ischemia: r Atrophy-intrinsic muscle atrophy
r Skin atrophy
◆ Plantar pressure assessment:
r Nail changes r Computerized devices
r Distribution of pedal hair— r Harris ink mat
decreased or absent
Dermatologic Examination
Neurologic Examination
◆ Skin appearance:
◆ Vibration perception: r Color or discoloration of skin, tex-
r Turning fork 128 cps ture, turgor, quality, dry skin
THE DIABETIC FOOT 179
◆ Calluses: discoloration—sublesion hem- TABLE 12.2. Risk Categorization System

orrhage
Frequency of
◆ Fissures (especially posterior heels)
Category Risk profile evaluation
◆ Nail appearance
r Onychomycosis, dystrophic, atro- 0 No neuropathy Annual
phy, hypertrophy 1 Neuropathy Semi-annual
◦ 2 Neuropathy, PVD, Quarterly
Paronychia
and/or deformity
◆ Ulceration, gangrene, infection (note lo- 3 Previous ulcer Monthly–
cation, size depth, infection status, etc.) or amputation quarterly
◆ Tinea pedis
Source: American College of Foot and Ankle Surgeons, Interna-
tional Working Group on the Diabetic Foot (1999).
Footwear Examination
is given in Table 12.2 (IWGDF International
◆ Type of shoe Consensus of the Diabetic Foot, 1999;
◆ Fit—breakdown of shoes inside and out-
Frykberg et al., 1999).
side the shoe
In the primary care setting, based on
◆ Foreign bodies
◆ Insoles, custom orthoses.
the risk, patients with risk level 1 or above
should be referred to a Podiatric physician
Once this detailed/comprehensive exam- for further detailed workup, such as obtaining
ination of the diabetic foot has been com- Ankle Brachial Indices, or Doppler segmen-
pleted, the patient can then be placed in a tal pressures and wave form analysis. Also,
classification representative of their individ- the identification of plantar foot pressures
ual accumulative risk category. By using a risk may require evaluation for fabrication of cus-
classification system, the physician is able to tom foot orthoses and/or extra-depth shoes.
design a treatment plan that may be able to Podiatric physicians, due to their unique edu-
help reduce the patient from a high-risk cat- cation, knowledge of biomechanics, and foot
egory to the lowest risk level, thus leading to anatomy, are well suited to care for diabetic
the prevention of an amputation. foot ulcers and prevent these complications
There have been several risk stratifica- that place the patient at highest risk of amputa-
tion schemes that have been proposed and de- tion. Limb salvage procedures are well worth
veloped, which assign different weights in im- the time and energy involved, based on the
portant risk factors for ulceration, although no high morbidity rate of those patients having
system has been universally adopted that can undergone an amputation. Patient quality-of-
or may predict ulceration. life is an important component that should be
An often used treatment base is the dia- considered when discussing the possible need
betic foot system developed at the University for an amputation, as it is clear that patients
of Texas San Antonio by Dr.’s Armstrong, appreciate the physician who tries hard to first
Lavery and Harkless (Armstrong and Lavery, save their foot, rather than bluntly offering
1998). This treatment approach provides a amputation as the only viable treatment proce-
clear, descriptive classification system that dure. Prevention is the goal we must all strive
may be used by all participants on a multi- toward, and with a well-organized system for
disciplinary team. This includes the patient examination and follow-up, we can now treat
as the center of the treatment team once our patients with intention rather than by ad-
they have been given the tools to participate dressing opportunities as they arise—that is,
fully in their care and management of any treating patients only when they have com-
complications that may arise over the years. plications. This comprehensive plan allows
A much simpler, but frequently used system the practitioner to be proactive, and not just
accepted by the International Working Group, reactive.
TABLE 12.3. Risk Factors for Lower both complications as well as lower extremity
Extremity Amputation in the Diabetic amputations as they relate to diabetes.
Foot
Absence of protective sensation due to peripheral
neuropathy REFERENCES
Arterial insufficiency
Foot deformity and callus formation resulting in focal Abbott, C.A., Vileikyte, L., Williamson, S., Carrington,
areas of high pressure A.L., and Boulton, A.J.M. (1998). Multicenter study
Autonomic neuropathy causing decreased sweating and of the incidence and predictive risk factors for di-
dry, fissured skin abetic neuropathic foot ulceration. Diabetes Care
Limited joint mobility 21:1071–1075.
Obesity Alberti, K.G.M.M., Aschner, P., Assal, J.-P., Bennett,
Impaired vision P.H., et al. (1999). Definition, Diagnosis and Classi-
Poor glucose control leading to impaired wound healing ficaion of Diabetes Mellitus and its Complications.
Poor footwear that causes skin breakdown or Report of a WHO Consultation. Part 1: Diagnosis
inadequately protects the skin from high pressure and and Classification of Diabetes Mellitus, pp. 1–31.
shear forces Armstrong, D.G., and Lavery, L.A. (1998). Diabetic foot
History of foot ulcer of lower extremity amputation ulcers: Prevention, diagnosis, and classification. Am
Fam Physician 57:1325–1332.
Frykberg, R.G., Armstrong, D.G., Giurini, J., Edwards,
The following list of risk factors is pro- A., Kravette, K., Kravitz, S., et al. (1999). Dia-
betic Foot Disorders, a Clinical Practice Guideline.
vided to consider helping clinicians in a mul- American College of Foot and Ankle Surgeons and
tidisciplinary team, to help direct care, and to the American College of Foot and Ankle Orthope-
educate patients during their examination, in dics and Medicine, p. 15.
order to allow patients to develop behaviors Frykberg, R.G., Habershaw, G.M., and Chrzan, J.S.
that will aide in prevention and to decrease (1998). Epidemiology of the diabetic foot: Ulcer-
ations and amputations. In Veves, A. (ed.), Con-
risk factors for lower extremity amputations temporary Endocrinology: Clinical Management of
in patients with diabetes (Table 12.3). Diabetic Neuropathy. Totowa, NJ: Humana Press,
p. 273.
Harris, M.I. (1998). Diabetes in America: Epideliology
and scope of the problem. Diabetes Care 21(Suppl.
CONCLUSION 3):C11–C14.
International Working Group on the Diabetic Foot.
If we adhere to a systematic regimen (1999). International Consensus on the Diabetic
of diagnosis and classification of risk fac- Foot. The Netherlands, Amsterdam: International
tors for each individual patient while utiliz- Working Group on the Diabetic Foot.
Pham, H., Armstrong, D.G., Harvey, C., Harkless, L.B.,
ing the multidisciplinary team approach that
Giurini, J.M., and Veves, A. (2000). Screening tech-
facilitates appropriate treatment of complica- niques to identify people at high risk for diabetic
tions, this may ultimately lead to a reduction in foot ulceration. Diabetes Care 23:606–611.
III
Special Care Issues

13
Prediabetes
A Risky Prodrome to Diabetes
James L. Dumbauld
St. Elizabeth of Hungary Clinic, Tucson, Arizona; and Department of Family Medicine,
INTRODUCTION about using too much sugar in your iced tea,

or you could end up with diabetes.”
Prediabetes is the most fascinating and With our current understanding of the
confusing area of the diabetes continuum. priming of the insulin production mechanism,
Fascinating because this is probably the phase and development of insulin resistance, that
of the condition in which the biggest dif- was a pretty good advice. The discovery re-
ference can be made in preventing compli- cently that increasing exercise and reducing
cations and thereby sparing human suffering high glycemic index foods in the diet can
and health care expense; confusing because of be potent treatments for insulin resistance
the various synonymous or overlapping labels has given strong scientific verification to my
and conditions. grandmother’s advice. Some of our newer di-
Metabolic syndrome, syndrome X, car- abetes medications can also be used to pre-
diovascular dysmetabolic syndrome, predi- vent diabetes through overcoming insulin re-
abetes, insulin resistance, impaired glucose sistance at the cellular level (NIDDK, 2001).
tolerance, impaired fasting glucose, polycys- A functional definition of prediabetes
tic ovary syndrome, dyslipidemia, gestational comes from William Cefalu, “a clinical state
diabetes. These are all terms that are used in which a normal or elevated insulin level
to define or describe patients in a “prodro- produces an impaired biological response”
mal phase” of diabetes. The overlapping of (Leahy et al., 2000).
these conditions has led to some interesting
and powerful clinical interventions, as well
as some basic “grandmother wisdom,” that ETIOLOGY THEORIES
have been helpful in the day-to-day care of
patients. For instance, my grandmother used The idea that insulin resistance was in-
to tell us as children, ”You’d better be careful volved in the causing diabetes is not new,
183
184 PREDIABETES
however, the potential for preventing the pro- to as HOMA-IR) index, which is calcu-
gression of prediabetes to the full blown con- lated from the relationship between fasting
dition of diabetes is recent and somewhat plasma glucose and fasting plasma insulin
exciting, particularly in the current era of “di- (Lebovitz, 2001). In our clinical practice,
abetes as epidemic.” The genetic underpin- we have found the fasting insulin level to
nings of diabetes remain beyond the scope be a cost effective and practical screening
of current medical or scientific alteration, and tool.
clearly play a part in the predisposition toward So now that we have identified those
diabetes. But, the obvious links between obe- patients likely to have prediabetes, how do
sity and inactivity, obesity and high caloric we treat them? The evidence that came out
diets (over-eating), and obesity and diabetes, soon after the release of metformin in this
taken together with the compelling evidence country, which showed a potent effect on
that weight loss, increased activity, and di- prevention of progression of prediabetes to
etary modifications can prevent development diabetes, was very exciting; however it in-
of the disease, give us new information about volved the off-label use of the medication
the etiology of prediabetes. This same series (DPP, NIDDK, 2001). It was a bit daunting,
of relationships also helps explain why the to say the least, to contemplate the informed
incidence of diabetes is increasing at such an consent process that would be involved in fol-
alarming rate. lowing this research guideline. Happily, soon
What is additionally compelling is the afterward came the evidence that diet and ex-
evidence that the hyperinsulinemic state ei- ercise were even more potent derailers of the
ther leads to or is at least strongly associated progression to diabetes, so with the help of
with a group of risk factors for cardiovascu- our nutritionist and diabetic educators, and
lar disease including atherosclerotic vascular some community groups interested in exer-
disease, hypertension, central obesity, dyslipi- cise modeling, we have the beginning of a
demia, and increased thrombotic state (Leahy diabetes prevention program.
et al., 2000).
PREVENTION
CONTROVERSIES IN
DIAGNOSING AND TREATING With the evidence that caloric and partic-
PREDIABETES ularly simple carbohydrate restriction, teamed
up with increased activity (diet and exercise),
The definition and clinical diagnosis is are potent interventions for our patients with
not yet clearly defined in practical terms. prediabetes; and the circumstantial evidence
The scientific community uses the euglycemic of increasing diabetes in parallel with increas-
clamp for research purposes to define predi- ing obesity in the United States, the gen-
abetes, but this is not very useful for clini- eral approach to the prevention of diabetes
cal practice. Plasma insulin levels, whether is straightforward. The difficulty lies in the
measured fasting (100–125) or postprandial facilitation of our patients’ decision making
(140–160), are predictors of the risk of de- processes to commit to the necessary self-
veloping diabetes (CDC-IR, Diabetes Care, management goals.
1998) and therefore serve as markers for Prevention of this common and increas-
prediabetes. Another interesting method is ing condition of prediabetes and the fully
an index popularized by Harold Lebovitz established disease that follows requires ba-
called the Homeostasis Model Assessment sic lifestyle changes. This is quite difficult
for Insulin Resistance (otherwise referred in the context of our present day culture
PREDIABETES 185
of fast-food, mobility, separation of people the burden of suffering and health care costs
from natural support groups, and the relentless through the identification and treatment of
advertising of unhealthy foods and beverages. prediabetes.
Today’s health professionals and educators
are well served to work in teams and be famil-
iar with practical decision-making facilitation APPLICATIONS
techniques.
Our experience in treating patients with We are often preoccupied with the adult
diabetes sheds light on the necessary steps population who come to health centers for
for those with prediabetes in order to avoid care, but prevention programs would be far
progression to diabetes and its attendant com- from effective if they do not include the na-
plications. The screening of all new patients tion’s children. While administrators are be-
to our practice, and the stratification into risk ginning to address nutrition issues in current
groups helps to identify those in need of fast- school lunch programs and campus vending
ing insulin levels. Those with elevated insulin machines, physical education programs and
levels are then offered the same team approach curricular requirements continue to dwindle,
as our diabetic patients, namely, group edu- and thus contribute to the current problems
cation, individual education, and continued of childhood obesity and diabetes. Involve-
tracking and reinforcement through primary ment in school health and physical educa-
care provider visits. We use a modified version tion programs will be vital to the overall
of our chronic disease (diabetes) flow-sheet long-term success of any diabetes prevention
to track and treat our patients with predia- effort.
betes in a uniform and comprehensive manner Outreach programs for community
(see Figure 13.1). The patient’s willingness screening of populations at high risk are an-
to make change, assessing the importance of other important component of prevention of
change in the patients mind, and the patient’s diabetes. Health fairs, churches, and other
confidence to carry out the selected goals also neighborhood events and festivals are impor-
play an important role in the facilitation of tant considerations for additional effort in or-
change (Davis, 2003). Our program is new der to find those at high risk who do not
and so experience is limited, but these seem frequent health centers.
the most likely interventions to have some The use of the chronic disease manage-
effect. ment model has been helpful for developing
The Secretary of Health and Human Ser- effective programs at our health center and the
vices estimates there are about 16 million sharing of experiences through the Arizona
people with prediabetes and most are un- Diabetes Collaborative has helped to identify
aware of the condition. Given that these peo- “best practices” and overcome barriers in a
ple are at 50% greater risk of developing more productive way.
cardiovascular disease than the general pop-
ulation, there is a virtual gold-mine of op-
portunity to save health care costs as well as CONCLUSION
reduce morbidity and mortality by discover-
ing and intervening early in the continuum The condition of prediabetes represents
(DPP, NIDDK, 2001). There is a multiplier the immediate threshold to the disease dia-
effect that comes into play because of a whole betes mellitus, but actually is only an identifi-
cluster of diseases and conditions that hover able point on the continuum from those people
around prediabetes, and so the quest for fu- at low risk of death and complications to those
ture health care providers becomes reducing at the very highest risk. The effort required to
186 PREDIABETES
o
of
High Risk/Pre-Diabetes Quality Indicators: Clinical
Patient: __________________________________________ DOB: _________________
MR# ___________________________ Provider: _________________________________
Frequency
q y Baseline 6 mo 1 year
y 18 mo 2y
year
Date/Initials
Re=referred C=Completed
Serum Insulin <17 q-visit
Assessment
Blood Pressure < 140/90 q-visit
Height q-visit
Weight q-visit
Body Mass Index (BMI) q-visit
Chol/TG < 200/200 Annual
S= Satisfactory SME= Self-Management Education Referral

Lab
HDL/LDL > 45/<100 Annual
Bun/Creatinine Annual
Ace Inhibitor Y or N
Interventions
Statin Y or N
ASA Y or N
Vaccines
Specify (ie. flue, pneumonia, etc)
PE
Full Physical Exam Y or N Annual
Meal Plan S or SMER
Physical Activity 4x/week

Self Care
Tobacco Cessation
T S or SMER
Medication S or SMER
This flow sheet indicates recommended services to be provided in the continuing care of persons with pre-diabetes. Docu-
ment values where indicated. Any discussions with patients or significant others should be documented in the “notes”
section in date order .
Signature initials Signature initials
FIGURE 13.1. High risk/prediabetes quality indicators.

PREDIABETES 187
identify prediabetes and intervene at an earlier REFERENCES

stage in the continuum is justified by consider-
ation of the expense, both in health care costs Clinical Alert: Diet and Exercise Dramatically Delay
Type 2 Diabetes; Diabetes Medication Metformin
and human suffering, involved in the treat-
Also Effective, NIDDK, NIH, USDHHS.
ment of diabetes and its attendant cardiovas- Consensus Development Conference on Insulin Re-
cular and microvascular complications. sistance. (1998). American Diabetes Associa-
The challenges for health professionals tion. Diabetes Care 21:310–314. 5–6 November,
and educators are several: to develop effective 1997.
Davis, C. (2003). Self-Management Support: Patients Are
screening and outreach strategies for finding
Care Managers. Presentation at Partners in Qual-
those at greatest risk; to continue discovering ity: Arizona State Diabetes Collaborative, 4/15/03,
the most efficient ways of facilitating behavior Phoenix, Arizona.
change in individual and small group settings; Diabetes Prevention Program, NIDDK, NIH, USDHHS
to help obviate the prevalent unhealthy forces (2001).
Leahy, J.L., Clark, N.G., and Cefalu, W.T. (2000) Med-
on our nation’s adults and children; and to help
ical Management of Diabetes Mellitus. New York,
overcome barriers to everyone receiving ap- Marcel Dekker, Inc.
propriate and affordable health care and pre- Lebovitz, H. (2001). Insulin resistance. Exp Clin En-
vention services. docrinol Diabetes 109(Suppl. 2):s135–s148.
14
Gestational Diabetes
Jorge A. Arzac
Methodist Medical Center, Dallas, Texas
INTRODUCTION and Classification of Diabetes Mellitus rec-

ognizes that the degree of hyperglycemia re-
Before the availability of insulin in the flects the severity of the underlying metabolic
early 1920s, pregnant women with diabetes process and its treatment more than the nature
faced very high maternal and perinatal mortal- of the process itself. Thus, for a clinician and
ity rates. Pregnancy was therefore not recom- patient, it is less important to label the partic-
mended in patients with diabetes. Today, with ular type of diabetes than it is to understand
the advent of insulin, these mortality rate in- the pathogenesis of the hyperglycemia and
creases have been virtually eliminated, so that to treat it effectively (American Diabetes
pregnancy should no longer be discouraged in Association, 2003).
a young woman with diabetes. Gestational diabetes mellitus (GDM) is
defined as any degree of glucose intolerance
with onset or first recognition during preg-
DEFINITIONS AND PREVALENCE nancy. This definition applies irrespective of
whether insulin or diet is used for treatment
In general, diabetes mellitus is classified or whether the condition persists after preg-
according to two broad etiopathogenic cate- nancy. It does not exclude the possibility that
gories as type 1 or type 2 (National Diabetes unrecognized glucose intolerance may have
Data Group [NDDG], 1979). antedated or begun concomitantly with the
Owing to the heterogeneity of disorders pregnancy (American College of Obstetri-
causing hyperglycemia, the NDDG and the cians and Gynecologists [ACOG], 1994).
World Health Organization (WHO) Expert According to the ADA Expert Com-
Committee on Diabetes in 1985 included Ges- mittee, 6 weeks or more after pregnancy
tational Diabetes separately into one of its ends, the patient should be reclassified into
various distinct types (NDDG, 1979; World one of the following categories: (1) diabetes,
Health Organization, 1985). (2) impaired fasting glucose (IFG), (3) im-
The American Diabetes Association paired glucose tolerance (IGT), or (4) normo-
(ADA) Expert Committee on the Diagnosis glycemia. In the majority GDM cases, glucose
189
190 GESTATIONAL DIABETES
TABLE 14.1. White’s Classification of Diabetes Mellitus in Pregnancy

Class Age of onset Duration Vascular disease Treatment
A-1a Any Any No Diet only

A-2b Any Any No Insulin
B >20 <10 No Insulin
C 10–19 10–19 No Insulin
D ≤10 or ≥20 or Benign retinopathy Insulin
F Any Any Nephropathy Insulin
R Any Any Proliferative retinopathy Insulin
H Any Any Coronary artery disease Insulin
T Any Any Renal transplant Insulin
a
Fasting blood sugar (FBS) <105 and postprandial blood sugar (PPBS) <120 mg/dl.
b
FBS ≥105 and PPBS ≥120 mg/dl.
Class E “Calcification of pelvic vessels”—no longer used.
Source: Modified from American College of Obstetricians and Gynecologists (2001).
regulation will return to normal after delivery found to have hyperbilirrubinemia, as well as
(ADA, 2003). long-term obesity and diabetes. Shoulder dys-
Approximately 0.3% of pregnancies in tocia, operative delivery, and birth trauma also
the United States occur in women with pre- are seen more frequently (ACOG, 1994).
existing diabetes mellitus (Buchanan, 1995), Maternal mortality has decreased dra-
and 2–3% more are complicated by gesta- matically after the advent of insulin, but it is
tional diabetes (Coustan et al., 1989). GDM still considered to be higher than the average
represents the majority of all pregnancies obstetric population.
complicated by diabetes. Gestational dia- Fetal mortality associated with diabetic
betes, therefore, is most likely to be encoun- ketoacidosis (DKA) is higher during the later
tered by every health professional caring for weeks of pregnancy. Increasing insulin resis-
pregnant women (Coustan, 2003). tance as pregnancy progresses produces in-
Table 14.1 illustrates a classification creased risk of DKA in the second half of
based on the presence of vascular disease pregnancy. This may be true at lower glucose
adapted from Priscilla White. This classifica- levels and requires close follow-up and ag-
tion did not include the category “Gestational gressive management (Coustan, 2003).
Diabetes.” Hypoglycemia also can affect pregnant
patients managed with insulin, and it is there-
fore important to counsel patients as to early
MATERNAL AND FETAL symptoms and management of this condition.
COMPLICATIONS Nephropathy can complicate pregnan-
cies associated with diabetes. Proteinuria of
Gestational diabetes, and especially its ≥300 mg/day can complicate both type 1 and
association with obesity and advanced ma- type 2 diabetes. Hypertension and retinopathy
ternal age increases the likelihood of devel- usually are present when nephropathy is de-
oping hypertension during the pregnancy. In tected. Significant proteinuria may make the
nonobese younger women, preeclampsia and diagnosis of hypertensive disorders of preg-
cesarean delivery seem to be the most com- nancy quite difficult. Most patients who de-
mon associations. The incidence of diabetes velop marked proteinuria during pregnancy
later in life is seemingly more common as well revert to their prepregnancy renal status after
in patients with GDM (ACOG, 1994). delivery.
Babies of women with GDM are more Diabetic nephropathy, in turn, can cause
frequently macrosomic, and more commonly higher perinatal mortality, preterm induction
GESTATIONAL DIABETES 191
and delivery, preeclampsia, severe anemia, in- treated can precipitate DKA in a pregnant
trauterine growth restriction, and fetal distress patient.
(Coustan, 2003). Hydramnios, or excessive amniotic fluid,
Diabetic retinopathy results from the complicates about 2% of gestational diabetic
damage to retinal arterioles and capillaries. pregnancies. The cause is currently unknown,
In its earlier stages (background retinopathy), and its presence is associated with an in-
microaneurysms, vessel obstruction, cotton creased risk for congenital malformations,
wool spots, hard exudates, small retinal hem- premature labor, and maternal respiratory re-
orrhage, and venous microvascular anoma- striction. In spite of these problems, it is
lies may occur. Vision is only affected if distinctly unusual for diabetes-associated hy-
there is macular edema or ischemia in back- dramnios to require therapeutic amniocentesis
ground retinopathy. About 15–20% of indi- (Coustan, 2003).
viduals with diabetes may have changes con-
sistent with background retinopathy at 5 years Placental Problems
and about 90% after 15 years. In prolifera-
tive diabetic retinopathy, neovascularization The placenta is responsible for fetal gas
occurs in response to retinal ischemia. This exchange, nutrition, waste removal, hormone
leads to hemorrhage, scarring, and contrac- production, and release into both the maternal
tion of the vitreous humor, causing retinal de- and fetal circulations. Any or all of these func-
tachment, and visual loss. This process can tions may be affected by diabetes, particu-
be prevented by laser photocoagulation and larly by the vascular disease present in women
tight metabolic control. Whether pregnancy with long-standing diabetes. Placentas from
exerts an adverse effect on retinopathy is still mothers with diabetes weigh more and are
controversial at the present time (Coustan, larger than those from mothers without di-
2003). abetes, with cellular hyperplasia dominating
Neuropathy in pregnant patients with di- over hypertrophy, and may in fact compete
abetes can be present in the form of visceral with the fetus for oxygen and nutrients. In the
or autonomic neuropathy causing symptoms presence of maternal vascular disease, the pla-
such as persistent pain, nausea and vomiting, centas may be smaller, rather than larger, than
early satiety and fullness, which can actu- those of mothers without diabetes. Both pre-
ally be due to gastroparesis. Less commonly mature senescence and immaturity of chori-
excessive postural pressure changes, and ab- onic villi have been described in placentas of
sence of normal respiratory variation in the mothers with diabetes (Coustan, 2003).
heart rate can indicate cardiovascular involve-
ment. Peripheral neuropathies are manifested Perinatal Mortality
in the form of paresthesias, most often in the
lower extremities. More severe forms lead to Although perinatal mortality is now sim-
skin ulceration and ischemia that requires am- ilar to normal pregnancies due to the modern
putation (Coustan, 2003). coordinated maternal–fetal care, it may still be
Hypertension has been seen to occur in a problem in patients who have long-standing
the presence or absence of nephropathy in hyperglycemia and vascular involvement.
diabetic gravidas, and it may be as high as Both fetal and neonatal deaths occurred
30% in patients with known vascular disease with increased frequency in diabetic preg-
(Coustan, 2003). nancies before the advent of modern man-
Urinary tract infections are more com- agement methods. The cause of fetal death
mon in patients with diabetes. Pyelonephritis remains incompletely understood. Maternal
can complicate up to 3% of patients with pre- DKA, associated with a 50–90% fetal mortal-
existing diabetes. Such an event, if left un- ity rate (Golde, 1991), is currently rare among
appropriately treated women with diabetes anomalies) is highly specific for diabetic preg-
(Coustan, 2003). nancy (Coustan, 2003).
There appears to be a clear association All structural birth defects seen in infants
between suboptimal metabolic control and of mothers with diabetes occurred by the
perinatal death. Animal studies suggest that 8th week of gestation. Most women do not
fetal insulinemia brought about by maternal seek prenatal care before this time. In animal
hyperglycemia may cause fetal hypoxemia studies, hyperglycemia can induce congenital
and lactic acidosis and, in extreme cases, fe- anomalies during this period of organogen-
tal death (Coustan, 2003). Likewise, the infu- esis (from the 5th to 9th week of gestation)
sion of large amounts of glucose-containing (Sadler, 1981; Buchanan et al., 1994).
solutions to pregnant women has been associ- There is an association between the level
ated with fetal acidosis (Kenepp et al., 1982; of glycosylated hemoglobin and congenital
Lawrence 1982). It thus seems likely that ma- anomalies in the offspring (Leslie et al., 1978;
ternal hyperglycemia is at least partially the Miller et al., 1981). Such an association is the
cause of the increased fetal death rate among basis for recommending adequate prepreg-
diabetic pregnancies. nancy metabolic control in patients with pre-
Perinatal mortality consists of both fe- existing diabetes with a concomitant decrease
tal and neonatal deaths. Although fetal death in the incidence of congenital anomalies from
probably is directly related to metabolic de- 7% to 2–3% as in the baseline population
rangement in diabetic pregnancies (described (Fuhrmann et al., 1984).
above), neonatal deaths appear to be caused Macrosomia is defined as a specific birth
more indirectly. In the past, the threat of fetal weight (i.e., 4,000 or 4,500 g) or as a relative
death has prompted attempts of early delivery. weight for gestational age (i.e., 90th, 95th,
Thus, prematurity and its sequelae increased or 97.5th percentile). The latter designation
the neonatal death rate. is more scientifically correct as a premature
In addition, infants of poorly controlled baby may be macrosomic for its age.
mothers with diabetes are more likely to de- Macrosomia is considerably more preva-
velop respiratory distress syndrome (RDS) at lent among offspring of women with diabetes
a given gestational age than infants of mothers versus nondiabetic pregnancies. This is true
without diabetes. And adequate control of for gestational diabetes as well as preexist-
glycemia seems to exert a protective effect ing diabetes (ACOG, 1994; ACOG, 2001).
in infants of mothers with diabetes (Karlsson Macrosomic infants of mothers with diabetes
and Kjellmer, 1972; Robert et al., 1976). are at risk for shoulder dystocia at the time of
delivery because typically they have increased
Congenital Anomalies body fat but not head or brain size. This
causes their shoulders to be abnormally broad
A good percentage of perinatal mortal- in relation to their head size. The incidence
ity and morbidity is related to congenital of shoulder dystocia for diabetic mothers re-
anomalies. Infants of mothers with diabetes mains elevated even when corrected for birth
are three times more likely than infants in weight (Langer et al., 1991).
the general population to manifest all types
of birth defects (Cousins, 1983). Cardiac, Fetal Hypoglycemia
neural tube, and skeletal defects are most
common, but a particular set of anomalies At birth, the maternal glucose contribu-
affecting the lower half of the body, the tion to the fetus is interrupted and, given the
caudal regression syndrome (congenital mal- state of hyperinsulinemia in the neonate, hy-
formation characterized by the association of poglycemia may occur.
hypo- or agenesis of the lower extremity of Hypoglycemia (or blood sugar of less
the spine with genitourinary and anorectal than 35 mg/dl at term, or less than 25 mg/dl
in a preterm infant) is more commonly as- mothers with diabetes. But in a particular
sociated with maternal hyperglycemia and study involving Pima Indians, cultural factors
infusion of intravenous glucose fluids dur- also may play a role. Intellectual development
ing labor (Lawrence et al., 1982). It usu- during the neonatal and later periods has been
ally occurs during the first 60–90 minutes of found to be inversely correlated between hy-
life, and is often asymptomatic. On the other perglycemia and ketonemia during the second
hand, symptoms may include irritability, ap- trimester.
neic spells, tachypnea, hypotonia, shakiness Animal studies and studies in human
and, at the extreme, convulsions. If hypo- populations (after corrections for genetic fac-
glycemia does not occur early in the neonatal tors) have demonstrated that exposure to hy-
period, it is unlikely to show up later. Early perglycemia can cause gestational diabetes in
institution of oral feeding may be helpful female offsprings for up to two generations
in preventing hypoglycemia. Hypoglycemia, (Coustan, 2003).
which is promptly treated generally, is not
associated with adverse sequelae (Coustan,
2003). CURRENT SCREENING AND
DIAGNOSIS OF GESTATIONAL
Neonatal Respiratory Problems DIABETES
Respiratory distress syndrome, as well In spite of the absence of data that uni-
as other forms of neonatal respiratory dis- versal screening for GDM in pregnant women
tress, occurs with increased frequency in in- may not confer a benefit to the population as
fants of mothers with diabetes. Before elective a whole, in the United States the 50-g, 1-hour
induction of labor, amniocentesis and phos- laboratory screening has become and proba-
phatidylglycerol determination is indicated to bly should continue to be widely used. There
establish fetal lung maturity. Good metabolic seems to be a lack of evidence that fasting im-
control during pregnancy seems to minimize proves the accuracy of the screening test and,
the incidence of RDS. in fact, fasting may pose significant logistical
problems. A 50-g, glucose load in 150 ml
Other Neonatal Problems of solution is therefore administered orally
without regard to the time elapsed since the
Additional neonatal problems in the last meal (ACOG, 2001).
neonatal period are polycythemia, hyper- The threshold value recommended by the
viscosity, hyperbilirrubinemia, and hypocal- American Diabetic Association is 130 mg/dl.
cemia. Thrombocytopenia is more common Increasing the threshold to 140 mg/dl has been
as well. Umbilical venous pH also was sig- used in the past to increase the specificity of
nificantly lower than in controls, although the test. Currently, either thresholds are con-
still within the normal range. Transient car- sidered acceptable (ACOG, 2001).
diac dysfunction, presumably due to increased Screening is traditionally recommended
thickness of the intraventricular septum, has between 24 and 28 weeks of gestation in nor-
been reported in neonates of mothers with di- mal patients, because studies have demon-
abetes even when metabolic control was re- strated that GDM is more prevalent with
ported to be good during pregnancy (Coustan, advancing gestation. However, in patients
2003). with traditional historic risk factors, screen-
ing early in pregnancy is preferable. Also, per-
Growth and Development forming a full 3-hour, 100-g oral test instead
of a 1-hour test may allow earlier detec-
Obesity may be a problem during child- tion and intervention. Historical risk factors
hood and adolescence in the offspring of include:
1. Previous adverse pregnancy outcomes ries switched from whole blood samples to
associated with GDM. plasma or serum samples. There are no data
2. Previous history of GDM. from clinical trials to determine which is su-
3. Family history of DM (first-degree rela- perior.
tive). Patients with only one abnormal value
4. Glycosuria.
have been demonstrated to manifest in-
5. Previous delivery of a >4,000 g baby.
6. History of polyhydramnios.
creased risk and morbidity associated with
7. Obesity. GDM. The relationship between carbohydrate
8. History of child with congenital anoma- metabolism and such problems is a continuum
lies. and no threshold will identify all patients at
9. Maternal age greater than 30 years. risk.
10. Member of an ethnic group with an in-
creased risk for the development of type 2 di-
abetes (examples of high-risk ethnic groups in- Monitoring Blood Glucose in a Woman
clude women of Hispanic, African American, Na- with Gestational Diabetes
tive American, South or East Asian, or Pacific Is-
lands ancestry). The modern management of dia-
11. Previous history of abnormal glucose betes during pregnancy relies on patient’s
tolerance (Coustan, 2003; ACOG, 2001). self-monitoring of glucose levels. The use of
test strips for blood and read by a reflectance
The specific diagnostic test recom- meter seems to be the most practical and eco-
mended by the ADA is the 100-g, 3-hour oral nomical way of monitoring blood glucose.
glucose tolerance test (GTT) and it consists of It is a common practice to monitor blood
a 100-g glucose oral challenge. This is admin- glucose levels four times daily during preg-
istered after an overnight fast of 8–14 hours, nancy. It is recommended that the patient
and after 3 days of an unrestricted diet con- record an initial fasting blood glucose and
taining at least 150 g of carbohydrate per day. then 1- or 2-hour postprandials after every
The diet preparation is important to induce an main meal. Macrosomia has been found sig-
adequate insulin response during the test. A nificantly more likely if 1-hour postprandial
positive diagnosis requires that two or more blood sugars exceed 130 mg/dl. Postpran-
thresholds be met or exceeded. Patients should dial blood sugars seem to be more predictive
not smoke before the test and should remain of fetal macrosomia than fasting ones. Un-
seated during the test (NDDG, 1979; ADA, like macrosomia, maternal mortality has not
2003; Coustan, 2003; ACOG, 2001). yet been shown to be affected by adhering
Table 14.2 illustrates two sets of di- to this threshold. Table 14.3 illustrates blood
agnostic criteria adapted from the original sugar level goals for pregnant women with
O’Sullivan and Mahan values after laborato- GDM.
TABLE 14.2. Diagnostic Criteria for Gestational Diabetes

Plasma or serum glucose level Plasma level
Carpenter/coustan conversion National Diabetes Data

Group conversion
mg/dl mmol/l mg/dl mmol/l

Fasting 95 5.3 105 5.8
One hour 180 10 190 10.6
Two hours 155 8.6 165 9.2
Three hours 140 7.8 145 8.0

TABLE 14.3. Goals of Treatment in sugar levels, seems to derive from ultrasound
Gestational Diabetes studies that showed an even further reduc-
tion in the incidence of fetal macrosomia
Times of testing Goals (mg/dl)
(Coustan, 2003).
Fasting 60–100 At the present time, it is recommended
2-hour postbreakfast 70–120 that women with GDM be given diet therapy
2-hour postlunch 70–120
for a period of 2 weeks if initial fasting blood
2-hour postdinner 70–120
sugars are under 95 mg/dl. If the patient ini-
Source: Coustan (2003). tially or after 2 weeks presents blood sugars
above 95 mg/dl, insulin should be considered
(Coustan, 2003; ACOG, 2001).
MANAGEMENT OF DIABETES
IN PREGNANCY
Exercise in the Treatment of Gestational
Diabetes
Diet in the Treatment of Diabetes in
Pregnancy Exercise can help achieve weight reduc-
tion and improve glucose metabolism, and
A pregnant woman with diabetes should
may help in the prevention of fetal macroso-
have normal, stable glucose levels and avoid
mia. Exercise programs should be encouraged
ketosis, but at the same time achieve adequate
during pregnancy (ACOG, 2001).
nutrition and weight gain. Nutritional coun-
seling should be done if possible by a reg-
istered dietitian. A diet should be prescribed Oral Antidiabetic Agents in the
based on weight and height. A 30 cal/kg per Treatment of Gestational Diabetes
day based on prepregnant body weight for
The sulfonylureas, first used for treat-
nonobese individuals is recommended by the
ment of type 2 diabetes, crosses the pla-
ADA. For obese individuals (body mass index
centa and could stimulate the fetal pancreas,
>30), a moderate caloric restriction (30–33%
leading to fetal hyperinsulinemia. Glyburide
so as to prevent starvation ketosis) seems to
has been compared to insulin in patients
decrease the incidence of fetal macrosomia
with gestational diabetes, showing similar
(ACOG, 2001).
glucose control, as well as outcomes such
as rates of cesarean delivery, preeclamp-
Insulin in the Treatment of Diabetes in sia, macrosomia, and neonatal hypoglycemia.
Pregnancy Furthermore, glyburide could not be detected
in the fetus. More data are needed to support
Based mostly on management of preg- recommendations for the newer oral agents
nant women with preexisting diabetes, it is such as metformin (Coustan, 2003).
a common practice to add insulin if medi-
cal nutrition therapy does not maintain fast-
ing plasma glucose below 105 mg/dl or FETAL ASSESSMENT IN THE
2-hour postprandial values below 120 mg/dl TREATMENT OF GESTATIONAL
or both. However, based on pregnancy out- DIABETES
come studies concerning fetal macrosomia,
there is reason to start insulin for patients Antepartum testing is recommended for
with fasting blood sugar greater than 95 mg/dl. patients with preexisting diabetes. Commonly
Furthermore, the concept of “prophylactic in- used are: (1) fetal kick counts starting at 28
sulin” administration to women with gesta- weeks (the patient documents fetal move-
tional diabetes, regardless of fasting blood ments every day, which should exceed a
predetermined standard), and (2) nonstress gists, obstetricians, neonatologists, nutrition-

testing or NST (which consists of fetal mon- ists, endocrinologists, and additional special-
itoring to look for fetal movement and fetal ists as required among others maintaining
heart accelerations associated with it) twice constant and open communication (Coustan,
per week with ultrasound assessment of am- 2003; ACOG, 2001).
niotic fluid volume (Coustan, 2003; ACOG,
2001).
Biophysical profile is done with ultra- DELIVERY
sound weekly to document fetal movement,
breathing, tone and amniotic fluid volume, or Delivery can be accomplished at 40
amniotic fluid index (AFI). This test is usually weeks in patients with good control. In women
performed once or twice weekly. A Contrac- with GDM, there is no evidence to support an
tion Stress Test (CST), which requires intra- induction before term. When control is less
venous fluids and oxytocin and involves hos- optimal, or in patients with preexisting dia-
pital and nursing care, is used in some centers betes, or when there are risk factors such as
according to local practice (ACOG, 2001). hypertension or previous stillbirth, delivery by
Ultrasound is used to estimate fetal induction should be accomplished at 38–39
weight in patients with suspected macroso- weeks of gestation or sooner, depending on
mia prior to delivery although it has not been the severity of the complication.
shown to be superior to clinical estimates. Amniocentesis, to document fetal lung
Expected ranges of error during the second maturity, is usually recommended at ≤38
trimester can be as high as 500 g (ACOG, weeks of gestation due to the more frequent
1997; ACOG, 2000). A “Level II” or “tar- incidence of RDS in patients with diabetes.
geted” ultrasound study is usually performed Cesarean delivery rates are more fre-
in the second trimester to look for fetal anoma- quent in patients with GDM compared to
lies (Coustan, 2003). mothers without GDM. This difference does
not appear to be related to fetal macrosomia. It
Laboratory and Ancillary Testing in the is likely that caregivers tend to perform more
Management of Diabetes in Pregnancy cesarean sections to prevent shoulder dystocia
at delivery. The incidence of shoulder dystocia
In addition to routine prenatal laboratory is increased in pregnant patients with diabetes.
tests, women with diabetes during pregnancy, It is therefore reasonable to recommend elec-
and especially those with preexisting diabetes, tive delivery by cesarean section if a particular
should undergo kidney function tests (24-hour threshold of fetal weight is exceeded, such as
collection for creatinine clearance and pro- when the estimated fetal weight is 4,500 g or
tein) and HbA1c at regular intervals, monthly greater. When the estimated weight is 4,000–
or bimonthly, depending on control. Con- 4,500 g, additional factors such as the pa-
sultation with the ophthalmologist for retina tient’s past delivery history, clinical pelvime-
assessment is indicated in the women with try, and the progress of labor may be helpful
preexisting diabetes. Urine cultures should to consider in determining mode of delivery
be performed to detect asymptomatic bacteri- (ACOG, 2001; ACOG, 1997; ACOG, 2000).
uria every month or two months to prevent
UTI, which could progress to pyelonephritis. Metabolic Management During Labor
Electrocardiography should be obtained in di-
abetic women with vascular disease or long- During labor, it is essential to maintain
standing diabetes. maternal euglycemia (60–120 mg/dl), and at
The management of diabetes in preg- the same time prevent ketosis, hypoglycemia,
nancy usually requires a team of perinatolo- and fetal acidosis. Frequent monitoring of
TABLE 14.4. Criteria for the Diagnosis of Diabetes Mellitus in the

Nonpregnant State
Impaired fasting glucose or
Normal values impaired glucose tolerance Diabetes mellitus
FPG <110 mg/dl FPG 110–125 mg/dl FPG ≥126 mg/dl

75-g, 2-hour OGTT 75-g, 2-hour OGTT 75-g, 2-hour OGTT
2-hour PG <140 mg/dl 2-hour PG 140–199 mg/dl 2-hour PG ≥200 mg/dl
symptoms of diabetes and PG
(without regard to time since last
meal) ≥200 mg/dl
Abbreviations: FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose. The diagnosis
of diabetes mellitus should be confirmed on a separate day by any of these three tests.
blood sugar is therefore essential (every 1–2 The use of fasting plasma glucose to
hours). Simultaneous infusions of intravenous diagnose diabetes after delivery is less cum-
glucose and insulin are therefore common. If bersome than the oral GTT but the ACOG
the patient is scheduled for an elective ce- believes the oral GTT will more accurately
sarean section, intravenous fluids of normal identify those women who now have im-
saline can be given prior to the procedure. paired glucose tolerance after delivery. This
Immediately after the procedure, a dextrose is thought to be important in counseling pa-
infusion can be started to prevent starvation tients in regards to subsequent glucose control
ketosis. before their next pregnancy (ACOG, 2001).
After delivery, insulin requirements usu-
ally fall to prepregnancy levels. During this
time, blood sugar control should not be as Contraception and Prepregnancy
strict and blood sugar levels may be al- Counseling
lowed to rise to 150–200 mg/dl without unto-
ward short-term effects. Insulin doses may be To minimize the incidence of congeni-
started at 1/3–1/2 of the predelivery amounts tal anomalies, adequate contraception coun-
and adjusted according to the blood sugar lev- seling and medical follow-up are highly rec-
els (Coustan, 2003). ommended in women with diabetes so that
pregnancy is not unintentional. Contraceptive
methods of virtually all types can be used in
POSTPARTUM SCREENING patients with diabetes. Progestational agents
like levonorgestrel implants may require
Gestational diabetes in women poses an closer glucose monitoring (ACOG, 2001).
increased risk of development of diabetes later Prepregnancy counseling usually in-
in life. This is particularly true of popula- volves reassessment of current diet and fur-
tions who do not have access to screening ther diet counseling, discontinuation of oral
and who have a high prevalence of type 2 di- antidiabetic agents, folic acid supplementa-
abetes. It is therefore appropriate to screen tion, basal kidney and retina assessments, and
these patients for diabetes annually with their institution of insulin and glucose monitoring
first screen in the postpartum period. Table regimens to achieve tighter control. Use of
14.4 illustrates the diagnosis criteria for dia- glycohemoglobin every 2–3 months can doc-
betes mellitus. There are no long-term follow- ument improvement in average glucose lev-
up studies documenting its benefit (Coustan, els. Exercise and weight reduction are usually
2003). encouraged (Coustan, 2003; ACOG, 2001).
REFERENCES therapy before and during pregnancy on the malfor-

mation rate in offspring of diabetic mothers. Exp
Clin Endocrinol 83:173.
American College of Obstetricians and Gynecologists. Golde, S.H. (1991). Diabetic ketoacidosis in pregnancy.
(1994). Gestational Diabetes. ACOG Technical Bul- In Clark, S.L., Cotton, D.B., Hankins, G.D.V.,
letin 200, Gestational Diabetes. Washington, DC: and Phelan, J.P. (eds.), Critical Care Obstetrics,
ACOG. Chap 17, 2nd ed. Boston: Blackwell Scientific Pub-
American College of Obstetricians and Gynecologists. lications.
(1997). Gestational Diabetes. ACOG Practice Bul- Karlsson, K., and Kjellmer, I.K. (1972). The outcome
letin 40, Shoulder Dystocia. Washington, DC: of diabetic pregnancies in relation to the mother’s
ACOG. blood sugar level. Am J Obstet Gynecol 112:213.
American College of Obstetricians and Gynecologists. Kenepp, N., Shelley, W.C., Gabbe, S.G., Kumar, S.,
(2000). Gestational Diabetes. ACOG Practice Bul- Stanley, C.A., and Gutsche, B.B. (1982). Fetal and
letin 22, Fetal Macrosomia. Washington, DC: neonatal hazards of maternal hydration with 5% dex-
ACOG. trose before cesarean section. Lancet 1:1150.
American College of Obstetricians and Gynecologists. Langer, O., Berkus, M.D., Huff, R.W., and Samueloff, A.
(2001). Gestational Diabetes. ACOG Practice Bul- (1991). Shoulder dystocia: Should the fetus weigh-
letin 30, Gestational Diabetes. Washington, DC: ing 4,000 grams be delivered by cesarean section?
ACOG. Am J Obstet Gynecol 165:831.
American Diabetes Association. (2003). Report of the Lawrence, G.F., Brown, V.A., Parsons, R.J., and Cooke,
Expert Committee on the Diagnosis and Classifica- I.D. (1982). Feto-maternal consequences of high-
tion of Diabetes Mellitus. Expert Committee on the dose glucose infusion during labour. Br J Obstet
Diagnosis and Classification of Diabetes Mellitus. Gynaecol 89:27.
Diabetes Care 26:S5–S20. Leslie, R.D.G., Pyke, D.A., John, P.N., and White, J.M.
Buchanan, T.A. (1995). Pregnancy in preexisting dia- (1978). Haemoglobin A1 in diabetic pregnancy.
betes. In National Diabetes Data Group: Diabetes Lancet 2:958.
in America. 2nd ed. NIH No. 95–1468. Washington: Miller, E., Hare, J.W., Cloherty, J.P., Gleason, R.E.,
NIH, pp. 719–733. Soeldner, J.S., and Kitzmiller, J.L. (1981). Elevated
Buchanan, T.A., Denno, K.M., Sipos, G.F., and Sadler, maternal hemoglobin A1c in early pregnancy and
T.W. (1994). Diabetic teratogenesis: In vitro evi- major congenital anomalies in infants of diabetic
dence for a multifactorial etiology with little con- mothers. N Engl J Med 304:1331.
tribution from glucose per se. Diabetes 43:656. National Diabetes Data Group. (1979). Classification
Cousins, L. (1983). Congenital anomalies among infants and diagnosis of diabetes mellitus and other cat-
of diabetic mothers: Etiology, prevention, prenatal egories of glucose intolerance. Diabetes 28:1039–
diagnosis. Am J Obstet Gynecol 147:333. 1057.
Coustan, D.R. (2003). Diagnosis and management of dia- Robert, M.F., Neff, R.K., Hubbell, J.P., Taevsch, H.W.,
betes mellitus in pregnancy. In Sciarra, J.J. (ed.), Gy- and Avery, M.E. (1976). Association between mater-
necology and Obstetrics CD-ROM, Vol. 3, Chap 13, nal diabetes and the respiratory-distress syndrome in
2003 Edition. the newborn. N Engl J Med 294:357.
Coustan, D.R., Nelson, C., Carpenter, M.W., Carr, S.R., Sadler, T.W. (1981). Effects of maternal diabetes on
Rotondo, L., and Widness, J.A. (1989). Maternal age embryogenesis: II. Hyperglycemia-induced exen-
and screening for gestational diabetes: A population- cephaly. Teratology 21:349.
based study. Obstet Gynecol 73:557. World Health Organization. (1985). Diabetes Mellitus:
Fuhrmann, K., Reiher, H., Semmler, K., and Glockner, E. Report of a WHO Study Group. Geneva: World
(1984). The effect of intensified conventional insulin Health Organization (Tech. Rep. Ser. no. 727).
15
Chronic Kidney Disease

Leslie Spry
Lincoln Nephrology & Hypertension, Lincoln, Nebraska
This chapter will examine the mechanisms to cleanse the body of unwanted metabolic
of chronic kidney disease (CKD) and dia- waste products and control the fluid and elec-
betes, natural history, and potential thera- trolyte balance of the body. This function is
pies available. Diabetes accounts for more usually measured in terms of glomerular fil-
than 40% of the individuals currently seek- tration rate (GFR). Glomerular filtration rate
ing dialysis and transplant (U.S. Renal Data may be thought of as a rough percentage of re-
System, 2003). Current estimates are that nal function and is usually expressed in terms
40 million Americans have or have the po- of milliliter per minute (i.e., 80 ml/minute
tential to develop diabetes mellitus (Coresh is roughly 80% of normal kidney function).
et al., 2003). Chronic kidney disease devel- Blood is delivered to the kidneys by the re-
ops in 10–15% of people with type 2 diabetes nal arteries and taken away by the renal veins.
and approximately 40% of people with type Glomerular filtration rate in adults is normally
1 diabetes. 100–120 ml/minute or 150 l/day. This liter-
ally means that the kidneys filter 150 l of
blood per day and sort out the desirable from
OVERVIEW OF RENAL the undesirable substances. The undesirable
PHYSIOLOGY substances then end up in urine that is ex-
pelled (cleared) from the body via bladder
The kidneys are retroperitoneal organs emptying. We commonly measure the clear-
that weigh approximately 150 g (1/3 lb) each ance of a substance from the body as a way of
(see Figure 15.1). Each kidney contains ap- estimating GFR. For example, insulin clear-
proximately 1.5 million glomeruli that are ance is felt to be the gold standard for mea-
the most basic functional unit of the kidney. suring GFR, but is difficult to do and is no
Chronic kidney disease results in the loss of longer used in clinical medicine (National
glomeruli, such that when the total number of Kidney Foundation, K/DOQI, Guideline 4 for
remaining glomeruli reaches 300,000, dialy- CKD). Iothalamate clearance is a radioactive
sis and transplantation are often needed to sus- substance that can very accurately estimate
tain life. The basic function of the kidney is GFR, but generates low-level radioactivity,
199
200 CHRONIC KIDNEY DISEASE
Vein Artery
Kidney
Ureter
Urethra Bladder
FIGURE 15.1. The vascular anatomy and structures of the kidney and urinary tract. These structures lie in the
retroperitoneal area. The large vein on the left is the vena cava and the artery on the right is the aorta (Used with the
permission of the National Kidney Foundation).
which is difficult to dispose of, and hence not clearance and uses age, sex, weight, height,
commonly performed. Much more common race, serum albumin, serum creatinine, and
clearance tests that are performed are crea- BUN to calculate a GFR. This equation can
tinine clearance and urea clearance. Creati- be accessed at http://nephron.com/cgi-bin/
nine clearance overestimates GFR and urea MDRD.cgi.
clearance underestimates GFR (especially at The basic structure of the kidney con-
low levels of GFR) and are commonly aver- sists of nephron (see Figure 15.2) that can be
aged to yield a more accurate estimate of GFR viewed as a series of structures involved in
that is clinically useful and also gives infor- clearance. The blood delivered to the nephron
mation about protein catabolism (see below). is filtered by the glomerulus, fluid then passes
The Modified Diet in Renal Disease (MDRD) through the tubules where important sub-
study (Klahr et al., 1994) developed an equa- stances are either reclaimed or excreted into
tion that has been validated to iothalamate the final urine. The tubules are also important
CHRONIC KIDNEY DISEASE 201
Glomerulus
Tubule
Nephron
FIGURE 15.2. A schematic representation of the nephron. Each nephron consists of an artery bringing blood to the
glomerulus, and the vessel taking blood away from the glomerulus. Blood is filtered into the tubule where the process
of sorting out unwanted wastes and reclaiming important chemicals and fluids occur (Used with permission of the
National Kidney Foundation).
in excretion of acids, production of hormones NATIONAL KIDNEY

such as vitamin D, erythropoietin, and renin. FOUNDATION K/DOQI
The tubules also adjust the final amount of GUIDELINES
water that ends up in the urine. The kidney
is also responsible for breaking down insulin The National Kidney Foundation (NKF)
and helping to regulate blood sugar. The kid- has published guidelines covering many as-
ney breaks down and excretes other hormones pects of CKD (NKF, K/DOQI, 2000, 2002,
such as parathyroid hormone (PTH) and does 2003a,b). These guidelines can be accessed
the same activity for many drugs. As the urine via the NKF Web site at www.kidney.org.
is finally produced, it flows into a collecting Chronic kidney disease is defined as
duct that sends the urine into the ureter and an abnormality of kidney structure or func-
finally into the bladder for final elimination. tion with or without alterations in GFR
All these complex functions are affected by that are present for more than 3 months.
CKD. In addition, anytime GFR is less than
TABLE 15.1. Stages and Prevalence of Chronic Kidney Disease

Prevalencea
Stage Description GFR (ml/minute) Population (1,000’s) (%)
1 Kidney damage ≥ 90 5,900 3.3

with normal or
increased GFR
2 Kidney damage 60–89 5,300 3.0
with mild
decrease in GFR
3 Moderate decrease 30–59 7,600 4.3
in GFR
4 Severe decrease in 15–30 400 0.2
GFR
5 Kidney failure <15 or dialysis 300 0.1
a
Data for Stages 1–4 from NHANES III (1988–1994). Population of 177 million with age ≥20 years. Data for
Stage 5 from USRDS (1998) includes approximately 230,000 patients treated by dialysis, and assumes 70,000
additional patients not on dialysis. GFR estimated from serum creatinine using the MDRD Study equation (see
text). Stages 1 and 2 kidney damage based on abnormal spot albumin-to-creatinine ratio.
Source: Based on data developed by the National Kidney Foundation (NKF, K/DOQI, 2002).
60 cc/minutes per 1.73 m2 and is present for of diabetes, small amounts of albumin
more than 3 months, CKD is present. The begin appearing in the urine (Mogensen,
NKF has developed a staging system based 1987; American Diabetes Association,
on GFR that includes descriptive characteris- 2002a). Special laboratory testing is neces-
tics of CKD and actions to be taken with each sary to detect small amounts of albumin in
level of kidney disease (see Table 15.1). the urine. The most commonly performed test
Specific guidelines have been pub- is a radioimmunoassay of the albumin in the
lished regarding nutritional management, urine. A colorimetric assay for albumin in the
anemia management, management of dyslipi- urine is also available. Normal amounts of
demias, and management of bone and min- albumin in the urine are less than 20 μg/mg
eral metabolism for CKD. There are also of creatinine (also expressed as milligram per
guidelines under development for manage- gram of creatinine) or less than 20 μg/minute
ment of cardiovascular disease and hyper- if a 24-hour collection is performed. Mi-
tension. croalbuminuria is said to be present when
excretion is greater than 30 μg/mg of crea-
tinine. Overt albuminuria (overt proteinuria)
NATURAL HISTORY OF is said to be present when excretion exceeds
DIABETES MELLITUS, TYPE 1 300 μg/mg of creatinine. Overt albuminuria
can be detected by routine urine testing such
Type 1 diabetes mellitus (diabetes) is the as with a urine dipstick without resorting to
result of an absolute lack of insulin produc- specialized testing. Microalbuminuria begins
tion by the body. This disease is covered in when GFR is in the normal range and would
“Chapter 6”, so this chapter will only deal with qualify as Stage 1 CKD under the NKF
the pertinent features seen in diabetic kidney classification system (NKF, K/DOQI, 2002).
disease. Overt proteinuria commonly begins between
The earliest form of CKD seen in 5 and 10 years of type 1 diabetes.
type 1 diabetes is microalbuminuria (see At approximately 10 years of type 1 di-
Figure 15.3). After approximately 5 years abetes, GFR begins to decline and several
GFR 100 75 50 25 ESRD
Onset
Diabetes
Microalbuminuria
@ 5 years
Falling GFR
@ 10 years
Hypertension
onset
Proliferative Retinopathy
@10--15 years
Overt Nephropathy and

Nephrotic Syndrome and
rapidly falling GFR
Planning for ESRD with

access placement, patient
education, transplant and
dialysis @ 15--20 years
FIGURE 15.3. Natural history of diabetic nephropathy, type 1.
important pathophysiologic changes occur. abetic nephropathy and is a combination of

Hypertension begins to develop. Retinopa- more than 3.5 g of proteinuria per 24 hours
thy usually occurs in the 10–15-year time (urine protein to creatinine ratio of greater
frame. The need for laser treatment of pro- than 3.5 on a spot specimen), hypoalbumine-
liferative diabetic retinopathy commonly oc- mia, and elevated serum cholesterol. The syn-
curs in the same time frame as well. The drome of diabetic nephropathy seen with-
combination of proteinuria, retinopathy, and out diabetic retinopathy should cause some
diabetic peripheral neuropathy is commonly concern that the CKD may be the result of
referred to as a diabetic triopathy and is par- some other kidney disease rather than true di-
ticularly characteristic of progressive CKD in abetic nephropathy. A kidney biopsy may be
persons with type 1 diabetes. Accelerated hy- the only way to differentiate other forms of
pertension is seen during the same time frame, kidney disease from typical diabetic nephro-
hence retinopathy also can be complicated pathy.
by hypertensive changes as well as diabetic Dialysis and transplant are commonly
changes. considered when GFR is below 15 ml/minute.
A rapid fall in GFR is seen in the 15– Placement of an arteriovenous fistula is
20-year interval, such that most people with recommended when the GFR falls in the
type 1 diabetes with CKD will require dialy- 15–30 ml/minute range (NKF, K/DOQI,
sis or transplant therapy within 5 years of the 2000, 2002). The arteriovenous fistula will
diagnosis of typical diabetic nephropathy. Di- facilitate management at later stages of the
abetic nephropathy is characterized by severe illness and requires 6 months or more to be-
hypertension, overt proteinuria, and declining come developed enough to use for dialysis
GFR. Nephrotic syndrome may be seen in di- access. Planning for transplantation should
also be started during the same time frame. tion to develop type 2 diabetes. They have
Please see Management of End Stage Renal a high incidence of atherosclerotic vascular
Disease (ESRD) for further discussion on this complications, including coronary heart dis-
topic. ease, atherosclerotic nephrosclerosis, and re-
sultant CKD. Hence, in type 2 diabetes, CKD
may result from nephrosclerosis, renal artery
NATURAL HISTORY OF stenosis secondary to atherosclerotic vascu-
DIABETES MELLITUS, TYPE 2 lar disease, and hypertensive nephrosclerosis.
Typical diabetic nephropathy may then de-
Type 2 diabetes is a disease that results velop in the setting of any one or all of these
from resistance to the actions of insulin in the diseases. This makes the timeline for the de-
body. Normal and even high concentrations velopment of CKD in type 2 diabetes very
of insulin may be available but the body does unpredictable.
not respond normally to glucose loads and the End stage renal disease progresses over
activity of the insulin is impaired at the cellu- time and dialysis or transplant therapy is
lar level. This type of diabetes is often geneti- necessary when the GFR reaches Stage 5
cally transmitted in families. This chapter will (less than 15 ml/minute). In type 2 diabetes,
deal with the myriad manifestations of CKD atherosclerotic vascular and cardiac disease,
in persons with type 2 diabetes. hypertensive heart and vascular disease, and
In contrast to type 1 diabetes, a patient obesity all contribute to the morbidity and
with type 2 diabetes appears to have many mortality commonly seen in this population
other metabolic complications that result in a with Stages 4 and 5 CKD. The creation of ar-
very different picture of CKD. The sequence teriovenous fistula access is also complicated
of events depicted in Figure 15.3 is also true in this population because of these preexisting
for type 2 diabetes but the time frame is not as and comorbid conditions.
predictable (ADA, 2002a.). Hence, microal-
buminuria progressing to overt proteinuria,
acceleration of hypertension, retinopathy, and DIAGNOSTIC EVALUATION
progressive decline in GFR characterize dia- OF CKD
betic nephropathy in persons with type 2 dia-
betes, but the timeline is not as predictable as The most important aspect in the di-
we see in persons with type 1 diabetes. There agnostic evaluation of CKD in diabetes is
are a number of reasons for this. a careful history and physical examination.
The person with type 2 diabetes fre- This will yield an accurate diagnosis and also
quently has other preexisting disease that provide information about complications of
may contribute to CKD. Such diseases as diabetes including hypertension, peripheral
hypertension frequently predate the onset of neuropathy, retinopathy, peripheral vascular
proteinuria in persons with type 2 diabetes and disease, and the possibility of renal artery
may result in kidney damage. Hyperlipidemia disease. Family history can give clues as to
is commonly seen in type 2 diabetes prior to the genetics involved and provide information
the onset of CKD, but in type 1 diabetes, hy- about hypertension, heart disease, hyperlipi-
perlipidemia is not common until after the on- demia, and ESRD as risk factors for the devel-
set of overt proteinuria or nephrotic syndrome opment of CKD. Certain ethnic populations
(ADA, 2002a.). with predisposition to diabetes are known to
The metabolic syndrome is the combi- be at particularly high risk for the develop-
nation of insulin resistance, dyslipidemia, hy- ment of CKD including black race, Hispanic,
pertension, and obesity (Scott, 2003). Many Pacific Islander, and American Indian (NKF,
of these patients have a genetic predisposi- KEEP, 2003).
The next step in the evaluation of CKD is may include other forms of diabetic neurolog-
to measure kidney function and look for signs ical injury including gastroenteropathy (in-
of kidney damage. A GFR calculation can cluding gastroparesis and diabetic diarrhea),
be done using the MDRD calculation noted autonomic neuropathy with orthostatic hy-
above. Urine should be measured for microal- potension, mononeuropathy with individual
bumin or overt proteinuria. This can be done muscle paresis, painful peripheral neuropa-
with an individual (spot) urine sample or a thy, radiculopathy, and abnormalities of sweat
24-hour collection. The patient’s GFR should gland control including postgustatory sweat-
be staged using the NKF’s CKD system. This ing. CKD is commonly seen in the setting of
staging system then gives the patient recom- diabetic neuropathy.
mendations for actions to be taken at each When CKD is seen in diabetes and
level of GFR. This will help to prepare the especially in type 2 diabetes, the possibil-
patient for dealing with ESRD, should ther- ity of renal artery disease and other forms
apy be necessary. of CKD, other than diabetic nephropathy,
Patients should undergo testing to in- have to be considered. Auscultation for re-
clude a chemistry panel that includes BUN, nal artery bruits, Doppler ultrasounds of the
creatinine, sodium, potassium, albumin, bi- kidney, magnetic resonance imaging, nuclear
carbonate, calcium, and phosphate levels. A medicine scanning with or without captopril
PTH level should be done in patients with and CT angiograms may be used to try and de-
Stages 3–5 CKD to assess secondary hyper- tect renal artery disease in appropriate clinical
parathyroidism (NKF, K/DOQI, 2003b.). A circumstances. A renal ultrasound should be
complete blood count should be done, which done in almost all cases of CKD in the patient
includes a hemoglobin and a hematocrit to with diabetes and should look for reversible
evaluate for anemia of CKD. With GFRs be- factors including obstruction, the presence of
low 60 ml/minute, anemia would be antici- two kidneys, size of the kidneys, and echo-
pated. A lipid panel should be done to look texture of the kidneys. Incidental mass lesions
for the characteristics of the nephrotic syn- are occasionally discovered during screening
drome, metabolic syndrome, and risk factors ultrasound of the kidneys and need to be evalu-
for coronary artery and peripheral vascular ated appropriately. Typical diabetic nephropa-
disease. HbA1c should be measured to as- thy results in large kidneys seen on ultrasound,
sess metabolic control of diabetes and estab- whereas diseases such as hypertensive and
lish prognosis for progression of CKD. A 24- atherosclerotic nephrosclerosis typically re-
hour urine collection can be used to measure sult in smaller than normal kidneys with in-
GFR and when urea clearance and protein creased echo-texture (suggestive of scarring
are measured, one also can determine nor- and loss of water content). Valuable informa-
malized protein catabolic rate (nPCR) that tion commonly derived from ultrasound also
can provide information about nutritional sta- includes obstruction of the urinary tract at any
tus and dietary protein requirements (NKF, level from the prostate to the renal pelvis. Ob-
K/DOQI, 2000, Nutrition Guidelines). A sub- struction is a reversible cause of CKD and
jective global assessment also can be used to should be sought in all cases.
evaluate nutritional status and assist in the di-
etary management of the diabetic with CKD
(NKF, K/DOQI, 2000, Nutrition Guidelines). TREATMENT CONSIDERATIONS
Neurology testing, including monofila- IN CKD
ment testing, will provide valuable informa-
tion regarding risks to the patient with dia- Once the diagnosis of CKD is made
betes and CKD. Typical diabetic triopathy in- in a person with diabetes, the most impor-
cludes diabetic peripheral neuropathy but also tant treatment considerations are based on the
stage of CKD. Specifically, levels of GFR and These agents have been shown to slow the pro-
proteinuria will guide therapy. Dietary man- gression of diabetic nephropathy and in some
agement includes the diabetic diet as recom- cases have been able to reverse microalbumin-
mended by the American Diabetes Associa- uria to normal levels of albumin excretion in
tion (ADA, 2002b.). In addition, diets such the urine. Therapy should be initiated as soon
as the Dietary Approaches to Stop Hyperten- as microalbuminuria is detected, regardless of
sion (DASH diet) are also recommended as the level of blood pressure. Hence, ACE-I and
lifestyle modifications in the treatment of hy- ARB therapy should be initiated in Stage 1
pertension and diabetic kidney disease (Sacks CKD found in patients with either type 1 or
et al., 2001; Chobanian et al., 2003). Protein type 2 diabetic nephropathy. Recent studies
restriction and restriction of phosphorus in the have suggested a synergistic effect of the com-
diet has been advocated by some based on bination of ACE-I with an ARB in the treat-
small studies (ADA, 2002b.), but no prospec- ment of proteinuria associated with both non-
tive randomized trials have been carried out diabetic and diabetic nephropathy (Campbell
in diabetic nephropathy of sufficient size to et al., 2003; Jacobsen et al., 2003). This com-
make a strong recommendation. The control bination results in a significantly greater fall
of diabetes with an HbA1c in the range of 6.0– in proteinuria than with either agent alone.
6.5 has been shown to treat and reverse mi- Hence, if either agent is incompletely effec-
croalbuminuria and prevent the progression of tive in reaching target blood pressure or de-
diabetic nephropathy (Diabetes Control and creasing proteinuria, the other agent could be
Complications Trial Research Group, 2003). added to try and achieve these goals.
Antihypertensive therapy is the key to The recent ALLHAT trial demonstrated
therapy of diabetic nephropathy. The Joint that thiazide therapy decreases mortality and
National Committee Report on Prevention, morbidity of hypertensive patients, includ-
Detection, and Treatment of High Blood ing patients with diabetes mellitus (ALLHAT
Pressure (Chobanian et al., 2003) currently Collaborative Research Group, 2002). Hence,
recommends treatment of diabetic CKD to a the addition of thiazide therapy such as hy-
target of 130/80. There have been suggestions drochlorothiazide and chlorthalidone (see Ta-
that diabetic CKD, especially with protein- ble 15.2) to the ACE-I and ARB agents would
uria in excess of 1 g per 24 hours, should be be the next reasonable addition in an at-
treated to a lower target of 125/75 (Bakris tempt to reach a goal blood pressure in dia-
et al., 2000). The control of hypertension betic nephropathy. These agents are effective
frequently requires multiple drug therapy to in Stages 1–3 CKD associated with dia-
achieve these targets. Studies have suggested betes, but are not effective with GFRs below
that an average of 3–4 drugs may be required 30 ml/minute. The thiazide diuretic metola-
in these individuals to achieve this type of con- zone is not only effective with GFRs be-
trol (Chobanian et al., 2003). low 30 ml/minute, but also results in sig-
The choice of agents in antihypertensive nificant complications including gout from
is also of critical importance. Type 1 diabetic hyperuricemia, hypokalemia, and hypomag-
nephropathy has been shown to respond to an- nesemia. If a diuretic is needed with Stage
giotensin converting enzyme inhibitor (ACE- 3 or greater CKD, loop diuretics such as
I) therapy (Lewis et al., 1993). In contrast, furosemide, torsemide, or bumetanide (see
type 2 diabetic nephropathy has been shown Table 15.2) should be used. Loop diuretics can
to respond favorably to angiotensin receptor also cause hypokalemia, hypomagnesemia,
blockers (ARBs) (Lewis et al., 2001; Bren- and gout. The combination of ACE-I or ARBs
ner et al., 2001; Parving et al., 2001). Please with diuretics frequently avoids the complica-
see Table 15.2 for examples of ACE-I and tion of hypokalemia. ACE-I and ARB agents
ARB agents used in diabetic nephropathy. may cause hyperkalemia and diuretics will
TABLE 15.2. Selected Antihypertensive Drugs

Drug class Generic names Trade names
ACE-inhibitors Captopril, enalapril, lisinopril, fosinopril, Capoten, Vasotec, Prinivil, Zestril,

moexipril, perindopril, quinapril, Monopril, Univasc, Aceon,
ramipril, and trandolapril Accupril, Altace, and Mavik
ARBs Candesartan, irbesartan, olmesartan, Atacand, Avapro, Benicar, Cozaar,
losartan, valsartan, telmisartan, and Diovan, Micardis, and Teveten
eposartan
Diuretics Bumetanide, furosemide, torsemide, Bumex, Lasix, Demadex,
hydrochlorothiazide, chlorthalidone, Hydrodiuril, Hygroton, Enduron,
methylclorthiazide, indapamide, Lozol, Mykrox, Zaroxlyn,
metolazone, spironolactone, Aldactone, Midamor, Dyrenium,
amiloride, triamterene, and and Inspra
eplerenone
Beta-blockers Acebutolol, atenolol, betaxolol, Sectral, Tenormin, Kerlone, Zebeta,
bisoprolol, carteolol, carvedilol, Cartrol, Coreg, Trandate,
labetalol, metoprolol, Normodyne, Lopressor, Toprol,
naldolol, pindolol, propranolol, and Corgard, Visken, Inderal, and
timolol Blocadren
Calcium channel Nifedipine, nicardipine, isradipine, Adalat, Procardia, Cardene,
blockers amlodipine, felodipine, and nisoldipine Dynacirc, Norvasc, Plendil, and
dihydropyridines Sular
Nondihydropyridines Diltiazem and verapamil Cardiazem, Dilacor, Cartia, Calan,
and Isoptin
Other agents useful in Terazosin and doxazosin Hytrin and Cardura
treating minoxidil and hydralazine Loniten and Apresoline
hypertension and clonidine and guanfacine Catapres and Tenex
diabetic nephropathy
counter this tendency. Virtually, all cases of compared to ACE-I and ARB agents are
CKDs are associated with volume expansion; clearly inferior (Lewis et al., 2001). The
hence low-salt diets and diuretics should be nondihydropyridines such as diltiazem and
used appropriately to control volume in dia- verapamil, in contrast, have been shown to
betic nephropathy. Thiazolidinedione-type di- decrease proteinuria in diabetic renal disease
abetic drugs, such as rosiglitazone (Avandia) (Parving et al., 1997; Bakris et al., 1998).
or pioglitazone (Actos), are known to be Hence, the nondihydropyridines may be addi-
salt retaining and may cause exacerbation of tive therapy or alternatives to ACE-I or ARB
congestive heart failure. Patients with type agents in patients with contraindications or
2 diabetes mellitus taking diuretic medica- intolerance of such drugs. Dihydropyridines
tion will experience antagonism by using should probably be reserved for add-on ther-
thiazolidinedione-type drugs. apy in patients not achieving target blood pres-
All calcium channel blockers are not sure with ACE-I and/or ARB with diuretic
equal when it comes to hypertension treat- therapy. These agents would be third-level
ment in diabetic nephropathy. Calcium chan- agents behind ACE-I, ARB, and diuretic ther-
nel blockers can be roughly divided into di- apy. Calcium channel blockers are more ex-
hydropyridines and nondihydropyridines (see pensive than the first or second line therapies
Table 15.2). The dihydropyridines are effec- for diabetic nephropathy, and this fact limits
tive antihypertensive agents but have been their usefulness in therapy.
shown to worsen proteinuria with monother- Beta-blockers are useful as antihyperten-
apy (Hoelscher and Bakris, 1994) and when sive agents but have some problems in people
with diabetes that needs to be considered. dietitian can appropriately adjust the diet to
Beta-blockers have been shown to reduce the requirements for diabetic nephropathy
mortality in essential hypertension and reduce and hypertension control. Hyperlipidemia is
cardiovascular mortality in patients with coro- a significant risk factor for progression of
nary heart disease (Chobanian et al., 2003). CKD (NKF, K/DOQI, 2003a) and requires
In people with diabetes, especially those tak- dietary management as well as drug therapy.
ing insulin, hypoglycemic unawareness may Recent evidence suggests that CKD is a risk
be a problem. In other words, patients may equivalent to established coronary heart dis-
not “feel” the adrenalin rush from low blood ease in the therapy of hyperlipidemia. Current
sugar if beta-blockers are administered. Beta- recommendations for CKD include targeting
blockers may cause hyperkalemia that will total cholesterol to less than 200, LDL
complicate management in the person with cholesterol to less than 100, and non-HDL
diabetes already prone to high serum potas- cholesterol to less than 130. Ophthalmology
sium levels either from the underlying di- referral is necessary because of the known
abetic nephropathy or as a complication of association of proliferative diabetic retinopa-
ACE-I therapy. Beta-blockers will be helpful thy with diabetic nephropathy. Referral to
in the patient with diabetic nephropathy and a neurologist may be necessary to establish
known cardiovascular disease. Current targets the nature and type of diabetic polyneu-
for hypertension control (130/80) will require ropathy. Regular programs for exercise and
3–4 drugs for control (Hansson et al., 1998; weight control are essential parts of lifestyle
Adler et al., 2000) and beta-blockers may be modifications for successful treatment of
very effective in the properly selected patient hypertension and maintenance of general
population with CKD and diabetes. health in patients with diabetic nephropathy.
Other agents (see Table 15.2) should be As patients progress to Stage 3 and
used in diabetic nephropathy as needed to greater degrees of CKD, progressive acido-
achieve target blood pressure. These agents sis may be seen. This is usually demon-
include peripheral alpha adrenergic drugs strated by serum bicarbonate concentrations
such as terazosin, doxazosin, combination less than 22 mEq/l. Systemic acidosis leads to
adrenergic drugs such as labetalol, central excess protein catabolism, osteoporosis, hy-
alpha drugs such as clonidine and guanfacine, perkalemia, and fatigue. Treatment is advo-
and vasodilators such as hydralazine and mi- cated to maintain a bicarbonate concentration
noxidil. Potassium sparing diuretics such as above 22 mEq/l and usually involves sodium
triamterene, spironolactone, and eplerenone bicarbonate either in tablet form or as baking
should have very limited use in diabetic CKD soda. The sodium load associated with sodium
because of the common tendency to hyper- bicarbonate administration can be a problem
kalemia in these patients. for hypertension and volume control, but it
Referral to other health care providers is generally felt that the sodium load can be
will help in the management of the myr- managed and the benefits of treatment out-
iad problems associated with diabetic weigh the risk (NKF, K/DOQI, 2000).
nephropathy. Early referral to a dietitian with Secondary hyperparathyroidism is a
experience in diabetic CKD is important common accompaniment of CKD in the dia-
(NKF, K/DOQI, 2000). These diets are betic. Recently published guidelines are avail-
frequently very complicated and require able from the NKF (NKF, K/DOQI, 2003b).
experience in listening to the patient and their Generally, PTH should be measured in any
dietary preferences. After review of dietary patient with Stage 3 or greater CKD. Dietary
preferences, taking into consideration stage phosphorus restriction of 800–1000 mg may
of CKD and assessment of 24-hour urine be appropriate for patients with Stage 3
for nitrogen excretion and nPCR, the renal CKD or greater. Phosphate binders such as
lanthanum, calcium carbonate, calcium ac- Avoiding subclavian central access cannula-
etate, and sevelamer may be necessary to tion also will be important in avoiding central
maintain phosphorus levels between 2.7 and venous stenosis as a complication of upper
4.6 mg/dl. Vitamin D therapy may be nec- arm AV access. Placement of pacemaker leads
essary if significant hyperparathyroidism per- in the central veins also complicate upper arm
sists despite adequate control of serum phos- AV access procedures and may result in arm
phorus and calcium concentrations. edema and venous hypertension.
Formal patient education regarding
ESRD should begin at Stage 3 CKD. Most
END STAGE RENAL DISEASE programs deal with at least six topics of dis-
cussion: (1) anatomy and physiology of the
Patients with Stages 4 and 5 CKD and kidney; (2) hemodialysis; (3) peritoneal dialy-
diabetes should be referred for appropri- sis; (4) transplantation; (5) diet; and (6) insur-
ate nephrologic care (NKF, K/DOQI, 2002). ance and psychosocial issues. The NKF offers
Stage 3 CKD could be referred, if necessary, a program known as “People Like Us Live”
to establish a diagnosis or therapy that is inef- that provides patients with videos and discus-
fective or in question. Hypertension, which sion about each of these topics. Several other
has not been successfully treated to target, programs are available commercially (Bax-
should also be referred for consultation. Pri- ter Health Care and others) and are often of-
mary arteriovenous fistula should be placed fered by local dialysis facilities or dialysis
when patients reach Stage 4 CKD. Compe- providers. There is currently legislation pend-
tent vascular surgeons should place arteriove- ing in Congress to fund predialysis education
nous fistula. Many studies indicate that the under Medicare much the same as is currently
more experience a vascular surgeon has, the reimbursed under Medicare for dietary edu-
more likely that arteriovenous fistula will be cation and for diabetic education. Early re-
successful (NKF, K/DOQI, 2000). Vein map- ferral to a nephrologist when patients reach
ping should be done prior to placement of the Stage 3 CKD is advocated so that this early
fistula. Forearm fistula are preferred over up- education can begin. Patients should be coun-
per arm fistula and brachiobasilic fistula can seled about modality choice. Modalities that
be successful but frequently require transloca- should be considered for patients contemplat-
tion to more superficial tissues over the biceps ing ESRD include hemodialysis, both home
muscle to allow easier access for dialysis. and in-center, peritoneal dialysis, and trans-
Currently, less than 30% of fistulas nation- plantation. In diabetes, options for transplan-
wide are primary AV fistula, but the NKF and tation include cadaveric kidney transplants,
the Center for Medicare and Medicaid Ser- living donor transplants, and pancreas–kidney
vices (CMS) have set a goal of more than transplants for people with type 1 diabetes.
50% primary AV fistulas in new patients with Living donor transplants may include living
ESRD by 2010 (USRDS, 2003; Centers for related donors (such as brothers and sisters) or
Disease Control, Health People 2010 Objec- living unrelated donors (such as spouse, sig-
tives Database, 2003 Update). Preservation of nificant other, or other altruistic individual).
the cephalic vein over the forearm and avoid- Patients who have ESRD education are more
ing intravenous needle insertion into this very likely to elect home therapies such as peri-
critical vein in people with diabetes at risk toneal dialysis or home hemodialysis (Gomez
for CKD is essential. Education of nurses and et al., 1999). Transplant evaluation is gen-
other professionals who place intravenous ac- erally performed with Stages 4 and 5 CKD.
cess devices about this critical vein will help Recent experience has demonstrated that pa-
to achieve the goal of more than 50% AV tients who undergo transplant without spend-
fistulas in this high-risk diabetic population. ing time on dialysis have better long-term
survival than patients who are on dialysis and transplant that was performed. People with
then are transplanted (Kasiske et al., 2002). type 1 diabetes will obviously require insulin
This form of transplantation is known as pre- management if only a kidney transplant is per-
emptive transplantation and is only possible formed. The target for glycemic control re-
with early referral to a nephrologist or a trans- mains an HbA1c of 6.0–6.5 range. If simul-
plant center. taneous pancreas and kidney transplantation
is successfully performed, then insulin will
no longer be needed. Some receive a kid-
POSTTRANSPLANT ney transplant and then seek a pancreas trans-
CONSIDERATIONS FOR plant at a later date; however, recent reports
DIABETES MELLITUS have questioned this practice (Venstrom et al.,
2003). Pancreas transplantation in type 1 dia-
The most common drugs used for betes may reverse some of the complications
immunosuppression after a kidney trans- of diabetes including peripheral neuropathy
plant are steroids, azothiaprine (Imuran), and may prevent recurrent diabetic nephropa-
cyclosporine (Neoral, Sandimmune, and thy. The patient may, however, experience
Gengraf), tacrolimus (Prograf), sirolimus worsening of retinopathy and gastroenteropa-
(Rapamune), and mycophenolate mofetil thy in the early posttransplant course. People
(Cell Cept). Each of these agents may result in with type 2 diabetics are not candidates for
particular problems for the diabetic transplant pancreas transplants.
recipient. Steroids may cause insulin resis- The most common cause of death post-
tance and poor glycemic control, weight gain, transplant is infection in the first 6 months,
osteoporosis, hyperlipidemia, and worsening but thereafter cardiovascular complications
hypertension. Several recent immunosuppres- are the most common cause of morbidity and
sive protocols have been developed that avoid mortality later in the posttransplant course.
or limit use of steroids in an effort to reduce Careful management of risk factors for car-
these posttransplant complications. Azothio- diovascular disease is necessary. Total choles-
prine does not have any particular complica- terol should be targeted less than 200 mg/dl,
tions in a person with diabetes but has been LDL cholesterol should be less than 100, and
replaced by mycophenolate mofetil in most non-HDL cholesterol should be less than 130
recent protocols. Mycophenolate mofetil fre- (NKF, K/DOQI, 2003a). Triglyceride levels
quently causes gastrointestinal symptoms in- should be targeted less than 500 mg/dl. Diet
cluding nausea, vomiting, and diarrhea that should reflect caloric needs and emphasize
may already be a problem related to diabetic weight control. Exercise is mandatory to pre-
gastroenteropathy. Cyclosporine may cause vent the weight gain commonly seen after
worsening hypertension and may induce some transplantation. Use of drugs for lipid control
resistance to insulin. Tacrolimus commonly must take into consideration the immunosup-
causes glucose intolerance and insulin resis- pressive drugs that are being used in order to
tance in peoples with diabetes after transplan- avoid interactions. Many of the statins must
tation. Sirolimus is associated with posttrans- be used cautiously or not at all in patients
plant hyperlipidemia and frequently interferes taking cyclosporine and tacrolimus so as to
with wound healing. Both of these problems avoid myopathy and rhabdomyolysis. Niacin
already plague people with diabetes. All of may worsen glycemic control and cause hy-
these agents suppress the immune system and peruricemia and gout. Fibrates may also be
may lead to infectious complications that are associated with myopathy in transplant recip-
already common in diabetes. ients, especially when given with statin drugs.
The management of the diabetic post- Secondary hyperparathyroidism, es-
transplantation is dependent upon the type of pecially when poorly controlled in the
pretransplant period, may become tertiary tion every 5 years are recommended. Tetanus
hyperparathyroidism after kidney trans- and diphtheria vaccinations every 10 years
plantation with the return of full vitamin D are recommended. Regular visits for appro-
metabolism in the new kidney. This will result priate screening examinations should be un-
in hypophosphatemia, hypercalcemia, hyper- dertaken, including rectal exams, pap and
calcuria, and stone disease. If the parathyroid pelvic examinations, and appropriate colorec-
glands do not diminish in size and function tal cancer screenings are advocated. Dental
with time after transplant, parathyroidec- care should be continued and appropriate an-
tomy after transplantation is occasionally tibiotic prophylaxis should be prescribed for
necessary to prevent complications. Calcium patients with fistulas and other intravascular
stones may obstruct the urinary system devices that warrant treatment according to
causing acute renal failure, rather than the American Heart Association guidelines
pain, in the denervated kidney transplant. (American Heart Association, 1997). Prior
Hypophosphatemia, hypomagnesemia, and to transplantation, patients undergo extensive
hypercalcemia may be seen for other reasons screening examinations and should have a
including steroids, diuretics, and other drugs baseline examination for most organ systems
given to the posttransplant patient. Attention available in their pretransplant records for
to calcium and other mineral metabolism will comparison.
help to prevent osteopenia and osteoporosis
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abetic patients with diabetic nephropathy. J Am Soc Sacks, F.M., Suetkey, L.P., Vollmer W.M., Appel, L.J.,
Nephrol 14:992–999. Bray, G.A., Harsha, D., Obarzanek, E., Conlin, P.R.,
Kasiske, B.L., Snyder, J.J., Matas, A.J., Ellison, M.D., Miller, E.R., Simons–Morton, D.G., Karanja, N.,
Gill, J.S., and Kausz, A.T. (2002). Preemptive kid- Lin, P.-H., and the DASH-Sodium Collaborative Re-
ney transplantation: The advantage and the advan- search Group. (2001). Effects on blood pressure of
taged. J Am Soc Nephrol 13:1358–1364. reduced dietary sodium and the Dietary Approaches
to Stop Hypertension (DASH) diet. DASH–Sodium Attack Trial (ALLHAT). JAMA 288(23):2981–
Collaborative Research Group. N Engl J Med 344:3– 2997.
10. U.S. Renal Data System, USRDS 2003 annual data re-
Scott, C.L. (2003). Diagnosis, prevention and interven- port. (2003). Atlas of end stage renal disease in
tion for the metabolic syndrome. Am J Cardiol the United States, National Institutes of Health,
92(1A):35i–42i. NIDDK, Bethesda, MD. Am J Kidney Dis 42(6,
The ALLHAT Officers and Coordinators for the ALL- Suppl 5):S1–226.
HAT Collaborative Research Group. (2002). Major Venstrom, J.M., McBride, M.A., Rother, K.I., Hirsh-
outcomes in high-risk hypertensive patients random- berg, B., Orchard, T.J., and Harlan, D.M. (2003).
ized to angiotensin-converting enzyme inhibitor or Survival after pancreas transplantation in patients
calcium channel versus diuretic. The Antihyperten- with diabetes and preserved kidney function. JAMA
sive and Lipid-Lowering Treatment of Prevent Heart 290(21):2817–2823.
16
Caring for the Uninsured and Diabetes

Daniel Casto
Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, Arizona
Quite possibly the greatest public health prob- have been diagnosed with diabetes, 5.2 mil-
lem to date is the lack of health insurance for lion people (or nearly one-third) are unaware
an estimated 43.6 million Americans, approx- that they have the disease (American Diabetes
imately 15% of the population. The number of Association, 2004). Lack of health insurance
uninsured is estimated to grow 1.5 million per has important health consequences for per-
year. During the past 2 years, some 75 million sons with diabetes. Inability to obtain neces-
went without insurance (Groman, 2003; sary care endangers the health of people with
Kaiser Family Foundation [KFF], 2003a). diabetes and has increasingly been shown to
Approximately 80% of uninsured Americans result in higher costs for the nation (Institute
are children and working adults (KFF, of Medicine [IOM], 2001, 2002; Reed and Tu,
2003b). Rising premiums, co-payments, and 2002).
deductibles make it increasingly unlikely for Nearly 40% of uninsured adults skipped
many to afford health insurance in the future. a recommended medical test or treatment,
Recently, we have seen a 12.7% increase in and 20% say they have needed but not re-
insurance premiums, which is quadruple the ceived care for a serious problem in the past
rate of inflation (Gabel, 2001). Uninsured year. Uninsured Americans have been found
patients pay $26.4 billion in out-of-pocket to be up to four times as likely as insured
expenses for health care and receive $98.9 patients to require both hospitalizations and
billion in care; $35 billion of it uncompen- emergency hospital care for conditions that
sated (comes from predominantly federal and could be avoided, like pneumonia and uncon-
state programs). These numbers illustrate trolled diabetes.
how the uninsured not only pay a great toll for Both uninsured adults and children
their care or lack of care, but also how health are less likely to receive preventive care
care costs exact a great toll from the taxpayers (American College of Physicians, 1999; KFF,
as a whole (Volunteers in Health Care [VIH], 2000b). Studies show that 25% of adults with
2004). diabetes who were uninsured for a year or
There are 18.2 million people in the more went without a checkup for 2 years,
United States, or 6.3% of the population, who compared to 5% of adults with diabetes who
have diabetes. While an estimated 13 million were insured (IOM, 2002). Uninsured people
215
216 CARING FOR THE UNINSURED
with diabetes are also less likely to receive 299% of FPL, and 19% are at or above 300% of the
regular eye and foot exams (IOM, 2002) and FPL. However, it is important to note that people of
less likely to have an HbA1c less than or equal lower socioeconomic status, rural populations, and
to 9.5% (Saaddine et al., 2002). Uninsured some racial and ethnic minorities are dispropor-
people with diabetes are more likely to use tionately represented among those who are unin-
sured.
the emergency room for care, more likely
Myth: Everyone has access to care through
to be admitted, less likely to be identified the emergency room.
with a primary care physician, and less likely Fact: Emergency rooms (ER) are the most
to follow-up with a physician (Wilson and expensive and inefficient way to deliver primary
Sharma, 1995; Oster and Bindman, 2003). care. Diabetes is a chronic condition that is well
This results in greater costs to the patient and treated through prevention and education that, for
the nation for uncompensated care. good reason, should not be done in the ER setting.
The truth is that lack of health insur- There is now a growing national problem of emer-
ance is a predictor of ill health, resulting in gency room overcrowding partly due to people in-
a 10–15% higher mortality rate, and in earn- appropriately using the ER as their main source
ings of 10–30% less because of poor health of care. Despite this perception of a “safety net,”
uninsured adults continue to demonstrate poor or
(KFF, 2002a). One study estimates that more
fair health and are not getting the needed medical
than 18,000 adults die each year in the United care.
States because of the lack of health insurance Myth: Women and children are most likely to
(IOM, 2002). be uninsured.
Fact: Young men are at greatest risk. Low-
COMMON MYTHS AND FACTS income women are more likely to qualify for Med-
icaid, which covers pregnant women and heads
REGARDING THE UNINSURED of single-parent families, who are usually women.
Most uninsured are adults: 40% are 19–34 years
The following are myths and facts re- old, 31% are 36–54 years old, and 21% are under 19
garding the uninsured in the United States years old. Children are less likely to be uninsured
(Source: KFF, 2003b; Ayanian et al., 2000; than adults. Medicaid has less restrictive criteria
Bell, 2000; VIH, 2004): for children than it does for adults. Medicaid only
covers adults who are disabled, pregnant, elderly,
Myth: People without insurance have ade- or who take care of dependent children. The fed-
quate access to health care. eral Children’s Health Insurance Program covers
Fact: Numerous studies confirm that not hav- children above Medicaid income eligibility limits,
ing health insurance reduces your access to pre- but cuts off those in families earning more than 200
ventive, primary, and specialty care. People with- of the FPL.
out insurance are more likely to live sicker and die Myth: Most people without health insurance
younger. have chosen to be uninsured.
Myth: Medicaid covers all poor people. Fact: Only 7% of uninsured adults reported
Fact: Only 41% of the poor are covered by that they were uninsured by choice or because they
Medicaid, which does not cover 26% of poor chil- did not believe in health insurance. Families and
dren, 40% of poor women, and 50% of poor men. individuals who are uninsured face a hard choice.
Myth: Most uninsured are poor, unemployed For many, health insurance premiums and fee-for-
minorities. service payments are simply not possible.
Fact: Most uninsured Americans are em- Myth: Even if there is a problem, nothing can
ployed and Caucasian (Bell, 2000, available at be done about it.
www.amsa.org). About 80% live in families where Fact: Many people are doing something
at least one person works and 80% are Ameri- about it in their offices, from donating free care,
can citizens. The uninsured can be found at every researching free prescription medications, volun-
income level: 64% are at <200% of Federal teering, and getting involved in organizing care.
Poverty Level (FPL), 16% are between 200% and One study estimates that 69% of private practice
CARING FOR THE UNINSURED 217
internists provide charity care and 55% of em- For an individual health practitioner to
ployee internists provide charity care (Fairbrother provide good cost-effective care to the unin-
et al., 2003). There are 750 Federally Qualified sured patients with diabetes two things are
Community Health Centers with 3,200 sites. To- essential:
gether these sites provide health care to 10 mil-
lion patients, 39% of whom are uninsured. There
are approximately 1,000 free clinics in the United (1) Current working knowledge of diabetes
States, offering health care to approximately 3 mil- care. The knowledge of risk factors, and thus
lion uninsured patients per year. There should be prevention, is critical in any program or prac-
greater efforts on a state and national level to under- tice because the cost of prevention (whether
stand why the uninsured have greater unmet health through vaccines for influenza and pneumonia
needs and to address how to improve our health or aspirin and ace-inhibitors for cardiac and
systems, including assessing whether we need to renal complications) is exponentially less than
increase the “safety nets” or whether there should the cure for preventable complications requiring
be a complete overhaul. hospitalizations and aggressive treatments. Any
provider must be thoroughly familiar with guide-
Diabetes is a chronic disease that is lines and practice current medicine. Some guide-
largely self-managed. This presents a great lines can be found in the 2004 Clinical Prac-
challenge and opportunity for those involved tice Recommendations for Diabetes (available
at http://care.diabetesjournals.org/content/vol27/
in the care of the disease. Relatively mod-
suppl 1/) at the National Guidelines Clear-
est lifestyle changes have been shown to both inghouse (see www.guideline.gov), and at the
prevent the onset of diabetes and control the American Association of Clinical Endocrinolo-
symptoms and complications. gists (see www.aace.com/clin/guidelines/diabetes
For many reasons, medicine in America 2002.pdf). Doing so will actually cost the patient
continues to be lopsided with more effort less over the life of their illness.
and resources being spent on treatment and (2) Commitment to work with the uninsured
fewer resources dedicated to prevention and patient. This includes a willingness to research op-
health promotion education. It is imperative tions and flexibility to learn from patients what
that the care of an uninsured person with di- works for them. Most people will pay for what
abetes starts with addressing lifestyle issues, they understand to be valuable. The challenge lies
in making the care not only affordable but also
specifically obesity and inactivity. While pre-
valuable; that is, taking time to find out what the
vention usually requires more than taking an- patient values. The start of caring is moving be-
other pill, it is a much healthier and econom- yond the label of “noncompliant patient” when a
ical approach. In terms of cost to the patient, treatment plan is not followed and understanding
many prevention and education strategies can why a patient did not come for a visit or take a
reap great improvements with little personal medicine. Most patients, if listened to, will have
outlay. a rational reason for not doing what the doctor
Often the lack of health insurance is only wanted. This is often difficult for physicians who
one of the many barriers an uninsured per- have a different value hierarchy than their patients.
son with diabetes faces in obtaining quality It is helpful to view the care of people with di-
health care. The physician or other health care abetes as a relationship that requires trust and to
know that this trust often takes time to establish.
professional needs to take into account “the
Many uninsured patients, for a variety of reasons,
big picture,” including ethnicity, culture, lan- have come to distrust, dislike or avoid doctors, hos-
guage, illness world view, religion, alterna- pitals, and medical systems. Some of it is due to
tive lifestyles, transportation, illiteracy, and the obvious reason that they cannot afford care.
family structure (Management Sciences for Some of it is due to the way they have been treated
Health, 2003). Many of these issues have been or mistreated. Many of the studies alluded to ear-
touched on in other chapters of this book, but lier in this chapter showing worse outcomes and
some issues will be revisited here. inadequate levels of care for the uninsured are no
surprise to those who have been working with the (3) Tell patients to call different pharmacies
uninsured. for pricing. Pharmacies buy in bulk and the prices
can literally change day by day.
Perhaps the first and most obvious place (4) If possible, use the cheapest in a class
to start is to help a person with diabetes of medicine. There is a 15-fold difference in start-
with the cost of medicines, since they all ing doses of captopril and fosinopril (Walgreen’s,
will at some point in their lives be on some 2004). Both are ACE-inhibitors commonly used
medication (Montemayor, 2002). There in the treatment of hypertension or proteinuria for
are inescapable costs associated with the people with diabetes.
(5) If you do not know the cheapest class,
diabetes care. Estimates range from $1,000
write two or three prescriptions. Then ask the pa-
to $5,000 per year, depending on the intensity
tient to do the research, fill the cheapest, and return
of medications and visits. A common drug or destroy the other unfilled prescriptions.
combination of aspirin, statin, sulfonylurea, (6) “Pill splitting” or cutting a 100 mg pill in
ace-inhibitor, and metformin or thiazidalone half with the intended purpose of using 50 mg/day.
can easily cost more than $100 per month This has been shown to be safe with atorvastatin,
(Walgreen’s, 2004). This estimate is for a pravastatin, and lisinopril, among others (Stafford
1-month supply of daily Aspirin 81 mg, and Randall, 2002). In general, if the pill is scored
daily Lipitor 10 mg, daily Lisinopril 20 mg, (see PDR color atlas), it can be split. Some health
twice-daily Glyburide 5 mg, and twice-daily plans even mandate this as a cost-saving measure.
Metformin 500 mg. Often, the costs of med- (7) Only use samples as a “bridge” to some-
thing else or for short-term indications. Sample
ications create a financial burden that many
medicines are usually quite costly if they are to
simply cannot bear and they end up not tak-
be purchased. In the long run, getting a patient’s
ing them. Quarterly doctor visits, laboratory sugar or blood pressure stabilized on an expensive
tests, annual specialty care (ophthalmology, medicine will end up costing them more.
podiatry, endocrinology, nephrology, and (8) Occasionally, it can be cheaper to pre-
cardiology), and classes with a diabetes scribe a combination form rather than two sep-
educator or dietician, while part of an optimal arately. For example, prescribing 70/30 insulin
care plan, are usually out of reach for the rather than Regular and NPH or Caduet rather than
uninsured. In some recently diagnosed cases, amlodipine and atorvastatin can be cheaper. How-
it may be that the patient has never needed or ever, prescribing combination forms is not always
wanted health insurance previously. Helping cheaper and should be researched.
(9) Patients living near an international bor-
them find affordable health insurance should
der will often go to Mexico or Canada to buy
be a first priority (ADA, 2004; National
cheaper medicines. There is a lot of news and pol-
Institutes for Health, 2003). itics surrounding this, but it is likely safer to get
The following is a practical list of things prescription medications somewhere than not at all
that my colleagues and I have found can help (Pugh, 2003). Let patients know the options and let
decrease the cost of medications for a person them decide whether or not they will pursue this.
with diabetes. Many of these may require a lit- (10) For patients with Internet access, they
tle research, but I have found willing partners can go online and order medications from Canadian
in my patients when their dollars are at stake. pharmacies. The state of Minnesota even maintains
Most patients do not know that there may be a website (www.MinnesotaRx.com) to help its em-
many options for a particular medicine and ployees.
(11) Almost all pharmaceutical companies
not just the only one prescribed.
have programs that will provide qualified appli-
(1) Prescribe generic medicines whenever cants with three months of free medicines (ADA,
possible. Savings can easily be 50%. 2004b). Every company has a different set of qual-
(2) Often prescribing #100 pills at a time ifications, income limits, and forms. This can be
will be less than #30 with 3 refills. I have found quite cumbersome for the patient and the physi-
this to be true with hydrochlorothiazide. cian at times. In a clinic where I worked, we found
we were processing 3–500 of these applications facilities, etc. Many communities have health
per month. Since almost none of our patients had centers or volunteer clinics that may be a
access to the Internet, our nurses were doing all source of local expertise for accessing ser-
this work. We instituted a small fee per applica- vices in that area (community health centers
tion to cover the cost of paper and time. We made by zip code can be found at http://ask.hrsa.
it clear to the patients that this was our fee and
gov/pc/ and volunteer clinics can be found at
not the pharmaceutical company’s and that it cov-
ered the service of application. They were free to
http://www.volunteersinhealthcare.org/links.
apply themselves. Patients were more than happy to htm or http://www.vimi.org/). If providing
pay a token to get three months of free medicines. care for uninsured patients is too difficult
I have found the best source to be a centralized in your office, volunteering at a free clinic
website (www.RxAssist.org) that lists all the med- or similar facility can provide much-needed
ications available, and has forms for each phar- services.
maceutical company that can be printed and sent Annual eye exams are an important part
in. of diabetes care. Asking a local ophthalmol-
(12) Early initiation of insulin. This may ogist/optometrist to donate a few screening
not only be a good idea in the course of their dis- exams per year is a way to start. The Amer-
ease, but also could be cheaper. By the time a per-
ican Optometric Association has a program
son with diabetes is on three oral medicines for
diabetes near maximum doses (sulfonylurea, met-
called Vision USA that provides free eye ex-
formin, and a thiazolidine), they are easily spend- ams annually (American Optometric Associ-
ing $200 per month for medicines. It will be much ation, 2004). Some community health cen-
cheaper to use insulin in place of one or all of these ters have retinal cameras and with “store and
medicines. forward” features can do dilated eye exams
(13) Tell patients to buy a glucometer with any time and send the images to an ophthal-
the cheapest test strips NOT the cheapest glucome- mologist later for reading. Unite for Sight
ter. After a few months they will thank you. (www.uniteforsight.org/) is a national non-
profit organization that develops sustainable
In the office or clinic, there are many sys- solutions to reduce eye health disparities.
tems and changes that can benefit the unin- Each of their 25 chapters works with local
sured person with diabetes. One model for community infrastructures to improve access
cost-effective care that has shown promise to health programs.
is the class or group-visit (Clancey et al., There also are organizations that provide
2003). There are several ways to structure financial assistance for people who need pros-
group visits. In an effort to get all patients thetic care (Amputee Coalition, 2004; Easter
screened and educated who were either new Seals, 2004; Prosthetics for Diabetes Founda-
patients with existing diabetes or patients with tion, 2004) or wheelchairs (Wheelchair Foun-
newly diagnosed diabetes, one clinic held dation, 2004).
a “diabetes day” each month (Zasworsky, In conclusion, we have a growing prob-
personal communication, February 11, 2004. lem in this country that involves not just the
Two groups (English and Spanish) would ro- lack of equal access to care but the resultant
tate through four services (ophthalmology, growing inequalities in health. Diabetes mag-
podiatry, diabetes nurse education, and reg- nifies the consequences of being uninsured be-
istered dietician) that were brought into the cause it is a chronic progressive illness. While
clinic. In this way, the patients would only having a national health plan (providing uni-
have one “visit” to the clinic and yet receive versal health coverage) alone is not sufficient
multiple services. to reach the desired outcome of good health
Networking with community partners for all, it would be undoubtedly the most es-
and agencies can help access resources, such sential step in decreasing health care dispari-
as specialty/consults, education, exercise ties in this country.
REFERENCES Easter Seals. (2004). Available at: http://www.easter-

seals.org. Accessed June 11, 2004.
American Association of Clinical Endocrinologists Fairbrother, G., Gusmano, M., and Park, H. (2003)
Medical Guidelines for the Management of Di- Care for the uninsured in general internists’ pri-
abetes Mellitus. Available at: http://www.aace. vate offices. Health Aff 22:217–224. Available at:
com/clin/guidelines/diabetes 2002.pdf. Accessed http://www.healthaffairs.org/. Accessed June 12,
June 15, 2004. 2004.
Gabel, J.R. (2001). Tracking Health Care Costs: Growth
American College of Physicians. (1999). Dr. Adding-
Accelerates Again in 2001. Health Aff Web Ex-
ton’s Statement at the November 30 Release
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at: http://www.acponline.org/hpp/adspeech.htm.
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Accessed June 15, 2004.
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Institute of Medicine. (2001). Coverage Matters: In-
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surance and Health Care. Available at: http://
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www.iom.edu/. Accessed June 15, 2004.
www.diabetes.org/advocacy-and-legalresources/
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healthcare/healthinsurance/uninsured.jsp. Accessed
Too Little, Too Late. Available at: http://www.
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diabetes.org/advocacylegalresources/healthcare/
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healthinsurance/uninsured.jsp. Accessed June 11,
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The Consequences of Being Uninsured. Available
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17
Disease Management in Rural Populations

Can it be Done?
Jane Nelson Bolin, Larry Gamm, Bita Kash, and B. Mitchell Peck
Texas A&M Health Sciences Center, School of Rural Public Health, College Station, Texas
INTRODUCTION intent of these programs to provide and im-

prove health care in rural locations, limited
Rural health care providers must cope access to health care by rural populations con-
with various challenges that far exceed recog- tinues as a significant concern.
nized, conventional concerns such as financ- Recently state and federal health agen-
ing, controlling costs, and ensuring proper cies have encouraged managed care and fee-
medical care. The provision of health care in for-service plans to implement disease man-
rural populations is additionally complicated agement (DM) services. However, DM may
by limited number of health care providers, present formidable organizational challenges
higher rates of uninsured, longer distances and a mix of benefits and costs for rural health
to travel for treatment, and fewer commu- care systems and their patients. This chap-
nity resources to supply and support health ter will report on six organizations that have
care (Bierman and Clancy, 1999; Keefover successfully instituted chronic DM in rural
et al., 1996; Noonan, 1997; Aadalen, 1998; areas.
Moscovice and Rosenblatt, 2000; Dalton,
2001; Welch et al., 2002; Beaulieu et al., Background
2003). In order to address rural access prob-
lems, federal and state health agencies have Conditions in rural America often bring
implemented a variety of programs, including unique and difficult challenges to those re-
Federally Qualified Health Centers (FQHCs), siding in this environment. However, rural
Critical Access Hospitals (CAHs), Rural As- life may be especially formidable for per-
sistance Center (RAC), Rural Health Clinics sons with chronic diseases such as diabetes,
(RHCs), and state sponsored Rural Devel- congestive heart failure, chronic obstructive
opment Councils (Kozma, 1998; Diamond, pulmonary disease, depression, and asthma
1999; Rawlings-Sekunda et al., 2001 June; because of the scarcity of health providers
Welch et al., 2002; Foote, 2003). Despite the and services in nonurban settings (Gamm
223
224 DISEASE MANAGEMENT IN RURAL POPULATIONS
et al., 2003; Moscovice and Rosenblatt, 2000; sum, a host of geographic, economic, cul-
Bolin et al., 2003; Call et al., 2000). Rural tural, and ethical challenges may confront
Americans are as culturally, racially, and eth- health care providers when addressing the
nically diverse as the topography of landscape needs of chronically ill patients residing in
where they live (Rosenblatt, 2002). For in- rural America.
stance, the rural population in North Dakota
may be quite different from rural residents of
the Pacific Northwest or Southeastern United The Rural Chronic Disease Management
States. Conditions in the rural Northeast are Research Project
distinct from those found in the rural South-
In September 2001, the Southwest Ru-
west. Regional differences in customs and
ral Health Research Center (Texas A&M—
ethnography, and indigenous characteristics
HSC School of Rural Public Health) initi-
handed down through multiple generations
ated a 3-year study analyzing health plans
of families and cultural groups create hard-
and health systems providing chronic DM
ships in health care delivery that may be quite
services to rural and underserved popula-
magnified in rural areas. Recent and past mi-
tions, titled “Chronic Disease Management
gration patterns to various parts of our Na-
in Rural and Underserved Areas: Patient
tion’s rural areas reflect homesteaders and
Responses and Outcomes.” To conduct this
workers seeking both land and/or work op-
study, the project team initially undertook site
portunities. These diverse and complex de-
visits to five health plans that had agreed
mographic features amplify the challenges
to participate, and later visited a sixth DM
that occur in instituting and developing DM
program serving the uninsured. The health
programs in rural locations (McGrath et al.,
plans participating in this study are listed in
1990).
Table 17.1.
As our nation’s infrastructure has
These site visits revealed a wide range
changed to accommodate more service-
of chronic diseases being managed formally
oriented industries, the agrarian economies of
by rural health plans, including (1) dia-
many rural areas have receded. Employees in
betes, (2) congestive heart failure, (3) chronic
rural locations often receive wages fixed at
obstructive pulmonary disease, (4) asthma,
or near poverty level, and these workers are
(5) depression, (6) hypertension, (7) osteo-
not as likely to be offered access to health
porosis, (8) tobacco cessation, and (9) prena-
insurance even if they are employed regularly
tal case management. Figure 17.1 shows the
(Coburn et al., 1999). Consequently, many ru-
specific chronic DM services being offered
ral working families living just above poverty
through the six rural health care systems par-
levels may be uninsured (Waitzken et al.,
ticipating in the study.
2002), and thus have greatly reduced access
to health care services.
Other issues common to rural areas in- TABLE 17.1. Health Plans Participating in
clude ethical challenges that may arise in pro- the Chronic Disease Management in
viding health services to residents in small Rural Areas Research Project
communities. Frequently, the health care pro-
Carle Clinic Health Plan (Champaign-Urbana, IL)
fessional’s work life and personal life over-
Marshfield Clinic (Marshfield, WI)
lap in his/her interaction with patients. This Geisinger Clinic (Danville, PA)
presents a situation that may cause confiden- Scott and White Clinic (Temple, TX)
tiality and privacy predicaments, as well as The Health Plan of the Upper Ohio Valley (St.
conflict of interest problems when medical Clairsville, OH)
St. Elizabeth of Hungary program for the uninsured
personnel and patients are faced with shared
(Tucson, AZ)
decision-making situations (Nelson, 2004). In
DISEASE MANAGEMENT IN RURAL POPULATIONS 225
Diseases Addressed by DM
in the Rural Systems
FIGURE 17.1. Diseases addressed by DM in the rural systems.
Survey of Health Plan Leaders mentioned, but to a lesser degree: tobacco

cessation (N = 8), osteoporosis (N = 5),
Following site visits to each location, prenatal (N = 2), and case management
the research team prepared and mailed a (N = 1).
self-administered survey to key DM leaders The number and type of chronic diseases
(physicians, nurse/case managers, and admin- mentioned by respondents reflect the chronic
istrators) at each of the six health care facili- disease burden shouldered in the particular
ties. A total of 315 surveys were mailed, and area served by each health plan. According
71 usable surveys returned. Of the 71 survey to key DM physicians, nurses, and admin-
responses, 15% came from DM administra- istrators, a large percentage of patient visits
tors, 45% of the replies were sent from DM pertain to the five most prominent chronic
nurses, and 40% of the returns arrived from diseases or conditions indicated in the sur-
DM physicians. vey. Diabetes was ranked highest among all
An examination of survey responses chronic diseases or conditions, and accounted
revealed the DM program identified most fre- for nearly 50% of all patient visits. After di-
quently was diabetes (N = 57), followed by abetes, the next four most common chronic
congestive heart failure (N = 37), chronic ob- diseases resulting in patient visits were:
structive pulmonary disease (N = 33), asthma congestive heart failure, chronic obstructive
(N = 32), depression (N = 15), and hyperten- pulmonary disease, asthma, and depression
sion (N = 13). Four other DM programs were (Table 17.2).
TABLE 17.2. Chronic Diseases Responsible for Greatest Percentage of Patient

Visits in Health Plans Serving Rural and Underserved Patient Populations
Percent of patients Overall percent of
Percentage of patient being treated for patients with this
Chronic disease visits (mean%) condition (mean%) diagnosis (mean%)
Diabetes 45 48 38
Depression 20 12 12
Chronic Obstructive 20 21 20
Pulmonary disease
Congestive heart failure 17.4 35 18
Source: Chronic Disease Management in Rural Areas Survey, 2002.

According to respondent estimates, 38% care facilities, a smaller health care workforce
of all patients under their care are being is present, and available medical equipment
treated for diabetes, while 24% exhibit de- is of less sophisticated quality (Bolin et al.,
pression and 20% experience chronic ob- 2003; Coon and Zulkowski, 2002; Call et al.,
structive pulmonary disease (Table 17.2). Re- 2000). Indeed, the benefits of DM for rural
spondents were also asked to estimate the populations are perhaps more significant than
percentage of their patients being treated for nonrural populations, given the restraints
for each disease or condition and who are of travel time for rural patients and scarcity of
participants in their DM program. Diabetes rural health care providers. Case studies about
was again listed the condition treated most three programs effectively providing DM in
frequently (48%), followed by congestive rural and underserved areas are discussed in
heart failure (35%), and chronic obstructive “Part 5” of this book.
pulmonary disease (21%) (Table 17.2). Al- Survey respondents identified success-
though diabetes accounted for the largest ful initiatives for instituting DM in rural ar-
number of patient visits, depression was eas, nevertheless many constraints or “im-
responsible for proportionally more pa- pediments” to success were also identified.
tient visits and congestive heart failure For example, respondents estimated that from
for fewer visits than one would expect, 37% to 45% of patients active within their re-
according to their proportions among all DM spective DM programs do not comply with
patients. Survey respondents noted a large DM program instructions or guidelines a ma-
number of their patients who evidence two or jority of the time. These impediments to DM
more chronic diseases, making case manage- are identified in Table 17.3.
ment more difficult and complicated to per- Most of the impediments listed in Table
form in such situations. 17.3 refer to conditions that may apply to
DM patients residing in urban and rural ar-
Challenges of Providing DM in Rural eas. That is, lack of motivation and denial,
and Underserved Areas insufficient attention to diet and exercise, and
lack of understanding may be found among
Historically, DM has been a phe- patients living anywhere. It is possible, how-
nomenon or model of health care utilized ever, that other impediments may be more
most often in urban settings. DM is fre- commonplace among rural patients in light
quently promoted by large health plans in- of rural conditions mentioned earlier. Drug
terested in quickly and efficiently reaching cost may be higher in small rural pharmacies
significant numbers of enrollees to reduce and less affordable to rural patients. Health
health care costs while improving treatment
outcomes. Not surprisingly, most studies sug-
gest that DM-related activities, and preven- TABLE 17.3. General Factors or
tive care generally, are less prevalent among “Impediments” to Patient Compliance
provider organizations located in rural areas with DM Guidelines
(Vaughn et al., 2002; Dennis and Pallotta, Impediments to patients’ compliance
2001).
Survey information from the Rural Attitudes—lack of motivation, denial
Behaviors—lifestyle, diet, exercise
Chronic Disease Management Research
Knowledge—lack of understanding
Study (2003) was instrumental in identify- Financial—drug costs, financial means
ing effective health plan strategies available Treatment—complexity, no provider support
for building or initiating DM programs with Mental state—depression, nerves
rural populations. DM fills a void in provid- Setting—transportation, distance, weather
ing unique and valuable service to patients in Source: Bolin, Gamm, Zunigh (2003). Chronic Disease Manage-
rural areas, where there are often fewer acute ment in Rural Areas: Year-2 Report.
care provider support may be less available, TABLE 17.5. Factors Affecting Patients’
depression may be as prevalent or more so Compliance with Disease Management
but less often treated, and distance concerns
• Prohibitive cost of drugs
that are compounded by lack of transportation • Inability to make lifestyle changes
or inclement weather may be more prevalent • Inability to understand program instructions
among rural residents. • Lack of physician support
When queried more specifically to pro- • Co-morbidities
• Denial of disease
vide reasons for rural patients’ noncompli-
• Distance to clinic
ance with DM, respondents identified factors • Lack of family support
ranging from cost of drugs, lack of physician
support, and patient’s denial of disease. Im-
pediments to DM specific to “rurality” were is not clear what the rate of noncompliance
such factors as limited health resources, travel is for nonrural patients—an area worth inves-
barriers, or lack of transportation and so- tigating. Respondents estimated that the rate
cial conditions such as unemployment and of noncompliance for congestive heart fail-
poverty. Table 17.4 lists disadvantages, of ure was 37%, diabetes 38%, chronic obstruc-
a rural nature associated with DM pro- tive pulmonary disease 42%, asthma 43%, and
grams, which were identified by the survey depression 45%. In follow-up questions, re-
respondents. spondents were asked to identify factors that
The extent of patient noncompliance affected patients’ failure to comply with DM
with DM was significant. The fact that be- program instructions. The following factors
tween 37% and 45% of patients active within (Table 17.5) were listed as affecting patient’s
the six participating DM programs do not compliance with DM.
comply with DM guidelines, a majority of the When asked to compare urban versus
time bears additional attention. However, it rural advantages and disadvantages to DM
across 14 participation and compliance items
presented in the survey, over 50% of the re-
TABLE 17.4. Specific Rural Disadvantages
spondents saw no difference between rural
Associated with Disease Management
and urban patients on 5 of 14 items that might
Programs
affect participation in DM programs. How-
Limited health resources ever, on six items, the ratio of respondents not-
Lack of urgent care facilities ing an urban advantage over a rural advantage
Reduced access to health resources (e.g., labs or ranged from nearly 3:1 (pharmacy) to more
pharmacies)
Limited access to specialty care
than 10:1 (social services & transportation).
Physician compliance in rural areas These areas of “relative rural disadvantage”
Rural doctors or nurses sometimes have less training include rural patient’s comparatively poor ac-
Overlapping relationships between work life and cess to supportive social services and lack
personal life of transportation to appointments, laboratory
Travel barriers and transportation
Increased time for DM nurses to drive to rural
services, pharmacy services, and scheduled
locations group DM activities. Table 17.6 provides a
Winter travel limitations to/from rural locations representation of factors perceived as favor-
Difficulty with transportation to clinic ing urban over rural patients’ participation in
Social conditions DM programs.
Patients less likely to participate in screenings or fairs
Rural prevalence of young, single mothers
Moreover, many of the survey respon-
Poverty and/or cannot afford health care dents view rural patients as less likely to
Lack of phone or phone failure obtain access to a physician who provides
Rural employment increases morbidity or injuries DM services. In three areas, there appears
Employment lay-offs initiate lack of insurance to be little difference between responses in-
Conflict of interest
dicated by rural and urban patients, or less
TABLE 17.6. Factors Favoring Urban Patients
Rural-Urban Advantages in DM
Urban Favored
Southwest Rural Health Research Center : Chronic Disease Management
consensus offered by respondents regard- relative advantage for rural patients in their
ing which group of patients is advantaged participation in telephonic case management
(Table 17.7). and patient dependence on the availability of
Considering the five elements where a DM program. Finally, a modest advantage
there appears to be an advantage for rural pa- is accorded more frequently to rural patients
tients, for only one element is there as much as than to urban patients on the element of satis-
a 3:1 ratio of response. Slightly under one-half faction with the DM program.
(45%) of respondents identified an advantage There is substantial agreement about the
for rural patients in the form of friends’ and types of disadvantages that rural patients face
neighbors’ support in DM and family support when compared to patients in urban settings.
in DM. One-third of the respondents noted a Both on-site interviews with DM leaders and
TABLE 17.7. Rural-Urban Advantages in DM
Rural-Urban Advantages in DM
Rural Favored
Southwest Rural Health Research Center : Chronic Disease Management

survey responses from these leaders, physi- extended family (Berger, 1998; Saha et al.,
cians, and DM staff members underscore 1999; Kim and Kwok, 1998). Moreover, the
similar challenges for rural patients. Rural quality of provider–patient communication at
patients are viewed as disadvantaged relative all points along the DM continuum is contin-
to urban patients on access to transportation, gent upon the patients’ ability to understand
laboratory services, supportive social ser- directions and instructions, which, when pos-
vices, and pharmacy services. They may be sible, should be delivered in the patient’s na-
less likely to have a physician who partici- tive language. Providers tend to overestimate
pates in DM. Likewise, with respect to travel patients’ understanding of treatment plans.
and transportation challenges for rural pa- Thus, steps should be taken to improve com-
tients, DM programs can help reduce both munication and understanding between pa-
frequency and costs associated with patient tients and health care workers when their pri-
visits to distant health care facilities or to mary language and cultural heritage are not
emergency rooms. Most of the social condi- shared (Calkins et al., 1997).
tions that are deemed to present disadvantages
for rural patients, although not directly ad- Future Potential and Promise of DM in
dressable by DM programs, may underscore Rural Health Care
the importance of the availability of timely,
accessible DM programs. The ability of disease management to
A majority of respondents viewed rural help control health care costs and contain
DM patients as having some advantage in health insurance expenditures for rural em-
participation in telephone case management, ployers makes the cost-saving potential of
experiencing the support of friends and DM more substantive with rural populations
neighbors in DM, receiving family backing where employee numbers tend to be smaller
in DM, recognizing advantages offered and hourly wages lower (Sidorov et al., 2002;
by DM, and being satisfied with DM. It Bolin and Gamm, 2003; Weiners and Harris,
appears that rural patients may be at a relative 2003). The positive impact of DM on health
disadvantage in being able to comply with care utilization and quality, as well, may be
DM activities, yet the responses suggest, too, particularly important to rural populations.
that rural patients may find DM activities Given a paucity of health care providers in
more important. It seems likely that the DM rural areas, combined with greater travel dis-
connection may substitute on occasion for tances to specialized facilities and providers
a rural patient’s travel to a distant provider for treatment of chronic diseases, the rural
on matters that can be responded to over chronically ill may gain greater benefits from
the phone. Such connections may offer DM than patients who are more proximate
immediate response or may be forwarded by to health resources. Uninsured and under-
the DM staff member to the physician and insured populations, and the providers who
then communicated back by the physician or serve them, may stand to benefit greatly from
the DM staff member to the rural patient. DM programs. Such programs offer patient
Some differences, yet unexplored, may education and care coordination that can help
be attributed to cultural features found control a disease and reduce acute care needs
in particular rural populations and/or the of patients, thus reducing associated nonreim-
level of cultural recognition demonstrated bursed costs that would otherwise be shoul-
by the provider/educator. For example, cul- dered by the providers.
tural differences in rural Native American, DM program respondents are over-
Hispanic, or African American populations whelmingly confident that DM improves the
may place greater importance on family, quality of patient care. DM’s contribution to
religion, or the beliefs of elders within the health care quality is reflected in research
reports from the systems (health plan or clinic) (among other diseases). These health plans
and in published high satisfaction levels with are achieving success in reducing patient mor-
DM activities on the part of patients (e.g., bidity, and improving patients’ overall health
as reflected in HEDIS). Although survey re- by employing the chronic DM model across
spondents are likely to see at least a moderate a variety of populations, including uninsured,
contribution of DM to the financial benefit of private pay, and Medicare.
the clinic, agreement on this is not as strong A prominent finding from the survey was
as it is for DM contributions to care qual- the extent to which health plans tended to rely
ity. Nonetheless, at least two of the systems more on nurses for patient monitoring and ed-
have published papers that point to signif- ucation, as well as the support and delivery
icant financial savings associated with DM of DM services. This is an important finding,
programs (Sidorov et al., 2001). Such find- and when considered in light of the success of
ings suggest that information on both clini- these programs, exploration of state-by-state
cal outcomes and financial outcomes should differences in licensing restrictions that might
be communicated frequently to physicians, prevent nurses from carrying out DM monitor-
clinic leaders, and others engaged in or poten- ing and delivery of services is warranted. Gov-
tially involved with DM. Also, there is need ernment agencies, foundations, health plans,
for more widespread discussion of possible and providers would benefit through support-
strategic benefits of a DM program for health ing research to identify methods for nonphysi-
plans and provider organizations. The study cians to provide DM monitoring and services
also found that nearly three-quarters (73%) in order to assure the greatest possible partic-
of physicians, nurses, and administrators re- ipation in DM.
sponding to the study believe that diabetes
DM was “very important,” with another 22%
of the respondents stating that diabetes DM
INFORMATION SYSTEMS AND
was “important.” Thus, 95% of respondents
DATA LIMITATIONS IN RURAL
regarded diabetes DM to be important pa-
tient health care. That is, an effective DM pro- AREAS
gram may enable a health plan to better man-
age higher-risk employer populations, Med- Close monitoring of patients’ clinical
icaid populations, or Medicare risk contract conditions require the rapid flow of informa-
enrollees. Benefits of this type can simultane- tion among team members. This may require
ously serve the interests of health plans and technological means for remote monitoring,
providers and increase access to care among especially in rural DM programs. In a con-
rural populations. gestive heart failure DM program instituted
by NYLCare Health Plans of New York, the
following informatics tasks were considered
Use of Established Clinical Guidelines essential:
and Protocol in Rural DM
(a) evaluation of the patient population
The models of diabetes DM employed for all high-risk, high-volume conditions that
by the plans participating in this study rely would benefit through DM;
(b) identification of national consensus
on national standards and quality indica-
guidelines;
tors as their programs’ benchmarks. Sur- (c) identification of patients with the
vey responses suggested that health systems target illnesses, with stratification;
are satisfactorily carrying out DM using es- (d) creation of a database to store and
tablished, recognized quality indicators for manage data;
diabetes, congestive heart failure, chronic (e) establishment of a communication
obstructive pulmonary disease, and asthma system to store and manage the patient data;
(f) establishment of a communication the day-to-day working relationships and

system to educate and monitor patients; and information sharing between activities of
(g) implementation of appropriate ana- DM staff and staff of providers and/or health
lytical systems to evaluate the impact of DM plans is the dominant concern, then building
(Roglieri et al., 1997). such a system may be more attractive.
Sophisticated electronic information Within the context of this broader de-
systems devoted to DM programs have been cision, a number of other factors may influ-
developed and utilized in many of the systems ence the decision of whether or not to buy or
participating in the study. In two of the inte- build a DM program. If providers are currently
grated delivery systems, DM nurses have ac- committed to clinical protocols for addressing
cess to electronic medical records (EMRs) as chronic diseases, then there are in-house clin-
well. DM participants value the latter arrange- ical champions of DM and there is in-house
ment, supporting rapid and continuous com- expertise on what goes into a DM program.
munication between the DM nurse and physi- Thus, a build strategy is supported. If one or
cian, regarding DM patients. At the same time, two of these elements are lacking, then such
there remain opportunities for integrating or circumstances may encourage a more scruti-
regularly querying DM information systems nized consideration of the buy decision. Also,
and EMRs to generate reports of DM contri- if there is a shortage of RNs in the region
butions on an ongoing basis. served by the provider or health plan sponsors
of a DM program, then a buy decision may
be supported. Moreover, if a health plan, for
BUY OR BUILD? PLANNING/ example, is financially challenged and needs
IMPLEMENTATION/ to capture DM-related cost savings among
SUSTAINABILITY OF DM chronically ill enrollees, then a buy decision
PROGRAMS is once more suggested. In making the buy
decision, of course, consideration should be
The decision to “buy or build” a DM given to the time and expertise that the rural
program must be addressed by health plans plan or provider must allocate to negotiating
serving rural and underserved populations by the initial DM contract and monitoring perfor-
carefully attending to clinical and business mance to ensure that expectations are being
issues. In the most general sense, the buy met.
or build decision may rest with how DM There are, of course, variants of or mid-
is viewed by the health plan or provider points between the build–buy options. DM
organization. Is DM perceived as a discrete companies can be contracted to help build a
or special product or service employed to DM program (via a consultant relationship or
control costs and improve outcomes beyond turnkey arrangement). Or, the build or buy de-
what providers and health plans do, or is cision may be modified over time. One health
DM seen as an integral part of reengineering plan in the study built its own diabetes DM
the processes of care that are supported by program, but “bought” or outsourced CHF
health plans and providers? If DM is viewed and COPD DM when it launched DM ef-
as a detached or unconventional service, forts in early 2000. Later, all programs were
then buy–build decisions may be determined brought “in-house” and managed success-
largely by whether a better DM product fully by the plan’s own cadre of DM trained
and performance can be provided more nurses who were responsible for specific DM
efficiently internally versus doing so through programs.
outsourcing. If, in contrast, DM services are The pros and cons of homegrown, out-
viewed as natural parts of what providers sourced, and mixed. DM program are identi-
and/or health plans seek to accomplish, and fied in Table 17.8.
TABLE 17.8. “Buying or Building” DM Programs in Rural and Underserved Patient

Populations
Program type Pros Cons
Homegrown Key personnel from the health plan are It takes longer to plan and implement a
involved from the start. DM program when designing it from
the ground up.
Existing human resources can be used at The potential overlapping of work and life
no significant additional cost. This relationships occurs due to small
provides more experienced and highly available labor market.
trained nurses a career ladder, and
opens up entry level health care jobs in
a rural community.
No loss of control or patient contact. DM Increased chance of conflicts of interest
workers are more likely to be familiar because of shared decision-making
with the culture of the patient process and relationship boundaries.
population.
The DM program can be customized to May have to build transportation services
local comorbidities including the as part of the in-house DM program due
degree of mental health services needs. to lack of reliable transportation in rural
community.
Outsourced Faster initiation of DM program. Higher front-end costs. Inability to
Outsourcing may cut support and manage change or content. Awkward
personnel costs. patient care and technology interfaces.
There is a rural advantage in patient Some DM companies treat only one or
participation in telephone case two diseases, & thus may not treat
management, making outsourced DM co-morbid conditions.
strategically a better choice.
The patient may be more responsive to Costs associated with contracting and
telephone DM than to providers who monitoring activities.
are their neighbors.
It may be possible to negotiate a financial Distant relationship, initially, between DM
incentive to be shared with physicians company and health care organization.
who choose to participate in DM
activities.
Mixed Homegrown disease plans may feel most Awkward interface between patient care
comfortable, rewarding, and and DM-provider technology.
educational to providers.
Outsourcing of diseases may prove most Difficult integration with other program
difficult or time consuming. applications.
Build DM program depending on existing Potential challenges with caring for
professional skill set, worker patients with co-morbidities.
availability, and interest.
It is not clear how much the decision to nal DM companies. Just as proximity and fa-
“buy” or “build” rests on the nonrural or ru- miliarity of local DM staff with rural patients
ral status of health plans, providers, and target may support the success of DM it may be the
patients. It may be that rural health plans and case that some rural patients desiring privacy
provider groups will have relatively less tech- may prefer to interact with out-of-area DM
nological expertise to support building home- staff contacting them by phone.
grown DM programs. At the same time, they There are advocates for each approach to
may be less able to afford the loss of growing DM development. Tamara Lewis, medical di-
resources for DM that might migrate to exter- rector for community health and prevention at
Intermountain Health care in Salt Lake City, part of The Medicare Modernization Act of
observes: “If you’re going to change a system, 2003 (CMS, 2004). DM and quality report-
you have to do it internally.” An outsource ing are both initiatives that help health care
DM company sometimes finds it difficult to providers work toward assuring and improv-
define what it is and is not supposed to be ing the quality of care. At this point, CMS
managing. Because many DM guidelines and has identified three conditions with 10 appro-
protocols are well established DM can be de- priate quality measures that can be reported
veloped locally (homegrown) relatively easily by participating hospitals. These three con-
and shaped into a valuable tool for controlling ditions include acute myocardial infarction,
costs and improving patient health and over- heart failure, and pneumonia. The opportu-
all satisfaction with health care across varied nity to merge quality indicator reporting and
populations. DM into one overall quality program that is
Another “pro-building” sentiment as- built from within the rural health plan and hos-
serts that “an outside company can really only pital simultaneously should be considered by
educate patients and monitor their compli- rural health care provider networks. The DM
ance. It is still up to providers to care for and initiative can be structured in a way to offer
manage the patient. That is where gaps begin incentives to the participating physicians, the
to exist with outside programs.” (http://www. quality indicator initiative will provide for im-
managedcaremag.com/archives/0001/0001. proved reimbursement rates for the hospital,
dmpac.doc op.html). while the health plan benefits from the results
At the same time, there is a rapidly grow- associated with reduced acute care utilization
ing outsourcing movement supported by an rates and therefore reduced cost of care.
increasing number of DM companies, some
operated by large pharmaceutical firms. Both
Medicaid and Medicare programs appear to CONCLUSIONS
be looking toward such companies to demon-
strate cost savings and quality improvement Many rural residents find it difficult to ac-
in care for the chronically ill. cess appropriate or timely care. Age, poverty,
The six DM programs that participated and lack of insurance or Medicare supple-
in the Rural Chronic Disease Management mental insurance may reduce their ability to
Study had all developed “homegrown” DM self-manage chronic illness. Travel distances
programs. The most successful programs ap- and shortages of care providers and ancillary
pointed advanced degree nurses at the helm in health services such as pharmacy and labora-
the design of DM programs, working closely tory access create additional barriers to care.
with physician leaders, and in charge of, or co- DM services are all the more critical to rural
partnering responsibility for, day-to-day op- chronically ill patients, who may need to rely
erations. These programs have also instituted more fully on DM resources to help manage
information systems and ongoing data collec- their condition rather than making frequent
tion procedures in order to establish bench- visits to providers.
marks and monitor patient care quality. Based primarily on recent research fo-
Building the management structure and cused in six health systems serving rural pop-
information systems necessary for an in- ulations, we have described how such sys-
house DM program could also help rural heath tems have gone about ensuring the availabil-
plans and/or providers to participate in other ity of DM services to their patients. Diabetes,
government supported and incentivized qual- CHF, and COPD DM programs were most
ity initiatives such as the quality indicators often in place across these systems. Patients
reporting initiative offered through the Cen- with diabetes account for the largest num-
ters for Medicare and Medicaid Services as ber of patients supported by DM. Depression
appears to require more DM patient visits be met by multiple payers—government and

and CHF patient fewer in relation to their nongovernment—rural health systems, and
proportions among those served by DM pro- DM programs—locally owned and adminis-
grams in the six systems. Disadvantages for tered or provided by outside firms.
rural patients identified by DM caregivers in
these systems appear in several forms—less Ac knowledgments. Funding for the
access to supportive health services (labora- Chronic Disease Management in Rural Areas
tory, pharmacy, and participating physicians), study was funded by grant # 5 U1C RH 00033
poverty, lack of a phone, lack of transporta- through the Southwest Rural Health Research
tion, and poor weather, and travel conditions. Center, the Office of Rural Health Policy and
At the same time, rural patients may have the Health Resources Services Administra-
a relative advantage over others in family tion, (HRSA) US Department of Health and
and neighbor support and desire to participate Human Services (HHS).
in DM.
For rural health plans and providers, par-
ticipation in DM programs involves a number REFERENCES
of considerations. There is evidence that DM
saves costs and improves health care qual- (2001). Asthma DM effort slashes utilization, produces
ity. The success of DM, however, is heavily substantial ROI. Dis Manag Advis 7(10):145–149.
Aadalen, S.P. (1998). Methodological challenges to
dependent upon access to supportive infor- prospective study of an innovation: Interregional
mation systems, acceptance and adoption of nursing care management of cardiovascular patients.
clinical protocols and guidelines for chronic J Eval Clin Pract 4(3):197–223.
disease, and careful consideration of multi- Beaulieu, N.D., Cutler, D.M., Ho, K.E., Horrigan, D.,
ple criteria in deciding which chronic dis- Isham, G. (2003). The Business Case for Diabetes
Disease Management at Two Managed Care Orga-
eases to address. An additional key decision nizations: A Case Study of Healthpartners and In-
for the rural health plan or provider group is dependent Health Association, The Commonwealth
whether to build a DM program or buy one Fund 1–72.
from an external vendor. A major part of this Bierman, A.S., and Clancy, C.M. (1999). Women’s
decision rests on whether DM is viewed as a health, chronic disease, and disease management:
New words and old music? Women’s Health Issues
discrete and separate service or whether it is 9(1):2–17.
viewed as an integral part of a health plan’s CMS, C.f.M.M.S. (2004). CMS Announces Significant
or provider group’s day-to-day work. At the Increase in Numbers of Hospitals Voluntarily Re-
same time, there are a number of other fac- porting Hospital Quality Data, Department of Health
tors to consider in this decision making, such and Human Services. 2004.
Dalton, J. (2001). Using OASIS patient outcomes to eval-
as provider commitment to clinical protocols uate a cardiac disease management program: A case
and guidelines for chronic disease, and the study. Outcomes Manag Nurs Pract 5(4):167–172.
availability of a clinical champion and in- Diamond, F. (1999). The short unhappy lives of too many
house expertise. Other factors are important DM programs. Manag Care 8(2):35–36.
to the decision-making process, such as the Foote, S.M. (2003). Population-based disease manage-
ment under fee-for-service Medicare. Health Aff
local availability of RNs and DM-related in- 342–356.
centives to providers and plans provided by Keefover, R.W., Rankin, E.D., Keyl, P.M., Wells, W.C.,
employers and Medicare and Medicaid pro- Martin, J., Shaw, J. (1996). Dementing illness in
grams. rural populations: The need for research and chal-
There is ample evidence that rural health lenges confronting investigators. J Rural Health
12(3):178–187.
systems can deliver effective DM services to Kozma, C.M. (1998). Strengthening evaluations of dis-
rural patients. It remains to be seen how fully ease state management programs. Manag Care In-
the needs of rural patients for chronic DM will terface 11(12):77–78.
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of-care challenges for rural health. J Rural Health J., Wilging, C., Wagner, W. (2002). Safety-
16(2):168–176. net institution buffer the impact of Medicaid
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program evaluation questionaire. J Healthc Qual a rural state. Am J Public Health 92(4):598–
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Policy 1–72. 361.
18
Caring for the Border Communities

Maia Ingram
Few would argue that the behavioral regi- serve to complicate a person’s ability to follow
men required for diabetes management is for diabetes self-management recommendations.
many a drastic and challenging change in
lifestyle. As we have seen in this book, the de- (1) Poverty. Approximately 30% of the
mands upon diet, physical activity, medication population on the U.S. side of the border live in
poverty. Of the 25 U.S. counties on the border, 3
regimen, and clinical attendance require that
are among the 10 poorest in the nation and 21 are
patients obtain and practice multiple skills. In- designated by the Federal Government as econom-
dividual self-management is the focus for con- ically distressed (HRSA, 2000).
trolling diabetes complications, however, the (2) Growth. At the same time, the border is
larger environmental context will either sup- experiencing rapid population growth compared to
port or hinder the ability of people with dia- other parts of the country. According to the U.S.
betes to adopt and maintain self-management Census, 2000, 2 of the 10 fastest growing cities,
behaviors (Jack et al., 1999). This chapter will Yuma, AZ and McAllen-Edinburgh-Mission, TX,
describe the specific challenges to those liv- are located on the U.S. side of the border, and bor-
ing with diabetes in border communities and der communities will double in size over the next
will recommend some core elements of di- 30 years (U.S. Census, 2000).
(3) Young population. The age distribution
abetes outreach and education programs that
on the border is contributing to the rapid population
have proven successful in this environment. In growth. Approximately 25% of the border popula-
addition, the chapter will explore strategies for tion is under 15 years of age (PAHO, 2000).
addressing broader environmental influences (4) Shared infrastructure. The U.S.–
on diabetes prevention and self-management. Mexico border is a line drawn on the sand;
however, communities on both sides of the line
share the same water, the same air, and many of
U.S.–MEXICO BORDER the same services. U.S. and Mexican citizens alike
ENVIRONMENT cross the line to visit relatives, shop, access health
care, and purchase medication.
The U.S.–Mexico border environment is (5) Militarization. In spite of a bicultural
shaped by five overlying factors, which in turn and binational community, U.S.–Mexico border
237
238 CARING FOR THE BORDER COMMUNITIES
residents are living in an increasingly militarized DIABETES ON THE U.S.–MEXICO

environment. In 2002, there were 9,500 border pa- BORDER
trol agents working in the region (Cañizo, 2004),
nine times as many as were allocated to the U.S.– The impact of diabetes on the U.S.–
Canadian border, which is twice as long. In addition
Mexico border is devastating. Diabetes was
to ground patrol, efforts to control illegal immigra-
tion include electronic sensors, night vision scopes,
the fourth leading cause of death among
aircraft, and most visibly, the construction of a steel Mexican communities on the border between
wall. The environment of low-intensity conflict in- 1995 and 1997 (Anonymous, PAHO, 2000),
creases the psychological stress of people living and the diabetes mortality rate in the border
within the community. region is nearly 50% higher than in the rest
of the country (ADA, 1996). Everyone that
you speak to in a border community will have
Clearly, people with diabetes on the a family member who has or who has died
U.S.–Mexico border are living in unique sur- from diabetes. While the population is young,
roundings. The rapidly growing population the occurrence of type 2 diabetes among
coupled with extreme levels of poverty ex- Mexican American children is being diag-
acerbate the inadequate infrastructure, and nosed at an increasingly younger age (ADA,
ensuing environmental concerns. While the 2000).
border environment offers the unique expe- The epidemic proportion of diabetes is
rience of shared culture flowing both north related to the border characteristics outlined
and south, the growing presence of uniformed above because these contribute to and aggra-
and armed patrol leads to escalating lev- vate an environment in which it is difficult to
els of intimidation and fear, which impacts prevent or control diabetes. The most glaring
one’s ability to access medical and other ser- issue is that the region is highly medically un-
vices. Although the population is relatively derserved. If the U.S.–Mexico border region
young, the morbidity and mortality related were a state it would rank last in access to
to diabetes is inordinately high. A person health care. More than 30% of the Hispanic
with diabetes must overcome numerous chal- population is uninsured (HRSA, 1999), a rate
lenges in order to access, interpret, and ap- twice as high in the rest of the country. Lack
ply information regarding how to control the of insurance, the seasonal nature of employ-
disease. ment for farmworkers, and fear and discrim-
This chapter focuses on the U.S.–Mexico ination related to immigration make it diffi-
border because of the enormous impact of cult for Mexicans living in border areas to es-
diabetes in border communities. The U.S.– tablish a regular source of care (Ruiz-Beltran
Canada border has a different scenario. Resi- and Kamau, 2001). The fact that residents fre-
dents on both sides of this border share com- quently cross over to Mexico to access med-
parable language and culture, socioeconomic ical services makes it difficult for physicians
status, population growth rate and age distri- to provide consistent diabetes treatment. Stud-
bution, as well as infrastructure. A stark differ- ies document that up to 40% of residents in
ence between the two borders is that Canada border communities in the United States go
is considerably less militarized. Because of to Mexico to utilize physician health care ser-
these characteristics, the U.S.–Canada border vices (Landeck and Garza, 2000; Marcias and
seems physically and psychologically invisi- Morales, 2001).
ble. One interesting similarity is the increas- A second issue is that the border environ-
ing trend of U.S. residents crossing both bor- ment creates specific challenges to diabetes
ders to obtain more affordable prescription self-management. Border residents who are
drugs. not eligible for Medicaid programs can rarely
CARING FOR THE BORDER COMMUNITIES 239
afford diabetes medications, making it diffi- they may become increasingly isolated and
cult for them to comply with their medical depressed.
regimen. Those who have insurance often do Finally, all of these issues coalesce to im-
not have pharmaceutical coverage and people pact the health perspective of people living
with diabetes frequently must decide whether on the border. This health perspective also is
to buy food or medication. Diabetes patients influenced by language and sociocultural fac-
resort to cutting pills in half or attempt to self- tors. First of all, there is a dearth of very ba-
regulate medication based upon how they are sic information about diabetes. Many health
feeling. While diabetes programs may make providers are not bilingual, and formal, cul-
glucose monitors available, there are few re- turally competent diabetes education in Span-
sources to cover the costs of strips. ish is often not available. Second, the issue of
Following recommendations related to health care access leads many people to feel
diet and physical activity are also problem- that if they do contract a disease there will
atic. The presence of lifestyle related risk fac- be very little they can do to treat it, so they
tors for diabetes and diabetes-related com- will be better off not knowing. A fair amount
plications (sedentary lifestyle, poor nutri- has been written about this phenomenon un-
tion) is 5–10 times higher in U.S.–Mexico der the term “fatalismo” or fatalism (Antshel,
border communities than in the rest of the 2002, 435–449), however, a better term might
country. While some of these behaviors can be “realism” given the challenges and barriers
be attributed to individual characteristics, it identified in this article.
must be recognized that the environment does Four issues are thus identified as related
not support engagement in healthy lifestyles. to the extreme prevalence of diabetes and
Border towns have very little infrastructure the high level of morbidity and mortality at-
for recreational areas and parks; even side- tributed to the disease as (1) access to health
walks to facilitate walking are scarce. Is- care, (2) difficulty in engaging in healthy
sues such as uneven pavement, lighting, and lifestyle, (3) lack of social support, and
wild dogs challenge even the more moti- (4) health perspective. The next section will
vated individuals. With respect to nutrition, present the elements of a successful diabetes
it is difficult to access healthy foods such as outreach and education model and provide de-
fresh fruits and vegetables, which are high- scriptions of how this model has been adapted
priced and often unavailable. Many of the to fit the characteristics of existing border
health messages, ubiquitous in mainstream, communities in the Arizona–Sonora region.
urban areas, do not reach these marginalized
communities.
A third issue is related to the social sup- DIABETES OUTREACH AND
port network that might facilitate diabetes EDUCATION PROGRAMS ON
self-management and care. There is a percep- THE U.S.–MEXICO BORDER
tion that Hispanic families are close knit and
available to one another. In many cases, al- In talking about diabetes education, it
though family ties may be strong, elderly peo- is important to reiterate that programs that
ple with diabetes are isolated within the bor- address individual diabetes self-management
der communities. Extended family members in a vacuum will have difficulty creating
may live in Mexico, and the economic and sustainable changes among their participants.
social reality has resulted in children mov- While people need access to information and
ing to urban areas. As residents age and begin support for diabetes management, the broader
to have more health issues, it is more diffi- structural and societal issues must be ad-
cult for them to travel to visit relatives and dressed for them to practice difficult behavior
changes. The final section of this chapter will ation of these programs that indicate:
offer some suggestions on how to work for a r Promotoras significantly improve com-
supportive environment. pletion of the diabetes classes. A program that had
A review of the literature indicates that included promotora follow-up achieved an 80%
diabetes education is an effective means to completion rate compared to 35% in a program
change patient self-management behaviors without that support.
(Peyrot, 1999; Brown and Hanis, 1999) and r Promotoras address a broad range of par-
greater understanding of diabetes has been ticipant needs that would be impossible to other-
correlated with greater blood glucose con- wise provide. Participants said that the promotoras
trol (Dalewitz et al., 2000). In 1998, com- provided support, motivated them, reminded them
munity agencies in Nogales, Arizona devel- to attend classes, reinforced information on dia-
oped a diabetes education and outreach model betes, provided transportation to the classes, and
ran support groups. The impact of the promotora
in response to the growing threat of diabetes
was summarized by one participant in the follow-
in the community. This program successfully ing way:
documented decreases in random blood glu- “To know that they are keeping an eye
cose, weight, and blood pressure among pro- on me, to know simply that they’re conscious,
gram participants. Since that time, four addi- just the fact of asking me how I’m doing really
tional border communities in Arizona in South helps.”
Yuma County, Tucson Southside and Ajo r Promotoras were also crucial in help-
in Pima County, and Cochise County, have ing participants understand and adopt self-
adapted the model to fit their specific needs management behaviors. Program participants de-
and have documented significant decrease in scribed the support of the promotoras as transfor-
mative because they could depend upon them to be
HbA1c levels over a 6-month period. While
available and to help them apply the information
the models differ across sites, program eval-
they had learned. An obvious example is in learning
uation has identified several key elements to to self-monitor glucose; the promotoras conducted
success. home visits to help participants use their monitors.
As one woman explained,
(1) Provide basic diabetes education. De-
“Without the promotoras I would not
mographic data on program participants revealed
have changed anything.”
that the majority had been living with diabetes for
15 or more years and had never had access to for- To be successful, it is important that the pro-
mal diabetes education. This program uses a cul- motoras not be engaged within the more traditional
turally competent, straightforward curriculum that health educator or case management role, but rather
employs a variety of teaching methods to cover the that they have the flexibility to respond to the mul-
definition of diabetes, nutrition, physical activity, tiple needs of program participants in innovative
diabetes complications, and foot and eye care. The ways. (For information on initiating a community
general format of the classes includes five 2-hour health worker program, contact the Arizona Com-
classes held once a week for five weeks. Graduation munity Health Outreach Worker Association or the
parties mark completion of the program. Evalua- Prevention Resource Center at the University of
tion of class participation revealed that providing a Arizona Mel and End Zuckerman College of Pub-
close-ended series of classes assisted participants lic Health.)
in developing a group identity and in completing (3) Ensure that diabetes education is linked
the program. to clinical care. In a local provider survey, health
(2) Include peer outreach and education. care providers in Nogales acknowledged that, given
This successful model depended upon use of com- time constraints, it is difficult to provide adequate
munity health outreach workers, or promotoras, to diabetes education to their patients. Recognizing
provide outreach, assist participants in incorporat- this reality, physicians are nonetheless skeptical of
ing self-management behaviors into their lifestyle, the accuracy and effectiveness of education pro-
and conduct ongoing support and follow-up. The vided through other venues. From the outset of
essential nature of promotoras is clear from evalu- the program, it is vital to create relationships with
physicians by informing that the resource is avail- participants indicated that many could not recall
able to their patients. a past eye examination. In many cases eye exams
Another strategy to link education and clini- are not covered by medical insurance. The commu-
cal care utilized within this model is to have the pro- nities utilizing this model found resources to pro-
motoras refer participants to clinical examinations vide this service, either through physicians volun-
and advocate for them within the health system. teering their time or through complementary grant
One community health center places a note in the programs.
patient file regarding the completion of diabetes ed- (8) Include patient empowerment. Empow-
ucation. Another program sends a follow-up letter ering people with diabetes to be proactive with re-
to doctors who referred patients with acknowledge- spect to their clinical care continues to be a chal-
ment of attendance or lack of attendance, education lenge for these programs. This issue is particularly
received, and results of clinical tests given as part acute on the border because many people cross
of the classes. back and forth for care and there is no consistent
(4) Address issues related to health care ac- record of treatment. The program in Nogales cre-
cess. Clinical targets cannot be reached without ated a diabetes empowerment card that includes
consistent clinical care and a diabetes education documentation of clinical visits, medications, class
program on the border should address this issue attendance, and personal goals. While the card is
with participants as they enter the program. Al- popular with program participants, infrastructure
though many are not eligible for insurance, there within the medical community has not been cre-
are some individuals who are not aware that they ated to ensure that the cards are viewed and filled
qualify for assistance, and diabetes programs can out by physicians.
be essential in connecting them to consistent med- (9) Conduct program evaluation for sus-
ical care. The education program also must stress tainability. Each of the five Arizona border com-
the importance of regular medical care and creat- munities employing this diabetes model are com-
ing a relationship with a provider. Two commu- mitted to program evaluation, although it demands
nities have adopted the use of a diabetes card to additional resources. Evaluation is essential to help
track clinical visits when patients cross the border programs improve their services and to document
to access medical care. changes in health outcomes. Perhaps more impor-
(5) Address access to medication. Hand in tant, sustainability is much more likely when a
hand with the issue of a consistent source of care, community program can demonstrate that it has
a diabetes program must address access to medi- made a difference in the health of people with
cation. It is unlikely that a program will have the diabetes. These programs were originally grant
resources to provide medication, but a program can funded, and of the three communities who have
help participants apply for special programs or can expended their grant, all three are sustaining their
obtain samples from pharmaceutical companies. program in some fashion.
This also is an issue that can be addressed on the
political plane, which will be discussed at the end
of this chapter. PROGRAM CASE STUDIES
(6) Consider alternatives to Certified Dia-
betes Educators. While certified diabetes educa- This section will briefly describe how the
tors are always preferred to present the classes, un- diabetes model is being applied in three Ari-
fortunately there are very few of them, especially zona border communities in Nogales, South
bilingual, in marginalized communities. Some pro- Yuma County, and Southside Tucson. The
grams have included a training component to help strengths and challenges of the programs also
local health care workers to gain certification. Eval-
will be presented.
uation of this model demonstrated, however, that
with back up and support from a medical profes-
sional, promotoras can deliver the diabetes curricu- Nogales, Arizona
lum and obtain similar results to those achieved by
certified diabetes educators. The diabetes outreach and education
(7) Provide clinical examinations as part model was created in this community in 1998,
of the program. Health information from program and the program itself represented one of the
first collaborative efforts between its two ma- each of whom had the responsibility for a
jor health providers: a small hospital and a certain “caseload” of participants. The pro-
community health center. One of the greatest gram developed a protocol for promotora con-
strengths of the program is the participation tact and follow-up so that all the participants
of a bicultural certified diabetes educator who received a base level of support. Of course,
also is a family nurse practitioner. This offered many participants sought out additional con-
a far greater measure of patient case manage- tact and assistance so support was not equal
ment than could be provided through other across participants.
programs. This program also helped to define The Yuma program also managed to
the role of the promotora and identified the more successfully link the program to clini-
need for flexibility. cal care. Housed within the community health
The education classes were based upon center, it was the first prevention/education
the idea that the program would provide program to be delivered and thus the coordi-
weekly classes and that there always would nator of the program also had access to patient
be an open door to community members. One records. When HbA1cs were indicated, the
of the lessons learned during the course of coordinator was able to order the test through
the program is that participants will be more the clinic. The promotoras were successful in
likely to graduate if they are part of a cohort calling participants and helping them sched-
of participants with whom they can identify ule appointments. While the promotoras were
and draw support. While the open door pol- from an outside community-based agency,
icy remained in place, more emphasis is now they were given an office in the clinic so that
placed on completing the full series of classes program participants could access them when
within a specific time frame. they made a clinical visit. Through the hospi-
Implementation of this program also has tal, the program also accessed local physicians
revealed the importance of the link between to provide eye and foot exams for free. It also
clinical care and the education program. It incorporated the exams as a class activity to
was well into the program that physicians be- maximize the number of people that received
gan regularly referring their patients to the the service.
classes, but feedback to the physicians has still The challenge for this program has been
not been incorporated. The strategy of having in sustaining the program within the clinic en-
physician offices forward patient HbA1c re- vironment. The clinic has hired a promotora to
sults to document participant progress proved provide the classes with their patients; how-
to be unrealistic and is no longer feasi- ever, the capacity to support participants to
ble under HIPAA guidelines. In response, the level offered previously is difficult. For-
this program developed a diabetes empow- tunately, the clinic continues to collaborate
erment card to encourage patient—provider with a community-based program to provide
communication. support for diabetes care, which enhances the
level of support for participants.
South Yuma County, Arizona
Tucson Southside, Arizona
This program also was the catalyst for
collaboration between the community health This program is funded through a non-
center and the regional hospital, and it ben- profit hospital and is unique in that it serves a
efited from the lessons learned from the large urban area. While the program benefits
Nogales program. The most successful aspect by having access to a broader scope of re-
of this program was the resources committed sources than in rural communities, the need
to promotoras. Aware of the need to conduct is overwhelming. The program is responding
extensive outreach to the farmworker commu- by holding classes in various sites in the
nity, this program funded four promotoras, community. Each site is in close proximity
to a health care provider and since the pro- r significant decrease in HbA1c at 6-month
gram has successfully created a relationship follow-up at the two sites that collected this mea-
with each provider, the physicians are reg- sure.
ularly referring their patients to the classes. Of equal importance are the improve-
The promotoras follow up on the referrals ments in basic quality of life described by
by providing personal invitations to join the participants up to one year after graduating
classes and the physicians receive a letter stat- from the program.
ing whether or not the patient participated
r The perception of diabetes changed from
in the program, what classes they attended,
and the results of health measures (weight, one dominated by fear, depression and futility to
an understanding of the disease and awareness that
blood pressure, random blood glucose, and
it is incurable but controllable.
HbA1c). r Participants feel healthier both physically
To facilitate regular physical activity, and emotionally.
each participant is provided with a free pass r Participants feel that there is support in
to the local community center walking track, the community and are less isolated.
which is inside and air-conditioned. The pro- r In general, participants feel more sup-
gram is attempting to form volunteer walking ported by their family members.
clubs to encourage use of the passes. How-
The actual words of program participants
ever, since not all participants are close to
underline the enormous need for diabetes ed-
this site, other resources for walking are cur-
ucation and support in marginalized commu-
rently being developed. This program also
nities, and the tremendous impact it can have
has incorporated a grocery store tour to assist
on health and quality of life.
participants in identifying diabetes-friendly
foods and teaching them to read labels. “This program really helps us know we can
live with diabetes and enjoy our life.”
“Now it is sickness that is tremendous, and
not tremendous. Tremendous because of the con-
PROGRAM OUTCOMES
sequences, but not so tremendous because you can
control it.”
These programs collected substantial “I am grateful, if I had not gone to the classes
data, both qualitative and quantitative, which I don’t know how I would be doing. They opened
provide rich descriptions about the impact of my eyes to the consequences; what diabetes is.”
the programs, both on quality of life and health “I believed that a diabetic had to stop eating
status. The major outcomes in participant be- everything, but you can eat everything in modera-
haviors that have been reported across pro- tion.”
grams include: “Before controlling my diabetes my feet were
always asleep, I was really tired. Now I feel good.”
r increase in regular glucose monitoring;
r increase in regular checking of feet;
r increase in adherence to diabetes diet; and
r increased physical activity. CREATING ENVIRONMENTAL
CHANGE
Behavioral changes have also resulted in
improved health status. While the data being Those people with diabetes living on
collected across sites varies, results demon- the border who have been fortunate enough
strate: to access diabetes education programs still
r significant decrease in random blood glu- must confront an environment unfavorable
cose that is maintained over 6-month follow-up. to self-management. Programs serving peo-
r decrease in diastolic and systolic blood ple with diabetes are most aware of the envi-
pressure, although significance varies across sites. ronmental issues facing their clients and can
r trend toward weight loss. advocate for policy level change.
Two of the communities utilizing this issues, such as raising awareness and provid-
diabetes model also had funding to mobi- ing services. Those running programs should
lize a community response to issues related understand that a policy-focused coalition is
to nutrition and physical activity. As part of an opportunity to think how to change the very
a larger initiative, these programs were in- environment that makes the success of their
volved in forming coalitions with the purpose programs so difficult.
of shaping and implementing policy neces- These communities had additional fund-
sary to support positive changes in lifestyle ing to support a policy effort, but the members
factors important to the management of di- were volunteers, and a coalition with the qual-
abetes. A key element of their success is ities outlined above can have notable impact
that they included decision makers and pro- in creating environmental change simply by
gram practitioners from health care providers, leveraging existing resources. A program in
schools, local and county government, com- any marginalized community that is thinking
munity organizations, and the media in the about providing diabetes outreach and educa-
process. tion should consider how to include a broader
The coalitions focused on issues such perspective in their effort and creating sustain-
as the availability and promotion of healthy able change.
foods in grocery stores and the creation of in-
frastructure to support physical activity. Their Ac knowledgments. The author of this
successes include: paper would like to thank the Mariposa Com-
r Allocation of funds to construct local munity Health Center, Sunset Community
parks.
Health Center, and Carondelet Community
r Green areas incorporated into local plans Foundation for contributing information on
for growth. their model programs in this chapter.
r Collaboration with local supermarkets to
promote healthy foods.
r The construction of major walking trails.
r Vending machines removed from
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Murry, V. (1999). Influence of the environmental Ruiz-Beltran, M., and Kamau, J.K. (2001). The socio-
context on diabetes self-management: A rationale economic and cultural impediments to well-being
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Pan American Health Organization. (2000). Mortality Border. Rockville, MD: U.S. Government Printing
Profiles of the Sister Communities on the United Office.
19
Utilizing Community Health Advisors

in Diabetes Care Management
Nancy J. Metzger & Linda Parker
Community health advisors (CHAs) are com- have promoted health and advocacy among
munity members who work almost exclu- groups that have traditionally lacked access
sively in community settings and serve as to adequate health care. Community health
connections between health care consumers, advisors are effective cultural mediators in re-
providers, and health care organizations. ducing barriers to care, improving access to
These individuals are an integral part of the the health care system, providing education
health care team and can be instrumental in for their clients, and providing emotional and
the success of community diabetes care man- resource support (CDC, 1994).
agement programs. This chapter describes the Upon review of the literature, com-
history and background of community health munity health advisors are referred to as
workers, the evolution of their role in the lay health workers, promotores, community
health care system, the current training and de- health workers, and health aides. The history
velopment available, and their role in a com- of the community health advisor began
munity diabetes care management program. with the Indian Health Service in 1955
with the introduction of the community
health representative program (Indian Health
WHO ARE COMMUNITY HEALTH Services website, 2003; www.ihs.gov/
ADVISORS? nonmedicalprograms/chr). In the 1960s,
community health advisors were used to
Community health advisors are work- reach people in underserved communities
ers who live in the community they serve, with health promotion and disease screening
are selected by that community, are account- programs. This type of worker has been used
able to the community, receive a short defined throughout the world for all types of roles
training, and are not necessarily attached to such as teachers, health care providers when
any formal organization (World Health Orga- none are available, and community leaders.
nization, 1987). Community health advisors The role of the community health advisor in
247
248 UTILIZING COMMUNITY HEALTH ADVISORS IN DIABETES CARE MANAGEMENT
the United States has varied in popularity, but assess what aspects of the community health
has been most utilized in rural and remote advisor role were measured in relation to the
communities. Only in the last 10 years has outcomes. The studies also utilized commu-
the community health advisor been a popular nity health advisors with various populations,
strategy in urban and minority communities. ranging from high-risk pregnant women to
Today, Meister (1992) estimates that there children with asthma to patients with diabetes.
are over 12,500 community health advisors Lastly, most data were self-report, therefore,
in the United States in both paid and unpaid rending application to other communities and
positions. populations weak. However, despite the diffi-
The role of the community health ad- culties with current study methodologies, all
visor varies in different geographic regions, the articles supported that community health
communities, and populations and contin- advisors are strong in reaching and serving the
ues to evolve in response to today’s health underserved and those hard to reach. Addi-
care environment. Community health advi- tional data suggest that the use of community
sors are seen as teachers, mentors, advocates, health advisors to impact behavioral change
and community activists. In 1998, a national requires many hours of face-to-face time with
survey was completed of community health the patient (Swider, 2002).
advisors that yielded some validated roles for From the literature review of a total
further study (Rosenthal, 1998). These roles of 19 studies, which met Swider’s inclu-
include cultural mediation, informal coun- sion criteria (2002), three of the studies de-
seling and social support, providing cultural scribed interventions with minority, low in-
health education, advocating for individual come, patients with chronic illnesses. In two
and community needs, assuring that people of the studies, hypertensive patients increased
receive services they need, building individ- significantly in keeping their follow-up ap-
ual and community capacity, and providing pointments after contact from a community
direct services. In addition, the Center for health advisor (Bone et al., 1989). The third
Public Awareness (1999), describes several study was a randomized clinical trial that
global functions for community health ad- focused on a group of people newly diag-
visors, which include decreasing health care nosed with diabetes who attended a nurse-
costs, increasing health care access, strength- led diabetes education class. All the patients
ening the local economy, and strengthening who completed the classes showed signif-
the family and community. However, there is icant improvement in knowledge, self-care,
currently no strong consensus about the role and hemoglobin A1c levels regardless of the
of the community health advisor and the ef- community health advisor intervention being
fectiveness of various aspects of the role. present or not. However, those patients who
received a community health advisor inter-
vention demonstrated a higher rate of com-
WHAT DO WE KNOW ABOUT pletion of the classes. Thus, the community
THE EFFECTIVENESS OF health advisors played a notable role in im-
COMMUNITY HEALTH proving patient participation rates, thereby
ADVISORS? improving the knowledge, self-care and clin-
ical indicator of HbA1c. The study limita-
In 2002, Swider completed a compre- tion is the use of the convenience sample and
hensive data-based literature review on the the patient self-report data (Corkery et al.,
effectiveness of community health advisors. 1997). The Border Health Strategic Initiative,
Of the studies reviewed, most were descrip- an additional research project funded on the
tive in nature and differed in the definitions of Arizona border provided individualized sup-
the community advisor role. It is difficult to port to patients with diabetes. This program
UTILIZING COMMUNITY HEALTH ADVISORS IN DIABETES CARE MANAGEMENT 249
demonstrated a significant reduction of 0.5% role has been operationalized in many forms
in HbA1c results 3 months after classes. The and styles. In addition, as community health
self-report measures of regular exercise, glu- advisors transition from various grant funded
cose monitoring, foot self-exam, and knowl- programs, their roles evolve and expand.
edge of HbA1c also was significant at 0.001. An early need identified was the need
The population with the community health to transition from “on the job” training
advisor intervention yielded better class at- to a postsecondary responsive curriculum.
tendance as well as clinical outcomes. The The earliest postsecondary certification pro-
community health advisor’s presence at edu- gram was developed with the U.S. Depart-
cational classes provided the value of social ment of Education and a partnership between
support (Meister, 2003). San Francisco State University and the City
From these few studies investigating the College of San Francisco in 1995 (University
role of community health advisors in working of Arizona, 2002). This certification program
with patients with chronic disease, we then was known as the Community Health Worker
try to identify the attributes that make com- Initiative and consisted of a 17-credit basic
munity health advisors most effective with curriculum. The program was urban-based
patients with chronic illness. With the goal and defined competencies and performance
of using community health advisors to op- standards within the curriculum. A secondary
timize a patient’s health status as well as gain of this initial certification program was
their self-management skills, the attributes the development of an employment market for
for effective use of community health ad- community health workers.
visors would include help with access to The University of Arizona followed with
care, advocacy, cultural education, and sup- a successfully funded program called Project
port. Glasgow and Osteen (1992) found that Jump Start, which was funded by the U.S
changes in the knowledge and attitudes of Department of Education and Health Re-
patients with diabetes are not sufficient to sources and Services Agency (HRSA) in
change self-management behaviors. The pres- 1998. This initiative focused on rural, un-
ence of self-efficacy is critical to the self- derserved, and border populations and de-
regulation of motivation (Bandura, 1977). veloped a 16-credit basic certificate program
The presence of self-efficacy may possibly be that detailed core competencies for commu-
developed with the social support provided by nity health workers. The curriculum was val-
the community health advisor. idated by employed community health work-
ers and their employers. The University of
Arizona program has continued to collabo-
HOW ARE COMMUNITY HEALTH rate with many community colleges across
ADVISORS TRAINED AND WHAT the United States to assess, implement, and
EDUCATION IS AVAILABLE evaluate this core curriculum (University of
FOR THEM? Arizona, 2002).
The University of Arizona Jump Start
Historically, the community health advi- curriculum is available in a guidebook, which
sor has had “on the job” training in response to details six modules that can be used in concert
the needs presented by the client or the com- with community colleges or as stand-alone
munity being served. With the continued uti- continuing education for community health
lization and proliferation of community health workers. This guidebook includes instruc-
advisors, the questions of education, train- tions, suggested learning activities, and rec-
ing, and competencies have been raised. Since ommendations based upon the Arizona expe-
many community health advisors are em- rience in helping community health workers
ployed through grants and volunteering, the achieve core competencies. See “Appendix”
for full community health worker’s curricu- ing tracks for community health workers
lum. The modules included are: comprising preparatory training, field work
1. Primary Health Care and Human Ser- experience, and academic course work. The
vices: The Community Health Worker’s World of current interest from a national perspective in
Work. the education and development of core com-
2. Communication skills: Obtaining, De- petencies for community health workers is a
veloping, and Providing Information. strong positive movement toward the support
3. Advocacy: The Role of the Community of this community position; however, the need
Health Worker within a Larger System of Primary for public policy to follow and match this ef-
Care and Human Services. fort cannot be unaddressed.
4. Community Health Education, Cultur-
ally Appropriate Health Education, Health Promo-
tion Information, and Disease Prevention Compe- WHAT ABOUT THE
tencies.
5. Capacity Building: Motivating Individ-
DEVELOPMENT OF ADVOCACY
uals and Groups to Action. FOR COMMUNITY HEALTH
6. Service Skills and Responsibilities: WORKERS AND PUBLIC POLICY?
Employment/Work Skills, Legal Responsibilities,
Organizational Skills, and Interpersonal Skills. As aforementioned, all the education,
In addition, modules 7–10 were developed training, and core competency achievement is
in response to educational needs identified by essential, but if the employment market is not
community health workers working with diabetic available and consistent, community health
patients.∗
workers will not achieve their optimal lev-
7. Diabetes and Current Research.
els of effectiveness in improving the health
8. Diabetes, Nutrition, and Exercise.
9. Diabetes and Medications. status of clients and communities. The de-
10. Diabetes Complications and Self-Care. velopment of advocacy and public policy is
critical.
From these funded projects, the objec-
The case study of the ongoing evolution
tives for postsecondary education of commu-
of the Arizona Community Health Outreach
nity health workers becomes apparent and
Worker (AzCHOW) can be reviewed as a
are currently embraced by partners across the
model for other groups of community health
United States (Proulx, 2004). These objec-
advisors. In May 2001, community health
tives include:
advisors in Arizona identified the need for an
1. Establish opportunities and recognition organization that would support and recog-
for community health workers through a new entry nize their work. AzCHOW, which comprises
point in postsecondary education. community health advisors, provides an op-
2. Validate and give credit for core com-
portunity for a collective voice for educating
petence through assessment of prior learning and
policy makers, finding methods of becoming
direct experience.
3. Design responsive postsecondary pro- financially sustainable and expanding their
grams that recognize the indigenous nature of the professional standing in Arizona (Collyer,
community health worker and the nontraditional 2004). To date, the organization has provided
characteristics of these students. public policy education for their members,
4. Establish curriculum standards and flex- completed incorporation as a nonprofit or-
ible delivery of training that meets student/worker ganization, written a member newsletter and
and employer needs. sponsored an advocacy day at the Arizona
5. Produce a cohort of model programs of Legislature. The group has provided valuable
excellence. education for legislators on the funding dis-
The national working group spearheaded cussion of Arizona Health Start, the only state
by the University of Arizona is currently funded community health advisor program
working on career education and train- in the state of Arizona (Collyer, 2004).
The organization of this grassroots 1. How do we design the care to assure the
group of community health advisors can ability to measure the effectiveness of the commu-
help to support education, substantiate the nity health worker? Can we look at populations
role in terms of presentation of case studies with and without the community health worker in-
and best practices, and provide assistance in tervention? Will we be able to see the value of social
support in improving patient participation, clinical
educating policymakers on the important role
indicators, cost benefit, and other variables?
of community health advisors in the current 2. How do we communicate these findings
health care delivery system. However, the to policy makers and health care payers to influence
need also is apparent to collect quality data a portion of the health care dollar allocation to fund
that illustrate the value community health community health workers?
advisors bring to health outcomes for patients 3. How do we reach consensus on the per-
and communities. formance measures for community health work-
ers when working with a specific chronic disease
and/or population?
WHAT ARE THE NEXT STEPS The case study, described below, mod-
FOR THE DEVELOPMENT OF els the use of community health advisors
THE COMMUNITY HEALTH in the continuing care of a high-risk dia-
ADVISOR IN THE CARE OF betic population and highlights many of the
PATIENTS WITH DIABETES? findings from the literature as well as the
support for the next step questions posed
The pertinent literature review illus- above.
trates the beginnings of the data management In summary, the role of the community
around best practices and clinical outcomes health advisor is established in our commu-
for patients with community health advisor nities as valuable. The role should strengthen
interventions. However, we still can see many as models of best practices and quality data
barriers to the development of public policy are collected and disseminated. These data
and financial allocations within the health care identify and support the value of the commu-
system to support these roles. Some of the ar- nity health advisor from a clinical outcome
eas for consideration when designing chronic perspective as well as from the cost bene-
care models utilizing community health work- fit implications for the care of patients with
ers are: diabetes.
CASE STUDY
The Role of the Promotora in the Continuing Health Care Model
Linda Parker
One of the greatest gaps in health care delivery and those that need health care is the high
rate of “no shows” or patients who do not keep their scheduled medical appointments. The
percentage of “no shows” can range from 40% to 60% or even higher on any given day.
This high no-show rate results in a loss of health care dollars, resources, and continuity of
patient care. As the population of the United States grows more diverse, the demand for
affordable and accessible health care becomes paramount. Unaddressed barriers to care,
such as language, transportation, cost and culture, are becoming all too familiar.
In the uninsured or “working poor” populations, patients do not keep appointments

for many different reasons, mostly socioeconomic and family responsibilities. Many of the
patients seen in Continuing Care Clinics are over 50 and assume care for their school-
age grandchildren, while others, are taking care of aging parents. Their day-to-day care of
grandchildren and aging parents take priority over medical appointments. Other reasons
patients miss their appointments include:
1. Preventive care is not a priority

2. Family emergencies dictate their daily agenda
3. They cannot get off work or afford to take time away from work
4. Lack of transportation
5. Traveling across the border to see relatives
6. Lack of funds to pay for appointment
7. They forget the appointment
Promotoras or Lay Health Educators bridge the gap between patients and the medical
staff. After appointments are made, promotoras make phone calls, usually in the evenings
when employed patients are home from work, to remind them of their appointments. It is
more effective to call three or four days before the appointment and again the day before the
appointment. Even with two or more reminder calls, many patients find it difficult to keep
their appointments because of unforeseen family situations or transportation problems that
frequently happen on the day of the appointment. During reminder calls, the promotoras
encourage patients to keep their appointments and to take care of themselves so they can
take care of their families.
A common challenge that exists is motivating patients to self-manage their diabetes.
In fact, many patients are not familiar with the idea of goal-setting or self-management.
During their medical visit, patients are taught that behavior changes such as healthy eating,
activity, monitoring of blood glucose, and stress management can have a positive effect on
their blood glucose levels and diabetes. Patients frequently tell us that these changes are
very difficult to make and hard to sustain. Some studies show that patients forget 50% of
what the doctor told them before they even get to their car. The promotoras bridge the gap by
making follow-up phone calls weekly or monthly to assess how patients are doing with their
self-management goals and to provide encouragement. The patients keep an empowerment
log to be reviewed by their doctor, dietician, or nurse during their next visit to the clinic.
The phone calls made by promotoras have been positively received.
The promotora serve as a vital link between clinic staff and the patient population. They
help patients overcome barriers of language and culture. They also help patients overcome
barriers of transportation, care giving, money, and other socioeconomic factors that prevent
them from health care.
APPENDIX modules as a basic training. The competen-

cies or performance abilities that the promo-
Training Curriculum tores should have and use in their direct ser-
vice roles and then a specific curriculum can
The core curriculum designed to train be designed to work with a specific population
Community Health Workers comprises six such as people with diabetes. Field work in the
community is integrated with each module al- r Assess ability of others to understand and
lowing for practice, growth, and discussion. adapt communication to meet individual needs, in-
cluding paraphrasing and/or translating and im-
parting information with a sensitivity to multicul-
Module I—Primary Health Care tural and multilingual needs.
and Human Services: The Community r Transmit information to health and hu-
Health Worker’s World of Work man service providers/agencies, including formal
and informal observations, environmental condi-
Core competency statement: Upon com- tions, treatment and care plan progress, and un-
pletion of this module, the community health usual client occurrences or risks, while protecting
worker will be able to describe primary health the confidentiality of this information to assure that
care delivery, principles of health promotion people access needed services.
and disease prevention, basic human service r Demonstrate communication skills,
needs, and how to assess these needs in a including listening, rapport and trust building,
community. perception and values clarification, respect and
empathy.
Objectives
Module III—Advocacy: The Role
r Explain the principal components of pri-
of the Community Health Worker
mary health care and human services and the his- within a Larger System of Primary
tory of these fields of work.
r Explain principles of health promotion Care and Human Services
and disease prevention. Core competency statement: Upon com-
r Use health and human services terminol-
pletion of this module, the community health
ogy and case finding assessment techniques.
r Prepare reports, activity logs, home visit worker will be able to network effectively to
forms, and related documentation of the commu- serve in an advocacy role to address individ-
nity health workers service in the community. ual and community needs.
Module II—Communication Skills: Objectives

Obtaining, Developing, and Providing r Describe and impart to community mem-
Information
bers the wide range of health care and human ser-
Core competency statement: Upon com- vices available, how reimbursement affects deliv-
pletion of this module, the community health ery, and how to access services.
r Serving as culture mediator, educate
worker will be able to network effectively to
providers/agencies of care and services about cul-
research and obtain primary health care and tures and practice/beliefs in the community and
human service information, and impart this how changes in provider attitudes, services and
information orally and in writing to the mem- practice approaches, and materials can promote fa-
bers of the community being served. vorable outcomes.
Objectives
Module IV—Community Health
r Access information through health and Education, Culturally Appropriate
human service agencies and providers as appro- Health Education, Health Promotion
priate, and as applied within the community-based Information, and Disease Prevention
agency or setting in which the community health Competencies
worker performs work/service.
r Use facility-specific guidelines and meth- Core competency statement: Upon com-
ods for sharing information. pletion of this module, the community health
worker will be able to provide culturally Module VI—Service Skills and

appropriate information and make health ed- Responsibilities: Employment/Work
ucation, health promotion, and disease pre- Skills, Legal Responsibilities,
vention accessible to a community through Organizational Skills, and Interpersonal
various methods of distribution. Skills
Core competency statement: Upon com-

Objectives
pletion of this module, the community
r Through a needs assessment, plan and health workers will be able to exhibit in-
lead health promotion activities, selecting appro- terpersonal qualities and skills necessary
priate education and public health resources, and to promote teamwork, respect for diver-
evaluate the outcomes of these activities. sity, individual self-esteem, and community
r Educate about preventive health screen- mobilization.
ings and health promotion practices.
r Promote healthy lifestyle practices and
encourage clients to manage and reduce health risk Objectives
factors. r Exhibit interpersonal skills as a peer to
r Teach concepts of health promotion and
meet people where they are and to build a trusting
disease prevention using the public health model
relationship.
and public health resources in groups, one-on-one, r Exhibit friendliness, sociability, confi-
and during home visits.
dence, professional conduct, and appearance;
demonstrate time management skills and organi-
Module V—Capacity Building: zational abilities.
r Exhibit qualities of being patient,
Motivating Individuals and Groups
to Action open-minded/nonjudgmental, motivated, and
self-directed.
Core competency statement: Upon com-
pletion of this module, the community health ∗
Supplemented Population Specific Modules
worker will be able to develop and use net-
works and coalitions to help communities Module VII—Diabetes and Current
build their capacity to care for themselves and Research
to use informal counseling and social support
to build the health of the community. Core competency statement: Upon com-
pletion of this module, the community health
worker will be able to identify the normal
Objectives functioning of the body and the changes as
r Help people identify assets, strengths, a result of diabetes.
and resources to empower clients and to mobilize
the community to solve their own problems and ad- Objectives
dress their own needs, including creating and using
good support materials and networking. r Identify the body’s normal functioning
r Network and develop coalitions to ad- without diabetes as well as the different types of
dress client needs for food, clothing, housing, and diabetes and their impact on the body.
hygiene services. r Describe symptoms and treatment goals
r Provide informal group counseling and for type 2 diabetes.
social support, including forming and leading sup- r Learn the differences between low
port groups. and high blood sugar and how to test blood
r Build client and community capacities to sugars.
protect and improve health and bring about com- r Discuss the role of the family in the pre-
munity participation. vention and management of diabetes.
Module VIII—Diabetes, Nutrition, and Objectives

Exercise r Identify the various body systems that
Core competency statement: Upon com- may be damaged from poorly managed diabetes
pletion of this module, the community health as well as the warning symptoms.
r Examine various self-care behaviors that
worker will be able to identify the needed com-
may prevent or delay complications from diabetes.
petency for healthy nutrition and optimal di- r Identify various resources and organiza-
abetes management. tions in the community that provide assistance
and education to individuals and families with
diabetes.
Objectives r Discuss the role of the community health
r Identify the various food groups and their worker in working with patients and families with
role in the development of a meal plan. diabetes.
r Construct a healthy meal plan being cog-
nizant of sugar, fiber, sodium, and cholesterol.
r Discuss methods in which to assist and
REFERENCES
support patients in maintaining a diet conducive to
diabetes management.
r Discuss various types of exercise, safe ex- Bandura, A. (1977). Self-efficacy: Toward a unify-
ing theory of behavioral change. Psychol Rev 84:
ercise recommendations, and the potential impact 191–215.
on diabetes management. Bone, L.R., Mamon, J., Levine, D.M., Walrath, J.M.,
Nanda, J., Gurley, H.T., Noji, E.K., and Ward,
E. (1989). Emergency department detection and
Module IX—Diabetes and Medications follow-up of high blood pressure: Use and effec-
tiveness of community health workers. Am J Emerg
Core competency statement: At the com- Med 19(1):16–20.
pletion of this module, the community health Centers for Disease Control and Prevention (CDC).
(1994). Community Health Advisors: Programs in
worker will be able to identify various types the United States, I and II. Atlanta, GA: USDHHS,
of diabetes medications and their roles. PHS, Centers for Disease Control.
Collyer, N. (2004). Development of AzCHOW Presen-
tation. Phoenix, Arizona: Arizona Rural Health
Objectives Conference.
Corkery, E., Palmer, C., Foley, M.E., Schecter, C.B.,
r Identify the various classifications of pre- Frisher, L., and Roman, S.H. (1997). Effect of a
scription diabetes medications and their differ- bicultural community health worker on comple-
ences. tion of diabetes education in a Hispanic population.
r Discuss the role of over-the-counter med- Diabetes Care 19(3):254–257.
ications, vitamins, and herbs on diabetes manage- Glasgow, R.E., and Osteen, V.L. (1992). Evaluating di-
abetes education. Are we measuring important out-
ment.
r Learn the potential role of nutrition and comes? Diabetes Care 15(10):1423–1432.
Meister, J. (1992). A Summary of the National Commu-
exercise and the use of various medications. nity Health Advisor Study, Baltimore, MD: Annie
E. Casey Foundation.
Meister, J. (2003). A Summary of the National Commu-
Module X—Diabetes Complications nity Health Advisor Study, Baltimore, MD: Annie
and Self-Care E. Casey Foundation.
Proulx, D. (2004). Development of Responsive Curricu-
Core competency statement: At the com- lum for Community Health Workers: A National Per-
spective. Phoenix, Arizona: Arizona Rural Health
pletion of the module, the community health
Conference.
worker will be able to identify potential com- Rosenthal, E.L. (1998). A Summary of the National Com-
plications from diabetes and preventive self- munity Health Advisor Study. Baltimore, MD: Annie
care interventions. E. Casey Foundation.
Swider, S.M. (2002). Outcome effectiveness of commu- for a Community Health Worker Basic Certifi-
nity health workers: An integrative literature review. cate Program, funded by the US Department of
Public Health Nurs 19(1):11–19. Education.
The University of Arizona, Arizona Health Sciences Cen- World Health Organization (WHO). (1987). Community
ter, Area Health Education Centers Program. (2002). Health Workers: Working Document for the WHO
Project Jump Start, Core Curriculum Guidebook study Group. Geneva, Switzerland: WHO
20
Complementary and Alternative

Medicine in Diabetes
Karen D’Huyvetter
Complementary medicine, also known as opathic medical system including lifestyle

complementary and alternative medicine issues, nutritional supplements, and botani-
(CAM), alternative medicine, functional cal medicine. Portions of other well-known
medicine, and integrative medicine, is re- and well-studied medical systems, such as
emerging as one of the fastest growing Ayurveda and Chinese medicine, are included
fields in medicine today. A 1997–1998 na- in the botanical section.
tional survey showed that 57% of individuals A basic tenet of most CAM medical
with diabetes reported using CAM therapies systems views the individual as a whole:
during that year; 35% used CAM specifi- a somatic-psycho-social-emotional-spiritual
cally for their diabetes (Yeh et al., 2002). being. To ignore or minimize these factors and
Individuals with chronic disease often turn treat simply the disease and its symptoms re-
to CAM therapies as adjuncts to standard sults in less than optimum care. It is the pack-
medical treatment. It is noteworthy, how- age of care, rather than the specific modality,
ever, that approximately 40% of these pa- that promotes healing and well-being.
tients do not discuss CAM therapies with their
physicians. Of those who do report CAM
use, only 35% of all self-reported supple- LIFESTYLE
ments are documented in the patient’s chart
(Cohen et al., 2002). Given that several herbs While diet and exercise are lifestyle
and supplements have properties that aug- choices that have obvious impact on dia-
ment or attenuate pharmaceutical agents, a betes (indeed, in most cases they can hardly
knowledge of CAM treatments for diabetes is be considered CAM), less apparent dietary
imperative. topics and practices such as spirituality, so-
The list of modalities considered “CAM” cial support, stress, and smoking can have
is extensive. Included in this chapter are profound effects on the disease and on the
some of the major therapies of the Natur- individual.
257
258 COMPLEMENTARY AND ALTERNATIVE MEDICINE
Diet sensitivity. The degree of insulin resistance

is correlated to the extent of nicotine used
Standard dietary recommendations are (Kelly, 2000). While encouraging patients to
well described. However, special mention quit smoking is always recommended, care
needs to be made regarding fats and type 2 must be taken when prescribing patches and
diabetes. In an extensive review, it was found gums to aid this process.
that quality of fat was essential in glucose
metabolism. Polyunsaturated fats and long-
Stress
chain omega-3 fatty acids were found to be
beneficial, while saturated fats and trans fats Acute stress, associated with fight-or-
were detrimental to glucose metabolism and flight response, is accompanied by clear and
insulin resistance (Hu et al., 2001). Indeed, adaptive severe insulin resistance, quickly re-
some of the adverse effects of a high fat diet versible with the removal of the stressor.
can be ameliorated with omega-3 fatty acids Studies have shown, however, that psychoso-
(Lichtenstein and Schwab, 2000), and an in- cial stress may be associated with continued
verse relationship has been shown between insulin resistance (Kelly, 2000).
vegetable fats and risk of diabetes (Lamson Cortisol, a major stress hormone, might
and Plaza, 2002a). It is important that the qual- contribute to insulin resistance by its tendency
ity as well as the quantity of fats are addressed, to oppose the action of insulin, however, the
as all fats are not created equal. relationship remains unclear. Evidence sug-
Cow’s milk has been implicated in the gests that consistently elevated levels of cor-
development of type 1 diabetes. Elevated IgG tisol greatly inhibit nonhepatic glucose uti-
antibodies to bovine serum albumin were lization (Kelly, 2000).
found to average seven times higher in chil-
dren with diabetes than their healthy coun-
Social Support
terparts. This, in conjunction with viral ex-
posure, may lead to a cross reaction with the Unlike other disease states, diabetes has
p69 surface cell antigen on beta cells, leading a significant impact on the social unit of the
to release of interferon gamma and induction patient, in addition to the patient themselves.
of the beta-cell surface antigen. While these Diet and exercise, the cornerstones of glucose
results are controversial, it seems that breast control, will be affected by the support net-
milk should be favored over cow’s milk, at work of the individual. Change in the habits of
least during the first six months of life (Head, people with diabetes will often be intimately
1997). tied, for better or worse, to the support of their
families, colleagues, and health care systems.
Smoking A field test of a one-year program of
education and support in Sweden, including
Smoking, while deleterious on many ongoing counseling, examined 100 patients
counts, has particular influence on carbohy- with type 2 diabetes. At the study onset, 51%
drate and lipid metabolism. In a group of in- of participants had HbA1c levels at or be-
sulin treated diabetics, smokers had a 15–20% low 6.5%. After 12 months of education and
higher insulin requirement and serum triglyc- counseling, 63% had HbA1c levels within
eride concentration than their nonsmoking this range. Interestingly, participants whose
counterparts; this went as high as 30% in diabetes was diet controlled and rated their
heavy smokers (Head, 1997). While complete loneliness as high were more successful in
abstinence appears to decrease insulin resis- lowering their HbA1c levels than their non-
tance, smoking cessation methods that em- lonely counterparts (Sarkadi and Rosenqvist,
ploy nicotine (gums, patches) decrease insulin 2001). This emphasizes the critical need for
COMPLEMENTARY AND ALTERNATIVE MEDICINE 259
social network (i.e., family) education, in con- fect diabetes are discussed, as well as nutrient
junction with patient education. status affected by diabetes medications.
Spirituality Vitamins
Prayer and religious practice, a corner- Vitamins are vital for life, and, ideally,
stone of illness treatment for millennia, have should be maintained in adequate levels in the
been largely disregarded in modern medi- foods we eat. With over-farming and genetic
cal practice. Recently, however, spirituality modification of foods, the vitamin and mineral
has been receiving attention as an adjunct to content today may not supply the nutrients of
health care, particularly in the area of im- the foods past, or even meet what is necessary
mune function. In diabetics, C-reactive pro- for optimal health. Add in fast foods, conve-
tein (CRP—an acute inflammatory marker) nience foods, and high fat and sugar choices
levels are known to be higher than in nondi- (some very cleverly disguised), and the abil-
abetics. CRP has been tied to cardiovascular ity to meet nutritional requirements becomes
disease, a common sequelae of diabetes. questionable.
A recent cross-sectional survey of 556 A large longitudinal study found that
diabetics examined attendance at religious adults who used vitamin supplements were
services and CRP levels. Those who did not 24% less likely to develop diabetes than those
regularly attend religious service were more who did not. The protective effect of vitamins
likely to have elevated CRP than those who at- remained when adjusted for age, race or eth-
tended religious services. After adjusting for nicity, education, cigarette smoking, systolic
demographic variables, health status, smok- blood pressure, use of antihypertensive med-
ing, social support, mobility, and BMI, the ication, serum cholesterol, body mass index,
association between religious attendance and exercise, alcohol consumption, fruit and veg-
CRP remained significant for respondents etable intake, percent calories from fat, and
with diabetes (King et al., 2002). total energy intake (Ford, 2001). Clearly, vi-
tamins are an important part of health main-
tenance.
Conclusions
The psycho-social-emotional factors in Vitamin B3 (Niacin, Niacinamide,

diabetes can and should be addressed in car- Nicotinamide)
ing for the individual. While maintenance of Niacin plays an important role in fat,
glycemic control is the ultimate goal, the well- cholesterol, and carbohydrate metabolism. It
being and quality of life of the patient must is an essential component of the glucose-
be addressed as well. tolerance factor, giving it a key role in hypo-
glycemia and diabetes (Murray and Pizzorno,
1999). Niacin has been shown to be deficient
NUTRITIONAL SUPPLEMENTS in people with diabetes.
Niacinamide, a water-soluble amide of
Several nutritional components have an nicotinic acid, has been used successfully to
effect on insulin resistance and diabetic con- prevent or delay the onset of type 1 dia-
trol. Further, diet, along with medications, betes, lowering the incidence from 15–20 per
may affect micronutrient status in diabetic 100,000/year to 8 per 100,000/year. Treat-
populations, leading to complications in their ment with high-dose niacinamide appears to
glucose control and in general health. Com- delay rather than completely reverse disease
mon vitamins, minerals, and nutrients that af- development in those with preexisting type
1 diabetes. However, treatment of ‘at risk’ Vitamin C (Ascorbic Acid)

groups, in the majority of studies, shows
promise in disease prevention (Anonymous, Because the transport of vitamin C into
2002b). cells is facilitated by insulin, it is often de-
Lipid profiles in people with diabetes ficient in people with diabetes (Murray and
have been improved with niacin supplementa- Pizzorno, 1999). High doses of vitamin C
tion. Niacin has been shown to increase HDL, have been found to inhibit aldose reductase,
decrease triglycerides, and decrease LDL in inhibiting the conversion of d-glucose to d-
patients with or without diabetes (Elam et al., sorbitol, then to fructose. Left unchecked, sor-
2000). HbA1c levels remained unchanged in bitol and fructose accumulate in cells, causing
this study, however, another study found ex- damage to glucose insensitive tissues: the eye
tended release niacin improved both HbA1c lens, renal glomeruli, and peripheral nerves
and lipid profile in diabetics (Pan et al., 2002). (Head, 1997), exacerbating many of the com-
Self-medication of high-dose niacin mon complications of diabetes.
should be discouraged. Flushing, stomach ir-
ritation, and hepatic damage may occur with Vitamin E
high doses (Murray and Pizzorno, 1999). In
normal individuals, niacin has been known Vitamin E appears to play a signifi-
to cause insulin resistance (Head, 1997). Be- cant role in preventing diabetes. In a 4-year
cause of the capacity to disrupt blood sugar prospective study, a low plasma vitamin E
control, diabetics taking any form of niacin was associated with a 3.9-fold increase in
must monitor their glucose closely (Murray risk of diabetes. A 1 μmol/l decrement in
and Pizzorno, 1999). serum vitamin E corresponded with a 22%
increment in diabetes risk. Supplementation
of vitamin E not only improves the action
Vitamin B6 (Pyroxidine), B12 (Cobalamin),
of insulin, but also has a number of benefi-
and Folic Acid (Folate)
cial effects that may prevent long-term com-
Vitamins B6 and B12 have been shown plications of diabetes (Murray and Pizzorno,
to be deficient in people with diabetes, es- 1999).
pecially those with diabetic neuropathy. Fur-
ther, B12 absorption is reduced by metformin. Minerals
B6 prevents the glycosylation of proteins, and
may be a safe treatment for gestational dia- Like vitamins, minerals are essential to
betes (Murray and Pizzorno, 1999). Studies life, and theoretically should be available from
have shown that folate, B6 , and B12 reduce foods. Since most multivitamins also contain
homocysteine levels in diabetics (Aarsand and minerals, it may be presumed that the decrease
Carlsen, 1998; Chait et al., 1999). in diabetic incidence and complications seen
with vitamin supplementation may include
Biotin minerals as well. Several specific minerals,
however, bear further mention.
Biotin supplementation has been shown
to enhance insulin sensitivity and increase Chromium
the activity of glucokinase. Biotin signifi-
cantly lowers fasting blood sugar and im- Trivalent chromium (Cr3) is a key con-
proves glucose control in both type 1 and type stituent of glucose-tolerance factor, and defi-
2 diabetes. Insulin requirements must be mon- ciency has been linked to decreased glucose
itored with high-dose biotin supplementation tolerance, increased serum insulin levels,
(Murray and Pizzorno, 1999). and decreased number of insulin receptors
(Lamson and Plaza, 2002b). There is evi- of insulin resistance (Yeh et al., Eisenberg,
dence that marginal chromium deficiency is Kaptchuk, and Phillips, 2003), and supple-
common in the United States (Murray and mentation may prevent some of the compli-
Pizzorno, 1999). cations of diabetes such as retinopathy and
Chromium is a part of a glucose/insulin heart disease (Murray and Pizzorno, 1999).
system that maintains homeostatic control of Magnesium levels are related to insulin
blood glucose. Cr3 has also been shown to resistance in type 1 and type 2 diabetes, as
have a positive influence on individuals with well as nondiabetics. Between 25% and 48%
no diabetic symptoms. Serum chromium lev- of type 2 diabetics have been shown to have
els in healthy individuals were found to be in- low magnesium levels (Patrick, 2002).
versely related to insulin peaks in response to The research on magnesium supplemen-
a glucose challenge. In people with diabetes, tation and glycemic control is mixed. Two tri-
however, levels did not fluctuate with respect als showed a decrease in fasting plasma glu-
to insulin (Lamson and Plaza, 2002b). cose and an increase in postprandial insulin.
Chromium deficiency has been associ- Three other trials did not show a change in
ated with hyperglycemia in test animals as blood glucose or HbA1c level (Yeh et al.,
well as humans, and is reversible by sup- 2003). However, magnesium deficiency in
plementation. It is effective in treating vari- people with diabetes is not under dispute.
ous types of diabetes, including type 1 and 2, Given that magnesium toxicity is rare (Pelton
gestational, and steroid-induced. Treatment of et al., 2001), it would seem wise to consider
type 2 diabetes with Cr3 has led to improve- supplementation. Caution should be used, as
ment in blood glucose, insulin, and HbA1c high doses may cause diarrhea.
levels in a dose-dependent manner. Higher
Cr3 doses also resulted in a decrease in choles- Potassium
terol levels (Lamson and Plaza, 2002b).
While many studies show positive effects A high potassium diet has several pos-
with chromium supplementation, the results itive results for diabetes control: it yields
are mixed. Further, some concern exists re- improved insulin sensitivity, responsiveness,
garding high doses and renal dysfunction, in- and secretion; it replaces potassium lost by
cluding decreased thirst, fatigue, and urinary exogenous insulin administration; and it re-
frequency. Other studies did not replicate this duces the risk of heart disease, atherosclero-
finding at the same dose; no changes in resis, and cancer (Murray and Pizzorno, 1999).
nal or hepatic function were found by labora- A potassium-depleted diet was found to lead
tory testing (Lamson and Plaza, 2002b). The to insulin resistance at postreceptor sites,
Drug-Induced Nutrient Depletion Handbook reversible when potassium was resupplied
(Pelton et al., 2001) states that side effects and (Kelly, 2000).
toxicity with chromium supplementation are Diet is the preferred method of increas-
virtually nonexistent in humans. ing potassium intake, as supplementation with
Diets high in simple sugars increase uri- potassium salts can cause nausea, vomiting,
nary excretion of chromium, but show no diarrhea, and ulcers (Murray and Pizzorno,
change in absorption rates. Antacids have 1999). Further, kidney disease can result from
been found to decrease absorption (Lamson potassium toxicity in people with diabetes, so
and Plaza, 2002b). supplementation other than dietary should be
used with care.
Magnesium Vanadium (Vanadyl Sulfate)
Hypomagnesemia is common in dia- Vanadium is a trace mineral believed

betes. Deficiency can potentially cause states to regulate fasting blood sugar and improve
sensitivity to insulin (Kelly, 2000). It is to be particularly relevant to diabetes, beyond

thought to be insulin-mimetic, and upregulate their cardiovascular protective effects.
insulin receptors (Yeh et al., 2003). Diabetes, both human and experimental,
In three small studies, vanadium has has been associated with disturbances in EFA
been shown to decrease fasting blood sugar metabolism; in particular, the conversion of
in people with diabetes; two of these also linoleic acid to GLA is inhibited. Linoleic acid
reported improvement in HbA1c and insulin shares functional similarities to potent insulin
sensitivity (Yeh et al., 2003). Beneficial ef- sensitizers, and has been shown to normal-
fects remained after cessation of active treat- ize impaired glucose tolerance and improved
ment. No change in insulin sensitivity was hyperinsulinemia in animal studies (House-
found with supplementation in obese nondia- knecht et al., 1998). Gamma linoleic acid,
betics (Kelly, 2000). however, is an important component of dia-
Gastrointestinal discomfort was reported betic complications, particularly neuropathy.
by many subjects, however, organically In a large multicenter trial, GLA supplemen-
chelated vanadium compounds cause less ir- tation was provided in the form of evening
ritation than vanadium salts (Yeh et al., 2003). primrose oil to patients with diabetic neuropa-
thy. Following 1 year of treatment, all symp-
Zinc toms of neuropathy improved (Head, 1997).
Sources of GLA include evening primrose oil,
Zinc is involved with the synthesis, se- borage oil, and black currant oil (Murray and
cretion, and utilization of insulin. It also exerts Pizzorno, 1999).
a protective effect against beta-cell destruc- Fish oils are an important source of
tion. People with diabetes are prone to insulin long-chain n-3 fatty acids, EPA, and DHA.
depletion due to excess excretion, and zinc The ability of fish oil to enhance the rate of
supplementation has been shown to improve glycogen storage allows skeletal muscle to
insulin levels in both type 1 and type 2 dia- increase its uptake of glucose, even under con-
betes (Murray and Pizzorno, 1999). ditions where fatty acid oxidation is acceler-
ated. Fish oil enhances insulin secretion by in-
Nutrients
corporation of n-3 fatty acids into the plasma
There are several nutritional components membrane. This reduces the concentration of
beyond vitamins and minerals that either have amino acids in the plasma membrane, de-
an affect, or are affected by diabetes. Further, creasing the production of prostaglandin 2
oral hypoglycemics and insulin may deplete (PGE2) which, in turn, suppresses the pro-
some of these essential nutrients, warranting duction of cAMP, a well-known enhancer
supplementation. of glucose-induced insulin secretion. Con-
sequently, fish oil enhances insulin secre-
Essential Fatty Acids tion from beta cells, regulating blood sugar
(Anonymous, 2000).
Essential fatty acids (EFA), including Fish oils have biological properties of
omega-3 (n-3), omega-6 gamma linoleic acid potential relevance for the prevention of type
(GLA), eicosapentaenoic acid (EPA), and do- 1 diabetes. One large case control study found
cocsahexaenoic acid (DHA) have been stud- that cod liver oil, given in the first year of life,
ied extensively for their beneficial effects on was associated with significantly lower risk of
cholesterol, triglycerides, blood pressure and type 1 diabetes (Stene et al., 2003).
cardiovascular disease, autoimmune disease, In type 2 diabetes, studies have shown
and inflammation (Murray and Pizzorno, mixed results. One study examined estab-
1999). Several compounds have been shown lished type 2 diabetics, providing a diabetic
diet along with EPA and DHA supplements, or ness in insulin resistance, when delivered both
diet alone. Essential fatty acids supplementa- parenterally and orally (Kelly, 2000).
tion resulted in significantly greater improve- Insulin sensitivity and glucose effective-
ment in glycemic status, blood pressure, and ness following oral glucose-tolerance test was
lipid profiles, as well as reduction in mea- performed on lean and obese people with type
sures of oxidative stress (Jain et al., 2002). 2 diabetes. Alpha lipoic acid treatment was
In other studies, supplementation with fish associated with increased glucose effective-
oils resulted in no change in either fasting ness in both lean and obese groups, while
serum insulin levels or insulin sensitivity, and higher insulin sensitivity and lower fasting
one study found an increase in fasting blood glucose were significantly changed in lean
glucose following fish oil intervention (Kelly, subjects only (Konrad et al., 1999). In another
2000). However, given the proven vascular study, blood glucose levels following ALA
benefits of EFAs, with careful monitoring sup- supplementation were not changed, however
plementation may be indicated. changes in coagulation factors and marked
Medium chain triglycerides (MCTs) are lipid lowering were seen (Ford et al., 2001).
a component of many foods, with coconut A dosage study of ALA showed a mean
and palm oils being the dietary sources with increase of 27% in insulin-stimulated glucose
the highest concentrations. In an inpatient set- disposal in treated subjects, with no signifi-
ting, an experimental diet containing 78% of cant differences between dosage levels. A rel-
fat calories as MCTs (31% of total energy atively low dose, therefore, is sufficient to pro-
intake) increased glucose metabolism in pa- duce effects (Kelly, 2000).
tients with type 2 diabetes. In five outpatients
with type 2 diabetes, an experimental diet con- Coenzyme Q10 (Ubiquinone)
taining 18% of calories from MCTs led to a
slight reduction in postprandial blood sugar Coenzyme Q10 (CoQ10 ) is a cofactor in
and no effect on fasting blood sugar. While the mitochondrial electron transport chain.
promising, the role of MCTs in the man- Because an adequate supply of energy is es-
agement of diabetes remains to be decided sential for the health of virtually all human tis-
(Anonymous, 2002a). sues, CoQ10 is a vital nutrient (Gaby, 1996).
Blood lipid levels should be monitored Many recent studies have demonstrated the
when supplementing with EFAs. While the effectiveness of CoQ10 in maintaining cardio-
results are mixed, and several studies have vascular health.
shown improved lipid levels, but one study Several studies have explored the role of
found an increase in cholesterol when supple- CoQ10 in diabetes. Administration of CoQ7
menting people with type 1 diabetes with n-3 (a nutritionally equivalent analog of CoQ10 )
fatty acids (Head, 1997). resulted in fasting blood sugar level declines
of at least 30% in 31% of the patients (Gaby,
Alpha Lipoic Acid (Thioctic Acid) 1996). A second study showed improvement
in pain and paresthesias in diabetic neuropa-
Alpha lipoic acid (ALA) is a naturally thy (Head, 1997). Several negative studies,
occurring thiol, synthesized in the liver. It is however, have indicated that beneficial effects
a potent antioxidant, a cofactor in many en- of CoQ10 administration may not be apparent
zymatic complexes, and may play a role in in the short term (Lamson and Plaza, 2002a).
glucose oxidation (Yeh et al., 2003). Alpha Many of the oral hypoglycemics and all
lipoic acid has been shown to improve in- of the lipid-lowering statins deplete CoQ10 .
sulin resistance in a number of animal models, Given its known beneficial cardiovascular
and experimental trials have indicated useful- effects, and emerging effects on glucose
TABLE 20.1. Oral Hypoglycemics, Exogenous Insulin, and Nutrient Depletion (Pelton
et al., 2001)
Hypoglycemic Nutrient
agent depleted Potential effects
Acarbose (Precose) Coenzyme Q10 Congestive heart failure, high blood pressure, angina,
Acetohexamide (Dymelor) mitral valve prolapse, stroke, cardiac arrhythmias,
Glimepride (Amaryl) cardiomyopathy, lack of energy, gingivitis, weakened
Glipizide (Glucotrol) immune system
Glyburide (Micronase)
Tolazamide (Tolinase)
Metformin (Glucophage) Folic acid ↑ Homocysteine, megaloblastic anemia, headache,
fatigue, hair loss, anorexia, insomnia, nausea, diarrhea,
↑ infections
B12 Fatigue, peripheral neuropathy, macrocytic anemia,
confusion, depression, memory loss, poor blood
clotting, dermatitis, anorexia, nausea, vomiting
Insulin K+ Cardiac arrhythmias, poor reflexes, weakness, fatigue,
thirst, edema, constipation, dizziness, mental
confusion, nervous disorders
control, supplementation in people with di- This section, like the nutritional sup-
abetes should be considered. plements, cannot be considered exhaustive.
The most rigorously studied herbs with the
Conclusion longest and most effective history of use are
discussed, with contraindications and interac-
This list of nutritional supplements is tions presented in tabular form. A table with
not meant to be exhaustive. Several other less well-studied, yet promising, treatments
substances, including beta carotene, calcium, follows.
manganese, l-carnitine, and glutathione, have
shown promise in the treatment of diabetes. Bitter Melon (Momordica charantia)
The standard medications for glycemic
control can and do influence nutritional status. Bitter melon is indigenous to tropical ar-
Table 20.1 presents the most commonly pre- eas in Asia, India, South America, and Africa.
scribed diabetes medications, their effect on It has been used widely in folk medicine as a
nutritional substances, and the potential con- treatment for diabetes (Murray and Pizzorno,
sequences. 1999). Theoretical mechanisms of action in-
clude increased insulin secretion, tissue glu-
Botanical Medicine cose uptake, liver muscle glycogen synthesis,
glucose oxidation, and decreased hepatic glu-
There are literally thousands of herbal coneogenesis (Yeh et al., 2003). The blood
compounds available and beneficial for vari- sugar lowering capabilities have been clearly
ous health conditions. Most of the herbs de- established in clinical trials and experimental
scribed in this section have been used for models (Murray and Pizzorno, 1999).
centuries, and are just now beginning to be Charantin, an active component of bitter
considered in mainstream medicine as options melon, is a more potent hypoglycemic agent
for diabetic control. As testing of botanicals than tolbutamide, a first generation sulfony-
increase, more use of the ancient treatments lurea. It also contains an insulin-like polypep-
may be seen. tide, structurally and pharmacologically
comparable to bovine insulin, which low- ate improvement in glycemic control, but only
ers blood sugar levels with fewer side ef- had a significant effect on triglycerides (10%),
fects than exogenous insulin injections (Head, and peroxides (15% plasma, 19% urine). Nei-
1997; Murray and Pizzorno, 1999). ther treatment affected HbA1c levels (Andallu
Positive effects have been shown using et al., 2001).
bitter melon. One study showed 73% of peo- No side effects or contraindications are
ple with type 2 diabetes had improved glu- known with bilberry fruit. High doses and pro-
cose tolerance with bitter melon juice. An- longed use of the leaves, however, may lead to
other small study showed a 54% decrease in chronic intoxication. This manifested in ani-
postprandial blood sugar and a 17% reduction mals as cachexia, anemia, icterus, and excita-
in glycosylated hemoglobin with an aqueous tion. Extremely high doses (1.5 g/kg per day)
extract (Dey et al., 2002). No adverse effects of the leaves over long periods could result in
have been reported in human studies (Yeh death (Blumenthal, 1998).
et al., 2003).
Bitter melon may have additive ef- Fenugreek (Trigonella foenum-graecum)
fects when taken with other glucose-lowering
agents (Basch et al., 2003a). While capsules Fenugreek is one of the oldest medici-
are available, the juice or extract form has nal plants. Proposed mechanisms of action in-
been used in most studies. However, as the clude delay of gastric emptying, slowing car-
name implies, the juice is extremely bitter and bohydrate absorption, inhibition of glucose
may be difficult to make palatable (Murray transport, increased erythrocyte insulin recep-
and Pizzorno, 1999). tors, and modulation of peripheral glucose uti-
lization (Yeh et al., 2003). In animal and sev-
Bilberry (Vaccinium myrtillus) eral small human trials, fenugreek seeds have
been found to lower fasting serum glucose lev-
Leaves of the bilberry plant were widely els, both acutely and chronically (Basch et al.,
used for diabetic treatment before the avail- 2003b).
ability of insulin. In addition, the berries, In people with type 1 diabetes, ingestion
containing anthocyanidins, have beneficial ef- of defatted fenugreek seed resulted in sig-
fects on microvascular abnormalities com- nificant improvement in fasting blood sugar
mon in diabetes (Dey et al., 2002). levels and glucose tolerance, as well as a
Bilberry has been shown to lower plasma 54% reduction in 24-hour urinary glucose ex-
glucose and triglycerides in animals. In hu- cretion, and reductions in LDL, VLDL, and
mans, it has been shown to improve retinopa- triglycerides (Murray and Pizzorno, 1999), in-
thy and normalization of collagen deposition dicating that fenugreek may aid with insulin
(Head, 1997). Interestingly, a recent study secretion (Basch et al., 2003b).
of mulberry (Morus indica L.), another rich Several small clinical trials have been
source of anthocyanidins, compared it to conducted in type 2 diabetics. In one study,
the standard antidiabetic medication gliben- fenugreek-treated patients showed statisti-
clamide. Patients with mulberry therapy sig- cally significant mean improvements for
nificantly improved their glycemic control glucose-tolerance test scores and serum-
over those on glibenclamide treatment. Mul- clearance rates of glucose (Basch et al.,
berry also significantly decreased serum to- 2003b). In a series of two crossover studies,
tal cholesterol (12%), triglycerides (16%), significant mean improvements were seen in
plasma free fatty acids (12%), LDL (23%), the fasting blood glucose levels and glucose-
VLDL (17%), plasma peroxides (25%), and tolerance test results in the fenugreek-treated
urinary peroxides (55%), while increasing patients, even though the dose of their stan-
HDL by 18%. Glibenclamide showed moder- dard antidiabetic medication (glibenclamide,
glipizide, or metformin) was reduced by 20% As well as potential hypoglycemic ef-

prior to the study period. The fenugreek pa- fects, garlic and onions have cardiovascular
tients also reported subjective improvements and immune enhancing qualities (Murray and
in polydipsia and polyuria (Basch et al., Pizzorno, 1999), and are generally well tol-
2003b). In a study of newly diagnosed peo- erated. The use of these herbs in diabetes is
ple with type 2 diabetes, however, the benefit valuable. Care is indicated with patients on
of fenugreek seeds was not seen to be signifi- anticoagulants.
cantly different than diet and exercise (Basch
et al., 2003b). Ginseng Species (Panax ginseng and Panax
In their review of clinical trials, Yeh and quinquefolius)
colleagues found that whole raw seeds, ex-
tracted seed powder, gum isolate of seeds, Ginseng root has been used for over
and cooked whole seeds seemed to decrease 2,000 years for health promotion. Of the gin-
postprandial glucose levels, while degummed seng species, American ginseng (P. quinque-
seeds and cooked leaves did not (Yeh et al., folius) and Asian ginseng (P. ginseng) are
2003). the most commonly used (Dey et al., 2002).
No adverse effects have been reported in Reported mechanisms of action include de-
clinical trials of fenugreek (Yeh et al., 2003), creased rate of carbohydrate absorption into
but interactions are possible due to decreased the portal hepatic circulation, increased glu-
intestinal absorption. Hypoglycemic symp- cose transport, and uptake mediated by nitric
toms are to be expected, and should be moni- oxide, increased glycogen storage, and mod-
tored (Basch et al., 2003b). ulation of insulin secretion (Yeh et al., 2003).
There are several clinical trials that pro-
Garlic and Onion (Allium sativa and Allium vide evidence for the hypoglycemic effects
cepa) of ginseng. One study demonstrated a reduc-
tion in the levels of fasting blood glucose and
Onions and garlic have demonstrated HbA1c in type 2 diabetes when ginseng was
blood sugar lowering action in several stud- taken before meals. The subjects also showed
ies. The active constituents are believed to be mood elevation, improved psychophysiologi-
the sulfur containing compounds allyl propyl cal performance and physical activity, and re-
disulfide (APDS) and diallyl disulfide ox- duced body weight (Dey et al., 2002).
ide (allicin) (Murray and Pizzorno, 1999). In a second group of studies on gin-
APDS may lower glucose levels by com- seng and people with type 2 diabetes, ground
peting with insulin for inactivating sites in American ginseng root in capsules of vary-
the liver, resulting in an increase of free in- ing dosage were administered prior to an oral
sulin (Dey et al., 2002; Murray and Pizzorno, glucose challenge. Ginseng significantly af-
1999). fected postprandial glycemia, with significant
In clinical trial, onion extracts reduced interaction for area under the curve. Com-
blood sugar levels in a dose dependent man- pared with placebo, all ginseng doses reduced
ner (Murray and Pizzorno, 1999). A second glycemia, without significant effect as to time
small study showed acute decrease in fasting of administration (Vuksan et al., 2000b). In
blood glucose and increase in insulin, show- a second similar study, people without dia-
ing an insulin-mediating effect in nondiabet- betes were compared to those with type 2 dia-
ics (Yeh et al., 2003). Also in nondiabetics, betes. In nondiabetics, significant reductions
using garlic was shown to decrease fasting in postprandial glucose were found only when
serum glucose. Studies in diabetics, however, the ginseng was taken 40 minutes prior to the
have been mixed (Yeh et al., 2003). challenge. In people with diabetes, however,
reductions in glucose were seen regardless of hypoglycemic medication dose considerably,

when ginseng was taken, either at challenge and five were able to discontinue medication
or before (Vuksan et al., 2000a). altogether and maintain glycemic control with
Adverse effects for ginseng have been gymnema alone (Dey et al., 2002).
reported, and include nervousness and excita- Gymnema extract given to healthy vol-
tion. These generally diminish with increased unteers does not produce any blood sugar low-
use or dosage reduction. Ginseng may in- ering or hypoglycemic effects. No side effects
hibit the effects of warfarin, and interact with have been noted (Murray and Pizzorno, 1999).
the monoamine oxidase inhibitor phenelzine.
Massive doses of ginseng may result in “gin- Soy (Phytoestrogens)
seng abuse syndrome,” characterized by hy-
pertension, insomnia, hypertonia, and edema Phytoestrogens in general, and soy in
(Dey et al., 2002). particular, have been receiving increased at-
tention of late due to substantial data that con-
Gymnema (Gymnema sylvestre, Gumar) sumption of plant-based phytoestrogens have
a beneficial impact on health. In diabetes, soy
Gymnema, an Ayurvedic herb, has been is thought to be beneficial both for glycemic
used for centuries as a treatment for diabetes. control and for obesity, although the mecha-
Gumar, the Hindi name, literally means “de- nism of action remains unclear (Bhathena and
stroyer of sugar.” Mechanism of action is un- Velasquez, 2002).
known, but postulations include an increase In a recent study of postmenopausal
in glucose uptake and utilization, increase in women with diet-controlled type 2 diabetes,
insulin release through cell permeability, in- phytoestrogen supplementation resulted in
crease in beta-cell number, and stimulation of significantly lower mean values for fasting in-
beta-cell function (Yeh et al., 2003). sulin, insulin resistance, HbA1c, total choles-
Chewing gymnema blocks the sensation terol, LDL, cholesterol/HDL ratio, and free
of sweetness. Individuals who had gymnema thyroxine. These results show that dietary sup-
extracts applied to their tongues prior to meals plementation with soy phytoestrogens favor-
ate fewer calories compared to controls. This ably alter insulin resistance, glycemic con-
has not been shown with ingestion of capsules trol, and serum lipoproteins (Jayagopal et al.,
or tablets, however (Murray and Pizzorno, 2002). A study examining a soybean-derived
1999). Touchi extract was tested against placebo in
In people with type 1 diabetes, sup- people with borderline type 2 diabetes. Ini-
plementation with gymnema resulted in in- tial fasting glucose and HbA1c gradually de-
sulin requirements being decreased by one creased, reaching statistical significance after
half, and reduced average blood glucose lev- 3 months. There were no complaints of side
els. HbA1c levels were reduced, but still effects or abdominal distention (Fujita et al.,
remained higher than normal. Cholesterol 2001).
and triglycerides were lowered significantly A review of the literature on soy and
(Head, 1997). Gymnema appears to enhance diabetes revealed that soy protein, along
the action of insulin in type 1 diabetes (Murray with soy fiber, decreased LDL, VLDL, to-
and Pizzorno, 1999). tal cholesterol, and triglycerides; decreased
In a study of 22 people with type postprandial hyperglycemia with no effect
2 diabetes, gymnema taken along with their on serum insulin; and improved glucose
oral hypoglycemic drugs improved glucose tolerance and glycated hemoglobin (Bhathena
control in all 22 participants. Further, 21 and Velasquez, 2002). While the number of
of the 22 were able to reduce their oral studies is small, the results are promising.
TABLE 20.2. Interactions and Contraindications of Selected Herbs (Brinker, 2001)

Herb Contraindications Interactions
Bitter melon (Momordica Pregnancy Insulin, chlorpropamide

charantia)
Bilberry (Vaccinium None known Warfarin and antiplatelet drugs
myrtillus)
Fenugreek (Trigonella Pregnancy Insulin, cholesterol lowering drugs, may retard
foenum-graecum) absorption of oral drugs, may interfere with
warfarin
Garlic and onion (Allium Stomach inflammation, Insulin, warfarin, indomethacin, dypiridamole,
sativa and Allium cepa) pregnancy, low anticoagulants, may be protective against
thyroid, presurgery, acetaminophen and isoprenaline toxicity
acid reflux
Ginseng species (Panax Hypertension, acute Insulin, warfarin, caffeine, phenelzine, lithium,
ginseng and asthma, acute amitriptyline, potentiates amoxicillin and
P. quinquefolius) infection, excessive clavulanic acid, morphine,
menstruation, methamphetamine
nosebleeds
Gymnema (Gymnema None known Insulin, enhances glybenclamide and
sylvestre, Gumar) tolbutamide
Soy (Phytoestrogens) Nontoxic goiter Thyroxine in infants, estrogen replacement
therapy
Drug–Herb Interactions Conclusions
While generally well tolerated, many It should be emphasized that while some
botanical substances react with other medi- of the most common modalities of CAM are
cations. Table 20.2 presents the contraindi- presented, Naturopathic medicine, similar to
cations and interactions of the botanicals Native American, Ayurvedic, or Chinese med-
discussed. ical systems, does not operate solely by treat-
ing the disease. Instead, the emphasis is on
Less Well-Studied Beneficial Herbs treating the whole person. An individual with
diabetes, for example, would likely receive
Table 20.3 provides botanical species some of the treatments outlined in this chap-
that are not as well studied for their effects ter. However, treatment would be individu-
on diabetes, but have shown potential in at alized to that particular person, and other
least one study. modalities such as homeopathy, counseling,
acupuncture, bodywork (manipulation, hy-
Conclusion drotherapy), and/or energy work (Reiki or
another healing touch therapy) would be
A plethora of botanical substances exist applied as well. It is precisely this indi-
that affect diabetes. Many of the lesser known vidualization of treatment that make CAM
herbs presented are from the Ayurvedic or medical systems so difficult to study in the
Chinese medical systems, and have been used reductionistic paradigm that guides current
successfully in other countries with good medical thinking. With time and understand-
results, but without the benefit of the rigorous ing, however, medical systems rather than
scientific study required in the United States. single treatments are beginning to be exam-
As the world becomes smaller, more of these ined; it is hoped that this will continue in the
traditional medicines may become available. future.
TABLE 20.3. Less Well-Studied Botanicals that May Benefit Diabetes

Herb Effects Reference
Aloe vera ↓ FBS and triglycerides in type 2 with or without Dey et al. (2002) and
standard anti-diabetic agents; hypoglycemic effects Yeh et al. (2003)
in type 2 and animal models; decreased FBS and
HbA1c in type 2
Salt bush (Atriplex Improved blood glucose regulation and glucose Murray and Pizzorno
halimu) tolerance in type 2; prevents diabetes in sand rats (1999)
Konjac (Amophophallus Reduced plasma cholesterol, LDL, total: LDL ratio, Chen et al. (2003)
Konjac C. koch) fasting glucose in type 2 on oral hypoglycemics
Cinnamon Decrease serum glucose, triglycerides, cholesterol, Khan et al. (2003)
(Cinnamomum cassia) LDL in type 2
Ivy gourd (Coccinia Change in glycemic control better than conventional Head (1997) and Yeh
indica) drug in type 2; blood glucose lowering in animals et al. (2003)
Horsetail (Equisetum Decreased blood glucose, no change in insulin Revilla et al. (2002)
myriochaetum) following OGTT in type 2
Fig leaf (Ficus carica) Decrease in postprandial glucose and insulin Yeh et al. (2003)
requirement in type 1; short- and long-term
hypoglycemic effects in animals
Ginkgo biloba Improves blood flow, thereby ↓ sequelae of diabetes Murray and Pizzorno
(1999)
Holy basil (Ocimum Positive effects on fasting and postprandial glucose in Yeh et al. (2003)
sanctum) type 2; hypoglycemic effects in animal models
Nopal (Opuntia Decreased fasting glucose and insulin levels in type 2; Yeh et al. (2003)
streptacantha) decrease postprandial glucose and HbA1c with
synergistic effects with insulin in animal models
Oolong tea Decreased concentration of plasma glucose and Hosoda et al. (2003)
fructosamine in type 2 or hypoglycemics
Psyllium (Plantago ↓ Total cholesterol, ↓ LDL, ↓ postprandial glucose Anonymous (2002c)
ovata) rise
Pterocarpus marsupium Prevents beta-cell damage in rats; regenerates Murray and Pizzorno
functional pancreatic bets-cells in animals (1999)
Milk thistle (Silibum Improved glycemic control in cirrhotic type 2 patients Yeh et al. (2003)
marianum)
Zygophyllum gaetulum Short- and long-term reduction in blood glucose, Jaouhari et al. (1999)
normoglycemia without change in body weight in
type 2
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21
Leading Edge Technologies Related

to Diabetes Care
Vicki B. Gaubeca1 and Donna Zazworsky2
1 Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
2 Carondolet Health Network; St. Elizabeth of Hungary Clinic, Tucson, Arizona; and Managing Partner,
Case Manager Solutions, LLC, Tucson, Arizona
This chapter will discuss two aspects that are the most technical not only offer the
of leading technologies for diabetes self- most information and data to the patient, but
management: (1) patient self-management are also more complicated to learn and use.
information systems, and (2) the use of tele-
health networks to provide health promotion
Glucometers
information to people with diabetes.
Glucometers are standard protocol for
anyone who has been diagnosed with dia-
PATIENT SELF-MANAGEMENT betes, whether it is type 1 or type 2. Glucome-
INFORMATION SYSTEMS ters vary immensely in size and in features.
Some glucometers only offer a reading of the
People with either type 1 or type 2 di- person’s blood sugar level, date and time of
abetes need to manage at least three princi- day; while others can program events (such as
pal components of their daily life to achieve stress), carbohydrates eaten, insulin boluses
optimum diabetes self-management: (1) diet, or medications taken, and exercise.
(2) exercise, and (3) medications. Often there In addition, the more advanced glucome-
are other components in play, such as address- ters offer graphs illustrating trends and aver-
ing how to get enough sleep, reduce stress, or ages of all results, by meals, by time of day, by
carve enough time in their lives for spiritual exercise, and so forth. With some glucometers
or leisure activities. you can also program weight, height, HbA1c
There are a sundry of tools available levels, blood pressure, etc.
in stores, bookstores, pharmacies, and on Each individual with diabetes will have
the Internet that can help patients with dia- to determine how much control they want to
betes manage their disease and facilitate bet- have on their diabetes and select the tools they
ter blood glucose control. In general, the tools can use for self-management. If they consider
273
274 LEADING EDGE TECHNOLOGIES
themselves technically literate, they will prob- calculate a bolus based on amount of carbohydrates
ably select a glucometer that will give them eaten.
r Ability to send information (glucose
as much information as possible as well as
one with the most number of programmable readings, especially) to a personal digital assistant
features. (PDA) via IR, radio frequency (RF), or cable.
Most glucometers (including LifeScan’s
OneTouch r
and Boehringer’s AccuChek r
Personal Digital Assistants
glucometers) offer free software that can be
downloaded from their web sites. However, In addition to self-management software
the patient will have to purchase a cable available for PCs and Apple computers, there
to download the information from the glu- are hundreds of software available for PDAs.
cometer to their home computer. These cables The biggest advantage of using a PDA is that
are available for purchase on the glucometer it is more portable than a desktop computer or
maker’s respective web sites. The software al- laptop.
lows patients to create reports and charts to an- A handy database to have on a PDA
alyze trends in blood glucose levels and their is one with nutritional information, such as
relation to diet, exercise, and sometimes, other BalanceLogTM , which allows individuals to
events such as stress. look up different foods and automatically in-
The individuals with diabetes can then puts calories, carbohydrates, fats, protein, vi-
share this information with their health care tamins, calcium, iron, fiber, cholesterol, etc.
professional to help tweak their treatment pro- This database even includes information for
tocol. They also can print a report and provide fast food restaurants. In addition, this soft-
a copy of this to their physician for their charts. ware allows individuals to add new foods and
Some physicians and health care profession- allows them to track target weight, exercise
als offer the cable and software on their office levels, meals, and snacks. It is a handy tool
computers, so during a health visit, the pa- for someone who wants to lose weight and
tient can download it there and save money start an exercise program. DiabetesPilotTM
on purchasing the cables. and GlucoPilotTM can also be used to track
Areas of improvement for glucometers nutritional and exercise inputs as well as med-
include: ications taken.
A quick search on the Internet will
r Less painful finger-sticks. Many people reveal more software for PDAs designed
with diabetes will lessen the number of times they to track blood glucose levels in relation
test their blood glucose levels because of the pain to exercise, medication, and diet. (A good
caused by finger-needle sticks. Some glucometers source for this information is the web site
have improved on this by allowing a person to draw www.diabetesnet.com.) Many of these soft-
blood from a needle prick on the forearm or by ware programs also will allow individuals
requiring less blood for testing. However, there is to transfer information from the PDA to a
still room for improvement. In addition, some com- PC/Macintosh version (via a quick synchro-
panies have experimented with infrared (IR) glu- nization process).
cometers with limited success. An area for improvement of PDA soft-
r A foods database that offers nutritional
ware is that there is yet a software program
information, including carbohydrate breakdown,
calories, portion size, etc. The most advanced glu-
that combines both diabetes self-management
cometers offer a place where a patient can manually information with a food database. A great
input the number of carbohydrates, fats, calories, program for individuals with diabetes who
etc. Why not actually include this information in want to gain better control would include diet
the glucometer? This would be extremely helpful (with breakdown of nutritional information),
to the individual with type 1 diabetes who needs to exercise, medications taken, stress levels on a
LEADING EDGE TECHNOLOGIES 275
scale, hours of sleep, and blood glucose lev- meals and snacks were eaten, activity levels
els. Being able to create reports and graphs and time of day of activity, and medications
with these variables would offer comprehen- taken.
sive information and facilitate better glucose
control. Pedometers
In addition, there is no commercially
available software or cable that will allow a In addition to following a healthy diet
person to download their blood glucose lev- and maintaining a healthy weight, the U.S.
els from their glucometer into a PDA. This Department of Health and Human Services
means that you have to manually enter blood recommends that all individuals walk at least
glucose results into the PDA. For a short time, 10,000 steps a day (between 4 and 5 miles)
Handspring offered a glucometer expansion to be fit. Many people have taken this recom-
module for one of their PDAs. Once you in- mendation to heart and, as a result, pedome-
serted the module into the Handspring PDA, ters have become popular.
you could insert a FreestyleTM test strip. In this Pedometers come in a variety of sizes
way, the PDA would convert into a glucome- and colors, and range from basic models that
ter. However, after Handspring was purchased provide only a step count to advanced models
by PalmPilot in 2003, the newer PDAs do not that provide step counts, miles walked, and
have the same expansion slot. calories burned. The more advanced models
even offer FM/AM radios or GPS tracking.
Manual Charts With some pedometers, like the ones of-
fered by SportsbrainTM , you can download
For those individuals with diabetes, who the number of daily or weekly steps taken
do not feel technically literate or who cannot to a website (see www.sportbrain.com). The
afford to purchase a computer or PDA, there website provides at-a-glance reports of steps
is always the use of regular paper charts and taken, calories burned, average miles per hour
forms to monitor self-management. walked, cheeseburgers burned, etc. The site
One of the most comprehensive manual also offers graphs of walks of 10 minutes
charts (especially for people with type 1 dia- or longer and logs these as a “SportActivi-
betes) is My Other CheckBookTM (available ties,” providing time of day, calories burned,
at www.diabetesnet.com). Shaped similarly to miles per hour walked, etc. In addition, you
a regular banking checkbook, this chart of- can join one or more online walk clubs
fers a place to write meals eaten (breakfast, and compare your performance with other
lunch, dinner, and snacks), time eaten, car- members.
bohydrate content of meals and comments. A word of caution about pedometers:
Above this table, is a chart where one can they are not very accurate. An informal study
write insulin doses taken, blood glucose level of three pedometers worn on the same day
by time of day and activity levels by time of yielded the following results:
day and intensity (see Figure 21.1 for sample
chart). Pedometer A Pedometer B Pedometer C
Free rudimentary charts also can be
found on the Internet, especially at web sites Day 1 5,016 4,383 2,621
Day 2 2,007 2,811 2,002
of pharmaceuticals and manufacturers of glu-
Day 3 11,406 9,479 9,327
cometers. At the most basic level, manual
charts should have a place to write the date, Most pedometers over-report steps be-
blood glucose levels obtained throughout the cause they count jiggles, including some that
day, time of day of blood sugar test, foods (car- count steps when you are sitting in a car go-
bohydrates and calories) eaten, times of day ing over a bumpy road. Others are so sensitive
FIGURE 21.1. This comprehensive checkbook size charting system allows the user to see all the things that affect
the glucose on one page.
they add steps when you simply open them to the pedometer. A good way to do this is to
read the number of steps taken. Some manu- count 10 steps on a flat surface and then an-
facturers caution that steps will vary depend- other 10 going up a set of stairs.
ing on where on the belt a pedometer is placed. Despite their inaccuracy, using pedome-
An article written by a Wall Street Journal re- ters is still a fun way to keep track of walking.
porter noted that a 1–5% variance should be Purchasing pedometers for the whole family
expected of pedometers (Bernstein, 2004). and initiating a friendly competition can be
An individual can get a general feel for a fun and healthy activity. Most people who
the accuracy of steps taken by getting to know have diabetes can invite complications with
a sedentary lifestyle. Pedometers can help and using a heart rate monitor can do only the
individuals ease back into an active lifestyle. exercises that keeps the heart rate within this
range. If one notice that the heart rate is at
147, one can decide not to do the arms in a
Heart Rate Monitors
part of the exercise or to shorten their stride
Many people who lead sedentary to bring their heart rate down.
lifestyles and who have tried to return to an ac- If a one does not have a heart rate mon-
tive lifestyle have failed because they believed itor, one can find their pulse on their neck or
that to become fit you had to run yourself into wrist, count the number of heart beats in 10
the ground. The truth is that an individual does seconds (and multiply by six) or 15 seconds
not have to feel pain to become fit again. In (and multiply by four) to get the number of
fact, being out of breath when you exercise is heart beats per minute.
not a good practice. If a person cannot find their pulse or hates
For this reason, heart rate monitors can doing the math while working out, another
be extremely helpful for people while they simple trick is to count out loud to 15. If the
exercise. When one knows one’s maximum person takes two to three breaths while count-
heart rate and keeps the heart rate between ing, they should be working within their heart
70% and 85% of this rate while exercising, rate limits. If they have to take more than three
not only will exercise be more enjoyable, but breaths, they are probably working too hard. If
it also will maximize the calorie burn and fat they only take one breath or they can breathe
loss. “Chapter 9” of this book discusses in through their nose while exercising, they are
detail the benefits of exercise. not working hard enough.
The best way to figure out the upper and Individuals should always consult with a
lower limits for exercise is to take a cardio physician before starting an exercise routine.
stress test and to specifically request the physi-
cian to provide the best heart rate range for Emerging Technologies
fitness. A person also can come up with a
ballpark of where these numbers should be Most emerging technologies related to
by using the following formula: diabetes self-management are driven by the
needs of people with type 1 diabetes. How-
1. Maximum heart rate = 220 – your age ever, people with any kind of diabetes (type 1,
(e.g., if you are 45 years old: 220 − 45 = 175. type 2, or gestational) can derive benefits from
Hence your maximum heart rate is 175). these technologies.
2. Multiply maximum heart rate by 70% to
get the lower limit of your fitness zone (using the
example above: 175 × 0.70 = 122.5; round up to
Insulin Pumps
123 for lower limit).
Insulin pumps have been in various
3. Multiply maximum heart rate by 85% to
get the higher limit of your fitness zone (using the
stages of development since the 1950s, but
example above: 175 × 0.85 = 148.75; round up to have recently gained tremendous popularity
149 for upper limit). in people with type 1 diabetes. Pumps offer
a continuous stream of insulin to the wearer
For example, a person is 45 years old that takes care of the glucose that is naturally
(see example above), he or she will know that released into the blood stream by the liver.
will gain maximum benefit from exercise by This stream is called the basal rate and is pro-
keeping their heart rate between 123 and 149 grammed according to the physiological pro-
beats per minute. file of the individual wearing the pump. Each
Empowered with this knowledge, a per- patient figures out his or her own profile in
son can join an aerobics class, for example, the first few weeks of wearing the pump. In
addition, the pump user can self-administer a challenges. The first one is the GlucoWatch r
,
bolus of insulin to cover carbohydrates in a which is a watch-like device that has a trans-
meal or to bring down a blood sugar that is dermal sensor that tests blood sugar levels ev-
too high. For a more detailed explanation of ery 10 minutes. The device, which was devel-
insulin and delivery systems, see “Chapter 7, oped by Cygnus uses an electrical charge to
Medication Management.” bring glucose levels to the surface of the skin
The single most important advantage of where the sensor can measure it. It must be
using a pump is that it uses only fast-acting calibrated with a glucometer and takes about
insulin (typically Humalog r
, but sometimes 4 hours to warm up every day. However, one
r
Regular insulin), thereby minimizing the advantage of this device is that it alarms if
unpredictable hypoglycemic events caused by there has been a drop in blood glucose levels
long-acting insulins, such as NPH r
, Lente
r
, by 35% in the last hour or if it goes under a
r
and Ultralente . A disadvantage to insulin certain threshold.
pumps is that, on average, users tend to The other product is the Sleep Sentry r
gain weight, since the pump offers them the Monitor, which is another watch-like device.
freedom of eating anything they want as Unlike the GlucoWatch, however, which mea-
long as they cover the carbohydrates in the sures blood glucose levels, this device mea-
meal. sures two of the most common symptoms of
hypoglycemia: sweat and a drop in skin tem-
Continuous Glucose Monitoring Systems perature. Although this device provides many
false alarms, measuring changes of temper-
Because of its sometimes rapid onset ature when bringing an arm out from under
and potentially lethal implications, one of the the covers, for example, or measuring sweat
biggest concerns for a person with type 1 di- from other causes, it does provide some peace
abetes is hypoglycemia. Some people who of mind.
maintain tight control of their glucose levels For more information about either de-
or who have too many hypoglycemic events vice or other emerging technologies, visit
develop a condition known as hypoglycemia www.diabetesnet.com, a web site that is up-
unawareness. This condition can be danger- dated regularly.
ous because the telling symptoms of hypo-
glycemia (cold sweat, nervousness, pit in the
stomach, keen vision, irritability, etc.) are not TELEHEALTH
present. People who have hypoglycemia un-
awareness sometimes slip into unconscious- Tools that support individual self-
ness or a seizure without feeling any warning management are important, however, tools to
symptoms. To counter this condition, physi- support patients in the learning process of how
cians will tell some patients to back down to be self-managers must also be considered.
from tight blood glucose control (if this is One method of support is through face-to-face
what is causing it). However, this does not take visits with health care providers and educa-
care of the hypoglycemic events that happen tors. Another method of support is through
while sleeping or in the constantly variable telehealth avenues.
lives of children with type 1 diabetes. The Telehealth is the removal of time and dis-
health industry has been furiously at work tance barriers to deliver health care services
developing a continuing glucose monitoring or related activities (American Nurses As-
system, but has yet to bring one to the market sociation, 1997). The spectrum of telehealth
that is accurate and affordable. includes telephones, computers, interactive
Two products have been approved by the video transmissions, direct links to health
FDA, but both of them are still wrought with care instruments and transmission of images,
and teleconferencing by telephone or video diabetes, particularly for those who live in
(American Nurses Association [ANA], 1997). rural settings. For example, the Arizona Dia-
The term telemedicine refers to the delivery betes Virtual Center of Excellence (ADVICE)
of medical specialties using telehealth tech- is a comprehensive program for diabetes
nology, such as teleradiology, telepsychia- prevention, assessment, and management uti-
try, teleophthalmology, and telepathology. Te- lizing the Arizona Telemedicine Program
lenursing has been applied to nursing special- Network. Partially supported by the Office
ties, such as primary nurse practitioner care, for the Advancement of Telehealth (OAT),
home care for wound assessment and patient U.S. Department of Health and Human Ser-
monitoring, school nursing, psychiatric nurs- vices, Heath Resources and Services Admin-
ing, and case management. istration (HRSA), ADVICE offers a unique
In all of these telemedicine services, a delivery system for diabetes-related clinical
patient is presented to a provider at another services, professional and patient education,
location via a camera and their interaction is and research and community service. The
usually transmitted through a T1 line (a spe- program has been testing new methods of
cial line that consists of 24 single digital tele- education and counseling services to rural
phone lines to enhance the clarity of the trans- areas.
mission) or via satellite. The image is trans- However, two major features also be-
mitted in two ways: store and forward or real ing tested through the project are teledia-
time. betes classes and telenutrition counseling.
Store and forward is when the image The classes that are currently being taught
is taken, stored, and then transmitted (for- to a group at a local clinic are also tele-
warded) for viewing at a later time. This vised to a community setting in the rural
is common for teleradiolgy, teledermatology, community with the support of a commu-
and telepathology. In the use of diabetes care, nity health worker—referred to as an “e-
a nurse could take a picture of a leg ulcer with a Promotora.” This person has been trained to
digital camera and then e-mail the image to a set up the special telephone that is equipped
wound specialist. Other uses would include with a camera and video screen, which is
monitoring blood glucoses with a special ma- plugged into a regular phone jack. People with
chine that forwards the data to an endocrinol- diabetes in the rural community can gather
ogist, who can then make changes to medica- at a community location such as a church
tions if needed. This information can be put or school and be active participants in the
in a graph to watch trends. classes.
Real time is when the image is viewed Telenutrition counseling utilizes the
live where the provider does a face-to-face same configuration as the telediabetes classes
patient visit. This could occur as a special- but is done on a one-on-one format. Patients
ist visit, an educational visit, or a nutrition are referred by a rural provider and then seen
counseling visit. Depending on the type of by the nutritionist located in an urban clinic
visit, the transmission may occur through a via a telemedicine connection at the rural site.
T1 line exclusively—this is obviously im- The rural site could be the patient’s home or
perative for clinical visits. Another method community location. Again, the e-Promotora,
is to plug into a regular telephone line at armed with the equipment and a toolkit of
the rural site for education or counseling— nutrition tools that the nutritionist may use
in this format, the transmission may not be as for the session, coordinates the visit and loca-
clear, but is less costly and more flexible for tion. For more information on these and other
connections. telehealth opportunities visit the following
All of these telehealth methods can web sites: http://telehealth.hrsa.gov/ or http://
be deployed when caring for people with www.telemedicine.arizona.edu/ADVICE/.
SUMMARY REFERENCES
Innovations in technology have been American Nureses Association (1997). Telehealth: A tool
making the lives of people simpler and bet- for nursing practice. In Nursing Trends & Issues,
ter. Although some might argue that technol- ANA Policy Series. Washington, D.C.
Bernstein, E. (August 2, 2004). “Watching Your Steps”
ogy has had negative effects on health (e.g., written for the Wall Street Journal. Reprinted in The
televisions and cars have caused an increase Arizona Daily Star.
in sedentary lifestyles), technology also can
be used to improve people’s health, raise
their awareness of health issues, and facilitate Recommended Further Reading
health consultations with communities living Walsh, J., Roberts, R., Varma, C., and Bailey, T. (2003).
in rural communities. Using Insulin. San Diego: Torrey Pines Press.
IV
Business Issues
22
Disease Management Research

and Policy Initiatives
Larry Gamm, Jane Nelson Bolin, and Bita Kash
Texas A&M, Health Science Center, School of Rural Public Health, College Station, Texas
INTRODUCTION—DISEASE practices at national, state, or local levels that

MANAGEMENT RESEARCH, THE significantly impact the organization, deliv-
COST–QUALITY NEXUS, AND ery, or financing of health services.2 At a more
IMPLICATIONS FOR POLICY general societal level, health policy encom-
passes widely institutionalized and accepted
The purpose of this chapter is to explore practices in both the public, private, and vol-
selected health policy issues emerging from untary sectors affecting access, cost, and qual-
recent research and documented experiences ity of care. The chapter will conclude with a
with disease management (DM) in the private discussion of several key policy issues for fu-
and public sectors. More specifically, it will ture research in DM.
identify some of the precursors to DM and
explore the increased reliance on and authori- “Disease Management is a system of coordinated
tative support of DM in America’s public and healthcare interventions and communications for pop-
ulations with conditions in which patient self-care ef-
private sector. Definitions of DM variously
forts are significant.” In part, DM is a response to recent
emphasize the role of the patient or informal studies suggesting that providers meet accepted stan-
caregiver, a closer relationship between pa- dards of care for chronic illnesses only about half of
tient and provider, guideline compliant care the time McGlynn et al. (2003). A more encompassing
by providers, and implementation and evalu- definition of DM is “a systematic, population-based ap-
proach to identifying persons at risk, intervening with
ation of population-based approaches to im-
specific programs of care, and measuring clinical and
proved care for those with targeted chronic other outcomes” Epstein and Sherwood (1996).
diseases.1 Health policy is defined here as 2 This definition is closely aligned with a definition of
a set of authoritative laws, regulations, and governmental health policy as public policy pertaining
to health and with public policy defined as “authori-
tative decisions made in the legislative, executive, or
1 Significant dependence is placed on the patient and in- judicial branches of government that are intended to
formal caregivers, as is indicated in a definition offered direct or influence the actions, behaviors, or decisions
by the Disease Management Association of America: of others” Longest (2002).
283
284 DISEASE MANAGEMENT RESEARCH AND POLICY INITIATIVES
Early pioneers of DM predicted that infor ensuring population health (Kindig, 1998).
terest in DM would grow among providers, There are several elements within nursing and
employers, and health plans, and would even- medical practice that share a population focus
tually catch the attention of Medicaid and that are related to DM. We briefly examine
Medicare programs. Medicaid programs in precursors to DM that reflect major elements
approximately two dozen states are pursu- of DM today.
ing one or more of an array of DM pro-
gram options varying across capitated and fee- Case Management
for-service environments relying on state or
locally developed DM programs or upon spe- Case management in health care dates
cific DM vendors. Current Medicare initia- back a century or more to visiting nurses
tives explore a variety of DM approaches, in- managing their own caseloads and over 50
cluding managed care and fee-for-service DM years to nurses managing rehabilitation care
opportunities. for Workmen’s Compensation clients or ex-
Disease management is closely inter- pensive medical cases for insurance com-
twined with quality improvement initiatives, panies (Lyon, 1993). Case management has
best practices guidelines, and improvement in since extended to other areas such as men-
patient’s quality of care. DM’s promise for tal health, care for the elderly and, more re-
reducing costs is based principally on the ef- cently, to AIDS patients. Chen et al. (2002)
fective delivery of timely and appropriate in- offers a distinction between case management
terventions, care management, education and (individualized care, relying on case man-
social support in the most appropriate settings ager judgments, targeting a higher risk or frail
so as to maintain an optimal level of health sta- population) and DM (addressing a specific
tus for the patient. Although there is increased condition and employing structured protocols
hope among policy-makers and health profes- and clinical guidelines).
sionals alike that DM can constrain costs and In DM discussions, case management
enhance quality (optimal health) of popula- and care coordination are frequently re-
tions, there are needs for research that demon- ferred to as forms of DM. Case management
strates these impacts and for policies that activities extend across patient assessment,
support access for various populations to ef- education, monitoring, referral, service co-
fective DM approaches. ordination, and support for DM administra-
tive functions (Huston, 2002). The Centers
for Medicare and Medicaid Services (CMS)
HISTORICAL PERSPECTIVE: has defined eligible case management ser-
PRECURSORS TO DM vices for Medicaid as including “(1) assess-
ment of the eligible individual to determine
Formalized DM programs among health service needs, (2) development of a specific
plans, health providers, and DM companies care plan, (3) referral and related activities
have become prominent within the last 10 to help the individual obtain needed services,
years. Disease management may be viewed, and (4) monitoring and follow-up” (CMS,
however, as an important member of a family 2001; CMS, 2002). This is in contrast to the
of population health management strategies CMS disease management pilot program, au-
(McAlearney, 2002). A focus on population thorized in the Medicare Modernization Act
health and “purchasing population health” is (MMA) that focuses on management of spe-
common to much of the discussion of DM. cific illnesses such as congestive heart fail-
But few have given attention to the wide range ure (CHF), diabetes, and chronic obstruc-
of agents or organizations that are responsible tive pulmonary disease (COPD) (Medicare
DISEASE MANAGEMENT RESEARCH AND POLICY INITIATIVES 285
Prescription Drug, Improvement, and Mod- Medicaid chronic DM program employs sim-
ernization Act, 2003). ilar telephone-based approaches manned by
nonprofessionals, with regular backup by
Patient Education nurses, to monitor and support DM for Medi-
caid primary care case management (PCCM)
Patient education has a long history in the enrollees (Bella, 2003; Indiana Chronic Dis-
clinician–patient relationship (HSTAT, 2000) ease Management Program, 2004).
and remains an important element of ser-
vices in prevention, primary care, and acute
care (Eakin et al., 2002). It is also an im- Community Health Nursing
portant component of DM. The effectiveness
Community health nursing has a sig-
of patient education has been found to vary
nificant history among population health
widely according to the setting and approach
initiatives. Community health nurses focus
employed (Clark, 2003). Educational effort
on interventions associated with individu-
alone, however, may have little impact (CDC,
als, families, groups, schools, worksites, or
2003). At its best, patient education empowers
communities and can include specialization
patients to take control of basic but important
in case management (Clemen-Stone et al.,
steps to self-management (Fulton et al., 2001;
2002; Kingma, 2003). Closely related is pub-
Barlow et al., 2002; Bodenheimer et al., 2002;
lic health nursing which is a practice that
Rollins, 2002; Tattersall, 2002).
supports population health, assessing health
needs, and influencing the direction of preven-
Nurse Call Centers, Telenurse tion and care (Public Health Nursing Section
APHA, 2004).
Nurse call centers, telenurse and simi-
lar programs have been used for patient edu-
cation, referrals, “telephone reassurance,” or Community Oriented Primary Care
“teletriage” in situations ranging from mild
symptoms or prevention issues to emergency Community oriented primary care
situations. In managed care, nursing call cen- (COPC) combines a population focus with
ters have been used to control utilization, as elements of several of the above approaches.
well. Ability of costly telenurse programs to COPC, traceable to the work of two South
work with customers across state boundaries African physicians in 1940, focuses on
remains a stumbling block in many states. the health of a defined population. COPC
Seventeen states have implemented participa- combines population or epidemiologic study,
tion in the nurse licensure compact that en- social interventions, and clinical care of in-
ables such RNs and LPN/VNs licensed in dividual patients. The patient, community, or
one state to practice in another consenting subpopulation are the subjects of diagnosis,
state, including practice via telenurse pro- treatment, and ongoing surveillance. In its
grams (NCSBN, 2004). In some integrated earliest form, COPC combined the interests
delivery systems, variations of this approach of public health and medical care, empowered
are used in DM care coordination for periodic patients and communities in the pursuit of
contact with patients. One integrated deliv- health, and relied upon trained community
ery system has used similar telephone-based health workers (Mullan and Epstein, 2002).
approaches to enable specially trained non- COPC is widely endorsed in family medicine
nurse paraprofessionals to work with patients programs, but has remained a model rather
on anticoagulant management (Schmelzer, than a widely implemented practice (IOM,
2003; Hillman, 2004). Similarly, Indiana’s 1984).
THE HEALTHCARE MARKET third reported no external incentives to use the

AND MAJOR GOVERNMENT processes and one-half reported no clinical IT
HEALTHCARE PROGRAMS capability.
In a related study of nine leading physi-
Within integrated delivery systems, DM cian organizations, top executives, finance,
programs may be “owned” by the clinic, by and information officers pointed to several
the health plan, or by both (Zuniga et al., barriers to adoption of care management pro-
2003). While health plans have traditionally cesses, especially to population DM and case
been the principal sources of DM, over the management. “Frequently mentioned barriers
last 10 years, a new industry of DM programs were lack of financial and staff resources, in-
has become a major player along side payer, adequate clinical information systems, doc-
provider, and patient. It is ironic that although tors’ heavy workload, compensation not be-
DM is premised on gaining patient involve- ing related to quality of care, and doctors’
ment, self-management, and compliance in resistance to change” (Rundall et al., 2002).
his/her own treatment, few public or private Among facilitators of such DM are “a group
policies have focused on providing incentives culture oriented to quality and supportive
for a stronger patient role. Although there are managerial and medical leadership” (Rundall
precedents for self-insured employers, man- et al., 2002). Health plans were frequently
aged care plans, and life insurance companies cited, too, as an important facilitator, espe-
rewarding employees or subscribers for not cially those paying more for high quality.
smoking (e.g., lower premiums), such behav- Health plans, even those in integrated
iors are not commonplace in fostering patient delivery systems, have been slow to adopt
involvement in their treatment for diabetes, DM. Today, however, most of the major na-
CHF, or other chronic illnesses. One excep- tional and regional health plans offer one
tion is PacifiCare Health Systems, which of- or more DM programs. Medicare and, espe-
fers a premium reduction to enrollees who cially, Medicaid in many states have shown
earn sufficient “health credits” by joining an increased interest in DM. These public pay-
online health club, complete a health risk as- ers and many private payers have been par-
sessment survey, or participate in a weight- ticularly interested in “return on investment
loss program (Sipkoff, 2003). (ROI).” At a minimum, the expectation among
Physicians have been slow to move to- payers is that within a year, DM programs
ward chronic DM. Knowledge of critical edu- will reduce claims equal to DM program costs
cational and behavioral interventions for more (Foote, 2003). Although there is interest in ev-
effective chronic DM has been shared in the idence of improved outcomes associated with
professional literature (Von Korff et al., 1997) DM; the principal concern seems to be with
but infrequently adopted among profession- reducing, or constraining the growth rate of,
als or provider organizations. A study of over costs of care for populations identified with
1000 group practices and Independent Prac- targeted diseases. In the case of Medicare,
tice Associations found two factors to con- unlike private health plans or even Medicaid,
tribute most strongly to physician adoption there is a high likelihood that a patient will
of organized care management processes— be enrolled until death, a situation which en-
public recognition and better contracts for courages a long-term look at the contribution
health care quality (Casalino et al., 2003). of DM.
Availability of various degrees of clinical in- A key question to ask in both policy and
formation technology was another important practice is how major players in the health sys-
factor in the use of these processes. Physi- tem shift from here (traditional care) to there
cians tended to use less than a third of care (DM practice). Both the market and Federal
management processes presented; and one- and State policy have contributed to growing
interest in DM (Berenson and Horvath, 2003; as community-based case management even

Foote, 2003). The general movement toward if hospital-based personnel are the principal
DM in America, however, has not followed case managers.
a clearly defined chronological development. In 2001, 71.2% of hospitals respond-
Major DM developments in the medical care ing to the AHA annual hospital survey re-
organization and funding arenas have over- ported offering case management services.
lapped, but have occurred roughly in the fol- Case management of CHF, for example, is
lowing order: employed by some acute care facilities to
avoid preventable admissions or readmissions
r Provider case management—service that will result in significant costs beyond
lines. the DRG-based reimbursement (Griffith et al.,
r Health plan DM roll-outs—internal and 2003). In some larger integrated delivery
outsourced.
r Medicaid targeted populations case
systems, in particular, case management ac-
management—elderly, HIV, prenatal.
tivities may be closely associated with the de-
r Medicaid PCCM—addition of DM. velopment of clinical service lines such as car-
r Medicaid DM initiatives—pharma- diology, women’s health, or mental health that
ceutical and DM companies. are intended to improve care coordination,
r Medicare demonstration programs— marketing, and/or efficiencies (Parker et al.,
early demonstrations and current broad 2001). The role of rural hospitals in integrated
experiments. pathways for managing chronic illnesses or
r DM for the poor and uninsured—FQHCs specific treatments, e.g., total hip replace-
and community partnerships. ment, has been outlined in terms of biopsy-
chosocial approaches to ensuring an appro-
Hospital-Based Case Management priate match between the patient and medical
and social services (Hicks and Bopp, 1996).
Hospital-based case management, dat- Apart from payment by Medicaid and
ing back to Boston’s New England Medical some health plans for PCCM, payers have not
Center in the 1970s, coordinates multidisci- traditionally reimbursed providers for their
plinary care activities and resources for pa- additional case management activities. There
tient populations according to type of illness is some evidence today of a greater will-
or condition (Zander and Etheredge, 1989). ingness of some payers to “pay for perfor-
Medicare’s prospective payment system pol- mance,” an approach closely allied in some
icy of 1983 and its diagnostic-related group instances with chronic DM. Private payers
(DRG) payment may have contributed to in- in California and several other states are in-
creased interest in this form of health man- creasingly engaging “pay for performance”
agement. Such case management attends to approaches wherein medical groups and other
both cost and quality of care to produce de- providers are paid at a higher level if they meet
sired outcomes for “predictable” patients and quality goals. California’s Integrated Health-
quickly identifies patients who do not follow a care Association’s participating insurers pay
predictable path and require additional atten- higher percentage add-ons to capitation to
tion during their hospitalization (Daniels and providers who demonstrate higher quality.
Ramey, 2005). In some instances, hospital- Michigan’s Blue Cross Blue Shield program
based case management follows a particular pays higher performing hospitals a percent-
patient after hospital discharge, as hospital- age increase to the DRG rate (Managed
based nurses continue to coordinate patients’ Care Week, 2004). The California Integrated
care in their homes or other settings (Grif- Healthcare Association’s measures include
fith et al., 2003). Some would argue that elements of prevention as well as chronic
this extension should rightfully be referred to DM components associated with diabetes,
asthma, and coronary artery disease. These of states are pursuing DM in conjunction with
are weighted at 50% while patient satisfaction their Medicaid PCCM programs. Medicaid
receives a 40% weight and IT investments a programs in some of these and other states
10% weight (Integrated Healthcare Associa- are also risk-contracting with pharmaceutical
tion, 2004). and other DM companies for controlling costs
and improving health outcomes.
Health Plan DM Given that Medicaid accounts for about
20% of state budgets and that care for the
Health plan DM rollouts began in the chronically ill accounts for about 80% of
1990s. Some health plans associated with in- Medicaid spending, the rapidly growing in-
tegrated delivery systems date their signifi- terest among State Medicaid programs in DM
cant work on DM to the early to mid-1990s. approaches is not surprising. As of February
Some health plans outsourced DM services to 2004, 21 state legislatures had considered leg-
DM specialty companies like Cor-Solutions islation on DM; many of these legislatures
that trace its history back to 1994. Pfizer, between 2002 and 2003 authorized pilot DM
Bristol-Myers Squibb Co., GlaxoSmithKline, programs, required health plans to offer DM
and McKesson are among the pharmaceuti- programs, or otherwise moved their Medicaid
cal companies with DM units that have con- programs toward establishing or expanding
tracted with state Medicaid and other health DM activities (NCSL, 2004).
plans over the last 10 years. A recent report based on an examina-
Managed care plans’ growing interest in tion of over 300 DM programs and a more
DM as a means of controlling costs and coor- intensive analysis of about two dozen with
dinating care is occurring just as such plans the most credible evidence of reductions hos-
pull back from primary care gate-keeping pital use and costs recommended a number
and preauthorization approaches in control- of elements for State Medicaid programs to
ling utilization of care. These DM programs consider in pursuing DM options (Brown and
and voluntary case management programs, fo- Chen, 2004). Among the observations were
cused on high-risk patient populations, have the availability of a comprehensive set of in-
attracted limited participation among patients terventions, not just one or two; participation
but are expected to become more important of bachelors and masters trained nurses as
in containing costs and improving care deliv- care coordinators and case managers; close
ery (Felt-Lisk and Mays, 2002; Mays et al., working relationship between DM profes-
2003). sionals and primary care providers; and a
prevention emphasis on early detection and
Medicaid Programs intervention.
The most common form of modern DM
Medicaid programs in two dozen states among state Medicaid programs is in the
have been adopting various forms of DM over form of contracts with DM companies or
the last decade. Medicaid and/or other state pharmaceutical-based DM companies. The
agencies in some states have pursued tar- Florida Medicaid program signed another
geted populations case management for high- two-year agreement in 2003 with several
risk groups such as elderly in community pharmaceutical-based DM programs—Pfizer,
settings, HIV, and poor, high-risk pregnant Bristol-Myers, Squibb Co., GlaxoSmithKline
women. Over 20 states have pursued or ini- PLC, and AstraZeneca PLC. The companies
tiated steps toward adopting some form of promise at least $64.7 million in savings to
DM for their enrollees. Medicaid programs Florida’s Medicaid program over two years.
have encouraged their capitated health plans In return, the drug companies are able to keep
to employ DM, and more recently a number their products in the state’s formulary and
avoid price discounts such as those demanded Initial efforts will concentrate on CHF and/or
of them by Medicaid programs in more than diabetes with significant co-morbidities; one
a dozen states (Meier, 2003). Because pre- or two areas may focus on COPD. More infor-
scription drug claims are the most timely mation on this program will be discussed later.
data available to DM organizations, access to The new program is not Medicare’s first
such claims can both help to identify eligi- foray into DM. Evaluation results of fee-for-
ble DM participants (based upon knowledge service Medicare Case Management Demon-
of the illness for which a drug is prescribed) stration projects between 1993 and 1995 at
and to monitor aspects of appropriate care three sites found little success because of lack
(MEDPAC, 2003). To demonstrate the volatil- of patient and physician interest in participat-
ity in Medicaid DM contracting, Florida re- ing and little evidence of outcomes improve-
cently announced its intention to drop its DM ment or cost reduction (Schore et al., 1999).
contracts with pharmaceutical-related compa- A capitated DM demonstration was initiated
nies at the completion of current contracts with proposals due in 2003. Also, the Medi-
in 2005. Announcements cited dissatisfac- care Coordinated Care Demonstration with 15
tion with resultant savings from the contracts projects sites is nearing completion. An early
(Associated Press, 2004). 1990s study of “fee-for-service” in Medicare
In February, 2004, the Centers for Medi- fee-for-service found it hard to gain participa-
care and Medicaid Services offered to match tion in DM.
state government costs in operating DM pro- The three-year Medicare Disease Man-
grams. The state is free to contract with DM agement Demonstration mandated under the
organization or establish a PCCM program Medicare, Medicaid, and SCHIP Benefits
working with PCCM providers to offer en- Improvement and Protection Act of 2000,
hanced care to those Medicaid patients with BIPA, got underway in early 2004. It will
chronic conditions (CMS, 2004). evaluate how the addition of DM services
combined with a prescription drug benefit im-
Medicare proves the health outcomes of fee-for-service
Medicare beneficiaries suffering from serious
Medicare is becoming more active in CHF, diabetes, or coronary heart disease. Like
the consideration of DM programs for Medi- many state Medicaid programs, it relies upon
care beneficiaries. In April, 2004, the RFP contracts with DM companies to offer the
for the chronic care improvement pilot services—to 30,000 people in parts of three
program pursuant to Section 721 of the states in this program (CMS, 2003).
Medicare Modernization Act (Medicare Pre- The DM pilot for Medicare fee-for-
scription Drug, Improvement, and Modern- service will attempt to test three innovative
ization Act of 2003) was announced. The elements in what might become a broad new
pilot program is a first step toward ex- strategy: provision of evidence-based care
tending a voluntary chronic care improve- support services for patients and providers, a
ment program to enrollees in the traditional new business model where DM providers are
Medicare fee-for-service. The program will at risk for outcomes, and a new administrative
fund 10 applicant organizations across re- model for Medicare in setting goals, working
gions of the nation to offer DM services to with new providers, and analyzing data per-
a total of several hundred thousand tradi- formance and costs (Foote, 2003).
tional fee-for-service Medicare enrollees. A The focus on 10 regions may allow for
wide range of DM providing organizations demonstrating the effectiveness of different
can apply—DM companies, insurance com- DM models in different settings and different
panies, integrated delivery systems, physi- Medicare populations (e.g., rural, minority,
cian group practices, consortia, or others. and poor). Although most discussion of the
pilot program point to CMS contract with workers, nurses, and lay health workers work
large DM companies including pharmaceuti- directly with patients who have a diagnosis
cal DM programs, other models are possible, of diabetes, hypertension, or both and have
as well, so long as each encompasses at least achieved major gains in patient health sta-
30,000 enrollees. For example, MMA empha- tus (Keys, 2003). A Rural Minority Geri-
sizes that some DM projects must emphasize atric Care Management Model has been em-
communication with local providers. ployed at FQHC sites in rural South Carolina
At the same time, the Medicare popula- to meet the need of poor primarily African
tion with more co-morbidities and drug pre- American adults 55 and older. This broad-
scriptions than the typical health plan ben- gauged program emphasizes eligibility find-
eficiary served currently by DM programs, ing, financial assistance, and other services
may prove more impervious to DM initiatives as well as health screening and care man-
(Foote, 2003). agement for diabetes, prostate cancer, and
other illnesses. It has attained major successes
DM for the Poor, Uninsured, and Safety on all counts (Forti, 2003). St. Elizabeth of
Net Providers Hungary clinic offers a DM program for the
uninsured poor in Tucson, Arizona, described
DM for the poor, uninsured, and safety in Part 5 of this book, and is still another
net providers is a relatively new phenomenon example of safety-net provider-based DM
as well. In 2002, the number of uninsured program.
Americans was estimated to be 43.6 million, An examination of chronic DM-related
up from 41.2 million in 2001. A report from activities among California safety net
Families USA estimates the number of unin- providers found a few bright spots in five
sured for one or more months during the urban counties and a rural region, but noted
24-month period of 2002 and 2003 at 82 mil- that most chronically ill patients in these
lion (Families USA, 2004). Estimates of one- areas served by the safety net providers did
third or more of the population under the age not receive such additional care management.
of 65 being uninsured underscore the impor- Major policy barriers were identified in
tance of DM among the uninsured. Moreover, addition to funding cutbacks in Medi-Cal
health and health access conditions among the and other health related programs. Among
uninsured create a scenario for “the perfect these are the unwillingness of health plans
storm” of costly, uncontrolled chronic dis- and other payers to pay for chronic care
ease: the uninsured are more likely to suffer improvement programs or related services
from chronic diseases, are less likely to have offered by non-PCP personnel, insufficient
a regular or usual health provider, have less funds and expertise to acquire clinical
timely access to health care, and are less likely information systems or advanced registries
to receive preventive services for chronic dis- to support DM, and shortage of personnel
eases (Gamm et al., 2003). to maintain antiquated registry systems or to
Several examples of community-based offer DM support that does not require med-
DM efforts that serve the uninsured or un- ical professional expertise (Bodenheimer,
derinsured have achieved impressive results. 2003).
Delta Community Partners in Care serve a Policy recommendations growing out of
10 county Mississippi delta area. They em- the analysis of DM among California’s safety
ploy a community-based case management net providers include the following:
model to improve the health status and risk
factors in its target population of African r Medicare, Medi-Cal and its managed care
American women under the age of 65. Social plans, and county indigent care programs
should “pay for programs” rather than cre- terol. Health care spending for these employ-
ating new categories of service or care- ees declined, as did negative clinical findings,
givers for reimbursement, e.g., an annual and worker absenteeism (Connolly, 2002).
bonus to a clinic that maintains a registry,
a “monthly global fee” to a clinic for the
care of each diabetic maybe with a bonus
added for avoiding hospitalization or ER CONTINUING POLICY AND
use, or a “global budget” for inpatient care RESEARCH ISSUES IN DM
in county health systems with additional
payments to primary care DM programs The preceding section offers a histori-
making DM profitable and hospitalization cal perspective and initial reflections on sev-
a cost;
r Payers should assist safety net providers
eral relevant DM policies and related research.
in developing and using registries and re-
There remain, however, other policy-related
minder systems and other tools supporting issues that will require the attention of re-
guideline based care; searchers and policy-makers alike. A few of
r States and counties should support collab- these are presented here.
oration on information systems and reg-
istries between county providers and com- Return on Investment
munity clinics and health centers that of-
ten serve the same patients; Return on investment remains a key issue
r Payers and safety net providers them- for chronic DM programs. One study identi-
selves should encourage clinics and other fies significant savings and quality gains as-
providers to develop simple reminder sys- sociated with a diabetes DM program oper-
tems and train nonprofessional staff to un- ated by a health plan in a multispecialty group
dertake some nonclinical tasks supporting practice (Sidorov et al., 2002). A recent anal-
care management; ysis of ROI for diabetes DM in two man-
r Federal, state, and local governments (and aged care organizations suggests that there
foundations) should invest in clinical in- is only a weak business case to be made
formation systems for safety net providers
(Beaulieu et al., 2003). More specifically, it
and facilitate conversion of county pri-
mary care sites into FQHCs to gain ad-
suggests that because of initial costs of the
ditional reimbursement that could con- program, the health plan’s saving may not oc-
tribute to improved chronic care (Boden- cur for 10 years after the member is in the
heimer, 2003). plan. Because of patient turnover, the plan
may not realize the kind of financial bene-
It is also possible for States to exert their fits it needs to convince investors and boards
influence in pressing for DM services among of the financial soundness of such programs.
plans and providers serving state Medicaid In contrast, Medicare and Medicaid may ben-
and SCHIP programs and state employee and efit eventually from the plans’ programs be-
retiree insurance programs. Apart from those cause the member will maintain good health
concerted efforts even municipalities collec- longer. Moreover, the employer may benefit
tively, or alone as in the case of Asheville, from lower premiums, less disability outlay,
NC, can design care management programs reduced absenteeism, and increased produc-
for city employees and reap savings on several tivity. The evaluators suggest that policies are
fronts. In the case of Ashville, the city paid needed to ensure that those organizations and
pharmacists $40 per patient per month to pro- programs that benefit contribute to the financ-
vide counseling on diet, exercise, stress reducing of DM programs.
tion, and medications to city employees with A recent survey found that a majority
asthma, hypertension, asthma, or high choles- of large businesses offer or are considering
offering DM programs, health screenings, flu services and ensure appropriate utilization

vaccinations, prenatal care, well baby/child and cost management for costly Medicaid pa-
care, or nurse hotline (DM News, 2003). tients. In conjunction with asthma and dia-
While some employers depend on their health betes, the work of the networks has improved
plans to select DM eligible employees, other care, reduced costs, and reduced ER use and
employers have found that their health plan’s hospitalization in comparison with patients of
DM program miss a high percentage of em- PCCMs who are not participating in such net-
ployees whose conditions are most important works (Simms, 2003).
among their younger workforce, e.g., high- Early research on Medicaid DM pro-
risk pregnancies. As a result, some employ- grams identifies quality gains and limited cost
ers have purchased DM programs directly savings (Wheatley, 2002). Additional steps
from vendors (Short et al., 2003). A 2004 that could be taken by state Medicaid pro-
report from American Association of Health grams include automatic enrollment of Medi-
Plans/Health Insurance Association of Amer- caid patients in DM programs (with an opt-out
ica reports on successes in 10 health plans with period) and addressing problems of low vol-
25 different DM programs. The report docu- untary enrollments. Medicaid DM programs
mented savings in health care costs across a that could appoint DM care managers to work
number of programs along with reduced hos- directly with hospitals or other providers to
pital admission and ER visits (Ghose, 2004). identify DM program eligibles can reduce the
Return on investment studies continue costs of locating hard to reach Medicaid en-
to be plagued by significant problems as- rollees. Hiring staff to locate DM eligibles
sociated with measuring costs impacts and may be preferable to paying the cost of emer-
clinical outcomes associated with DM inter- gency room visits or acute care hospitalization
ventions (Johnson, 2003). Although there are (Wheatley, 2002).
both growing optimism and reports of cost
savings and impacts on quality of care, the Co-morbidities
evidence to date is both limited and mixed
(Short et al., 2003). The Pacific Business Co-morbidities remain a challenge for
Group on Health found a lack of comparable- DM efforts. In particular, there is need for
population-based outcomes to enable eval- evidence of the ability to simultaneously
uation of DM programs offered by health manage multiple chronic conditions in the
plans and calls for improved sets of outcomes same patients. Foote (2003) contends that
measures (Pacific Business Group on Health, new generation DM programs are address-
2002). ing a broader array of illnesses and are cross-
training DM personnel to address overall self-
State Incentive Programs care for patients rather than a specific disease
(Foote, 2003). Nonetheless, a number of pay-
Some states have created incentives for ers still rely on a number of separate DM pro-
physicians to provide DM services by pay- grams to serve disease specific populations,
ing an additional per member per month but patients eligible for multiple services
to Medicaid PCCM physicians who provide are generally assigned to only one (Foote,
“enhanced services” associated with DM or 2003).
care coordination (Sprague, 2001). The North The importance of DM providers being
Carolina Medicaid program links hundreds able to address multiple co-morbidities is un-
of thousands of PCCM patients to Commu- derscored by evidence that 88% of Medicare
nity Care Networks of primary care providers, spending is directed to beneficiaries with three
health departments, and social services de- or more chronic conditions with another 77%
partments. The networks work to coordinate to those with two chronic conditions (Crippen,
2002). This concern is reflected in part by Those with this combination of illnesses
testimony from the American Academy of tally 4.5 times greater total health care
Family Physicians who testified that a primary expenditures than for individuals without
care physician should be the primary point of depression (Egede and Zneng, 2003).
contact for DM and that federal support of
DM organizations will further fragment care, To Buy or Build a DM Program
be more costly, and nonbeneficial to the chron-
ically ill elderly patient (American Academy To “buy” or “build” is a choice that
of Family Physicians, 2003). Medicaid programs and health plans must
In Florida, the PCCM Medicaid recip- make. Building a DM program from scratch,
ient with multiple illnesses is assigned to assembling “off-the-shelf” components, part-
the DM vendor that has responsibility for nering with a DM vendor in a “turn-key” ar-
the most serious illness. Performance audits rangement, and buying from a DM vendor are
of the Florida program have been critical of among an array of options. Although it ap-
this approach doubting the ability of the spe- pears that the “buy” option is becoming more
cialized DM vendor who focuses profession- popular, the “build” or “assemble” choice may
ally on one illness to adequately manage the offer greater payoff for state Medicaid pro-
co-morbid conditions; the DM organizations grams and other payors. In particular, it may
counter that their nurse care coordinators have offer the opportunity to address more con-
sufficient experience to deal with the addi- ditions, more providers, and more popula-
tional conditions as they arise (Silberman tions through DM programs. Moreover, it may
et al., 2003). In any case, there is no evi- be possible to attain savings and synergies
dence that the DM organizations coordinate among Medicaid and many other health and
around particular types of patients or share human services programs in the state. It may
“best-practices” with one another regarding also optimize DM program lengths between
the various co-morbidities. Medicaid and those responsible for health care
Because patients with concurrent for state employees and retirees.
chronic conditions are more likely to gen- Alternatively, negative aspects of the
erate higher expenditures than a patient build approach can include greater upfront
with one condition, one wonders whether costs and time to hire expert personnel and
evaluations of DM program performance expert consultant to construct the DM pro-
considers costs and cost savings for each gram from scratch or combine components
condition. Behavioral health conditions, from other sources; and lack of knowledge of
for example, combined with other chronic likely effectiveness until the product has been
conditions illustrate research and policy operating for a year or more (NGA, 2003).
challenges. Psychosis and depression alone Also, where one works with local providers
and together score the greatest yearly costs and others to construct DM programs, DM ac-
among Medicaid patients, and often combine complishments might be constrained by con-
with other conditions like diabetes, asthma, tinuing provider resistance to adopt clinical
or peptic acid disease to produce high costs protocols and related care management op-
(Garis et al., 2002). Diabetic adults are portunities.
more likely than nondiabetics to have a There are some key advantages for buy-
major depressive disorder, but diabetics, with ing, i.e., contracting for, DM that may be ap-
worsening health status, are nearly six times pealing to Medicaid agencies, especially in
more likely to develop a major depressive times of financial stress. DM vendors may be
disorder. Diabetics with depression report relied upon to provide the necessary research
poor physical and mental health, use more development, information systems, and to put
outpatient care, and fill more prescriptions. personnel in place immediately. Also, DM
vendors may put their fees at risk; vendors target populations. Both public and private
may forgo up to 100% of their fees if agreed markets have treated DM services as admin-
up cost-saving targets are not met. Negative istrative services rather than defined bene-
elements of “buy” approaches include: DM fits. This allows for more experimentation and
companies may not manage all of the services easier dropping and adding of services by
desired; relationships between the companies health plans or other payers (Foote, 2003). At
and providers may be distant; placing DM the same time, however, as the DM services
vendors at risk can create adversarial stance become more widely accepted, it will become
between the vendor and the State; and ne- obvious that additional services (benefits) are
gotiating and monitoring such contracts re- being offered to some populations (and not to
quires expertise on the part of the responsible others) even though the revenues contributed
state officials. Pharmaceutical companies may by or on behalf of each “enrollee” are the
present a special form of contracting, but may same. The fact that some patients view DM as
in some instances be principally limited to a benefit is reflected in the efforts of enrollees
management of pharmaceuticals in conduct- to “buy” DM services after their group had
ing DM. Some address multiple aspects of been dropped by a health plan that had offered
care and multiple conditions. the DM services (Bolin et al., 2003). And, of
The Indiana Medicaid program empha- course, physician providers may see an ad-
sizes an “assemble” approach in contrast to ditional DM “benefit” or “service” provided
build or buy approaches. That is, they have by a new “provider,” the DM company, as
assembled a number of existing components bleeding off revenues that should be coming
into a custom built DM program for their to traditional medical care providers (Ameri-
Medicaid fee-for-service patients. They are can Academy of Family Physicians, 2003).
now proposing to open its services to other
providers as well (Indiana Chronic Disease DM Programs’ Dependence Upon
Management Program, 2004). Information Systems
For any DM option that relies on on-site
DM providers, there is a need for a sufficient DM programs’ dependence upon infor-
population base to cover the cost of a DM mation systems has brought renewed attention
provider, something which may be problem- to the need for more widespread clinical in-
atic for rural or frontier areas. It is possible formation systems and/or registries. In some
that higher payments or other resources could instances, attention is focused on systems that
be offered for provision of DM in such geo- combine clinical guidelines with patient data
graphic areas either directly by Medicaid or from claims, self-reports, or other sources
through an external DM company (possibly (Foote, 2003). Disease management registries
making up some of these revenue losses in within FQHC administered chronic disease
DM provision in more populated regions). It “collaboratives” reflect similar integration.
appears to be the case that in states relying Less common, but occasionally found in in-
on external DM vendors, telephonic DM ap- tegrated delivery systems, is the integration
proaches are more regularly used in rural areas of information in the form DM personnel of
(Silberman et al., 2003). the health plan being able to review and write
to the clinic’s electronic medical record and,
DM as a Benefit or Administrative Service thus, communicate directly with the physician
regarding care coordination for the patient
The issue of treatment of DM as a ben- (Bolin et al., 2003). Via the MMA of 2003
efit or administrative service is likely to be- and other Federal initiatives, additional incen-
come a more important issue as DM benefits tives are being offered to enable providers to
or services are made available to additional develop clinical information systems that can
support DM and other quality related activi- Indiana Medicaid plan offers telephone-based
ties. DM to fee-for-service/PCCM Medicaid pa-
tients, relying on paraprofessionals (backed
DM and Clinical Quality up by nurses); making this service available to
other patients as well. This trend is in keeping
DM and clinical quality are closely with treating DM as an administrative service.
related topics. Much of the content of DM If DM were treated as a benefit, it might point
programs is parallel to clinical guidelines toward consideration of new classes of health
prescribing certain tests and treatments workers for reimbursement, something which
for chronic illnesses. In many respects the is frequently the subject of intense debate.
contributions of physicians, hospitals, and
health plans to DM efforts is dependent upon Predictive Modeling Technologies
their day-to-day support of quality-related
guidelines. Moreover, DM may contribute or Predictive modeling technologies are
detract from ability of health care providers to important components of DM. The technolo-
conduct their work. Although DM programs gies can identify those patients at various
may help the Medicare patient overcome risk-levels calling for DM interventions are
fragmented care offered by up to six physi- also criticized as potentially being used to
cians and up to 20 prescriptions in a given weed out chronically ill patients from insur-
year (Anderson, 2002), it may add to clinical ance coverage. Large insurers are investing in
complexity for providers. That is, multiple predictive modeling technology that can be
DM companies may contact the same physi- used to estimate total spending for a group of
cian about his/her patients. Moreover, DM in members, forecast individuals most likely to
such a fragmented situation may offer little in be hospitalized, and to perform analyses that
the way of support for quality improvement support such functions as targeting preventive
or reengineering of clinical practices in the care or DM or pricing contracts with employ-
direction of better overall chronic DM (Foote, ers and providers. Using data such as age, gen-
2003). der, zip code, medical and pharmacy claims,
and laboratory results, predictive models are
Training Needs of DM Paraprofessionals increasingly accurate in predicting costs for
groups and individuals (Benko, 2004).
Training needs of DM paraprofession- A series of recent lawsuits against a
als should be addressed on a state or national few health insurance companies for canceling
level. Paraprofessionals play an important role policies or increasing premiums of sicker pa-
in DM efforts. If DM grows as rapidly as antic- tients (Benko, 2004) suggest that policies will
ipated in Medicaid and Medicare, the capacity be needed to ward off unethical use of such
of current DM companies and even that within technologies. (Does the denial of the right to
integrated delivery systems may be quickly sue HMOs in state courts apply to HMO deci-
exceeded (Wadhwa et al., 2004). This capac- sion to deny coverage?) Misuse of these tech-
ity limitation is linked in large part to the short nologies may dissuade some patients from
supply of nurses. Nurses are the principal seeking tests or screenings if they think the
disease managers, care coordinators, or case results could be used to exclude them from
managers in most DM programs. Some tele- insurance coverage. Such predictive model-
health programs, community-based DM ini- ing, however, offers significant promise for
tiatives, and other DM-related programs make better targeting of DM efforts and for “sever-
some use of social workers, community health ity adjusting” in assessing the quality and
workers, or other paraprofessionals to handle effectiveness of both medical care and DM
nonmedical aspects of DM. For example, the programs. The same technologies, it should
be noted, can be used by state governments Acknowledgements. Funding for the

or possibly by self-insured employers to bet- Chronic Disease Management in Rural Areas
ter assess the risk-levels present among those study was funded by grant # 5 U1C RH
for whom they provide benefits; they can use 00033 through the Southwest Rural Health
such information in negotiating contract with Research Center, the Office of Rural Health
health plans. Policy and the Health Resources Services
Administration (HRSA), US Department of
Health and Human Services (HHS).
CONCLUDING COMMENTS
Disease management offers the promise REFERENCES

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23
Legal and Regulatory Considerations

of Diabetes Disease Management
Jane Nelson Bolin, Bita Kash, and Larry Gamm
Texas A&M Health Sciences Center School of Rural Public Health, College Station, Texas
INTRODUCTION PROLIFERATION OF DM
REGULATIONS AND GUIDELINES
Laws and regulations pertaining to health
care have increased dramatically in the past Observers of health care delivery in
20 years and have assumed heightened, some the United States have recognized the trend
would say overstated, significance in the oper- toward greater regulation and standardization
ation of health plans and patient care services. in the delivery of health care services. The
Many health care organizations are not fortu- realities of tightened fiscal constraints, and
nate enough to have an attorney available for recognition that adherence to DM guidelines
frequent consultation. Therefore, acquiring a improves overall quality of care, have moti-
basic understanding of the laws affecting the vated the development of new approaches to
delivery of health care is a valuable investment caring for chronic disease and contributed to
of time and money. the proliferation of guidelines. Indeed, over
In this chapter, we provide an overview 67 guidelines exist on diabetes mellitus alone
review of laws and regulations and dis- (National Guideline Clearing House, 2004).
cuss certification and accreditation options Professional standards and review organiza-
that pertain to diabetes disease management tions (SROs and PROs) have sprung up both
(DM). Our discussion includes recently en- in the private and public health care sector.
acted Medicare and Medicaid DM provisions, Federal and State public health programs have
HIPAA, as well as a discussion of accredita- launched several new initiatives. In 2003,
tion programs such as the Joint Commission Medicare initiated the chronic care improve-
for Accreditation for Hospital Organizations ment program (CCIP) for fee-for-service
(JCAHO), National Commission for Quality programs (MMA, 2003) and began testing
Assurance (NCQA), Utilization Review and pay-for-performance (P4P) reimbursement
Accreditation Committee (URAC), and the incentives and directives intended to encour-
American Diabetes Association (ADA). age the use of DM guidelines (NCQA, 2004;
301
302 LEGAL AND REGULATORY CONSIDERATIONS
CMS, 2004). The focus of these programs certification requirements also may vary
is on encouraging health providers to adopt state-by-state and therefore the information
standards and guidelines relating to care of discussed in this chapter is offered solely to
patients with chronic diseases, addressing, provide an overview and is not intended to
for example, diabetes, asthma, congestive be offered as specific legal advice. Decisions
heart failure (CHF), and chronic obstructive relating to legal considerations for individual
pulmonary disease (COPD). programs should be made after consulting
Compliance with the numerous laws, with those familiar with applicable state laws
regulations, guidelines, and standards can as well as health law generally.
be overwhelming and confusing. Yet, much
of the work required for compliance with Federal Laws and Regulations in Disease
federal regulations and guidelines can be Management
accomplished through accreditation or
certification with organizations specializing Numerous federal laws and regulations
in quality of care and outcomes evaluation, apply to health providers and health care fa-
such as JCAHO or NCQA. Accreditation cilities, as well as the operation of health plans
and certification are evidence of compliance generally, but not all apply specifically to DM.
with evidenced-based guidelines, and in It is beyond the scope of this chapter to discuss
many cases are recognized by Medicare all of the tangentially relevant federal health
and Medicaid programs that a program care laws. Instead, our focus is on those laws
meets appropriate standards and guidelines. and regulations that pertain most to the pro-
Adherence to evidence-based guidelines also vision of DM services, and demonstration of
demonstrates that a DM provider is capable compliance with regulations and guidelines.
of implementing guidelines that improve For example, the recently passed Medicare
patient outcomes and improve overall quality Prescription Drug, Improvement, and Mod-
of care. Much of an organization’s success ernization Act (MMA, 2003) contains specific
in marketing and expanding DM programs requirements and inducements for providers
will be based on an ability to demonstrate to initiate and implement chronic disease care,
improved health, reduced acute health including CCIPs and other pilot projects. Nu-
events, and cost-savings while carrying out merous other federal laws relate in some
population-based management of chronically measure to DM and include the Healthcare
ill patients. However, implementation of Quality Improvement Act (HCQIA); Bene-
guidelines, regulations, and DM processes fits Improvement and Protection Act (BIPA);
takes time and effort, and can be challeng- the Health Insurance Portability and Account-
ing for DM programs. Accreditation and ability Act (HIPAA) and discrimination laws
Medicare? Medicaid?
HIPAA? HCQIA?
NCQA? JCAHO?
“I can’t keep it all
straight”.
LEGAL AND REGULATORY CONSIDERATIONS 303
TABLE 23.1. Laws and Regulations to Consider

Regulation or agency Who is covered? What is covered?
Medicare [MMA] All participating health care Initially CCIP will be tested in pilot programs
providers and later launched in all FFS and managed
care programs.
Medicaid (state-by-state) Diabetes and other chronic See state summary in Table 23.2
diseases
HCQIA (Health Care Hospitals Requires peer review and credentialing of
Quality Improvement physicians.
Act)
Health plans (if accredited Legal responsibilities include a defined process
by NCQA) for the appointment of “medical staff”,
creation and approval of medical staff
by-laws.
BIPA [“Benefits Applies to DM plans Patients with advanced CHF, diabetes or CHF.
Improvement and participating in the BIPA Program reimburses for patient visit plus cost
Protection Act of demonstration projects of prescription drugs.
2000”]
HIPAA [“Health All health plans. All health All PHI generated in any format, including
Insurance Portability care providers who have electronic, paper, and oral information.
and Accountability access to PHI including
Act”] electronic transmittal of
PHI.
Consolidated Health About 20 federal Federal agencies, which share health data, are
Informatics Initiative departments or agencies, required to adopt the same clinical
including HHS, DoD, vocabularies and integrated methods of
SSA, GSA, and VA. transmitting that information. Establishes a
portfolio of existing clinical vocabularies and
messaging standards enabling federal
agencies to build interoperable federal health
data systems.
Discrimination Laws All health care providers, It is unlawful to discriminate on the basis of
(Title VII, ADA, and health care one’s race, ethnicity, gender, religion,
ADEA, and state employers disability, or age.
discrimination laws)
such as the Civil Rights Act of 1964 (Title Department of Health and Human Services
VII), Americans with Disabilities Act (ADA), (DHHS) to develop a plan to reduce the cost of
and Age Discrimination in Employment Act care for chronically ill Medicare beneficiaries
(ADEA). providing for a phased-in development, evalu-
Table 23.1 provides an overview and ation, and implementation of the Chronic Care
summary of the laws, which are discussed in Improvement program. The Act includes pro-
more detail subsequently: visions establishing testing sites for the CCIP.
The CCIP is intended for Medicare beneficia-
Medicare Prescription Drug, Improvement, ries enrolled in the traditional fee-for-service
and Modernization Act of 2003 program to ensure access to chronic DM pro-
grams for conditions such as congestive health
The MMA (2003) contains numerous failure, diabetes, and COPD. The implemen-
provisions relating directly or indirectly to tation of chronic DM programs for Medicare
the provision of chronic care or DM ser- enrollees requires that the beneficiary partici-
vices. MMA requires the Secretary of the U.S. pate in the care program on a voluntary basis
and be able to terminate participation at any Delaware, Florida, Georgia, Illinois, Indiana,
time. Iowa, Maryland, Maine, Minnesota, Missouri,
Under MMA–CCIP, chronic care can Mississippi, North Carolina, New Jersey, New
be provided either directly by the provider Mexico, Oregon, South Carolina, Tennessee,
or through contracts with DM organizations, Texas, Utah, Washington, and West Virginia
health plans, and consortiums. Programs that (NCSL, 2004). According to the National
can demonstrate improvement in quality of Conference of State Legislatures (NCSL),
care, beneficiary satisfaction, and achieve tar- DM for patients enrolled in their Medicaid
geted cost-savings, will be able to expand programs (NCSL, 2003). Some states have
chronic care programs in the future. Although contracted with commercial vendors to pro-
this new legislation introduces new protocols vide diabetes DM to their Medicaid patients,
and regulations for care management plans, while other states require Medicaid managed
the opportunities for DM activities seem to care companies contracting with the state to
outweigh the restrictions. provide diabetes DM. Table 23.2 provides a
Most legislated care management ele- listing of states that have passed legislation
ments in the MMA–CCIP are consistent with pertaining to Diabetes DM.
widely used DM care plans as published by
the JCAHO, NCQA, and DM Association of
Federal Health Care Quality
America (DMAA). These elements include:
Improvement Act
r designated point of contact,
r self-care education for beneficiary, The HCQIA was passed in 1986. In
r education for physicians and other passing this law, Congress made five specific
providers, findings:
r use of monitoring technology,
r the provision of information to patients (1) The increasing occurrence of medical
about hospice and end-of-life care, malpractice and the need to improve the quality
r demonstration projects to evaluate meth- of medical care have become nationwide problems
ods to improve the quality of care pro- that warrant greater efforts than those that can be
vided to beneficiaries with chronic condi- undertaken by any individual State.
tions, and (2) There is a national need to restrict the
r diabetes laboratory screening tests cov- ability of incompetent physicians to move from
ered for individuals at high risk for dia- State to State without disclosure or discovery of
betes. the physician’s previous damaging or incompetent
performance.
With its numerous other provisions and (3) This nationwide problem can be reme-
amendments, the law brings about the most died through effective professional peer review.
sweeping changes to Medicare law in over (4) The threat of private money damage lia-
40 years. One can expect more changes as bility under Federal laws, including treble damage
data from the CCIP demonstration projects liability under Federal antitrust law, unreasonably
becomes available. discourages physicians from participating in effec-
tive professional peer review.
(5) There is an overriding national need to
Medicaid and State Regulation provide incentive and protection for physicians en-
gaging in effective professional peer review. (See
As of 2004, 24 states had passed specific 42 U.S.C. §11101).
laws pertaining to state-level or Medicaid DM
programs, with 15 states mandating or requir- While the HCQIA does not specifically
ing diabetes DM. States with any DM spe- target DM, the HCQIA does include a re-
cific laws are: Alabama, Arkansas, Colorado, quirement that health care providers who seek
TABLE 23.2. Summary of State Mandated Diabetes DM Programs

State Type of program Medicaid related? Other diseases
Colorado Pilot program funded through private No Asthma

donations
Florida DM provided by DM organizations Yes Asthma, CHF
under contract to state
Illinois Voluntary diabetes DM phased in. Yes Asthma
Indiana Currently testing pilot program No Asthma,
evaluating possibility of future DM hypertension,
programs CHF
Maryland Diabetes DM provided through six Yes Asthma and high
MCOs under contract to the state. risk pregnancy
Maine Diabetes DM required by Medicaid Yes
laws
Minnesota Diabetes DM required by Medicaid Yes
laws
Missouri Diabetes DM required by Medicaid Yes
laws
Mississippi Diabetes DM required by Medicaid Yes Asthma
laws
North Carolina Diabetes DM required by the Carolina Yes Asthma and CHF
ACCESS program.
New Jersey HMOs with DM services in place are Yes Asthma and CHF
available to enrolled Medicaid
beneficiaries
Oregon State contracts with commercial DM No Asthma and CHF
vendors
South Carolina State contracts with Medicaid MCOs Yes Asthma
for adult diabetes DM
Washington Contracts with outside vendors of FFS Yes Asthma and CHF
Medicaid patients to provide
diabetes DM
West Virginia Contracts with MCOs to provide Yes Other high risk
Medicaid DM to high risk conditions
Source: National Conference of State Legislatures, August 2004.
privileges and credentialing through health Benefits Improvement and Protection Act
maintenance organizations (HMOs) or man-
aged care organizations (MCOs) will adhere Benefits Improvement and Protection Act
to the standards of their peers and established legislation was designed to determine whether
clinical guidelines for disease prevention and providing DM services to Medicare beneficia-
management. The majority of MCOs and ries with advanced CHF, diabetes or coronary
HMOs now use evidence-based guidelines to heart disease results in improved outcomes
decrease deviations in health care services and without increasing program costs. Those cov-
outcomes (Gosfield, 1996). Both the NCQA ered under BIPA received funding for the
and the Joint Commission require the use of cost of prescription drugs required for ben-
evidence-based guidelines to become accred- eficiaries enrolled in the program, in addition
ited or certified, and can require providers to to their usual patient fees (HHS.gov, 2003).
adhere to such guidelines in order to maintain BIPA also enhanced reimbursement for ser-
privileges and credentialing. vices delivered via telehealth and modified
requirements of reimbursement eligibility of “marketing” and may be shared subject to a

delivery and receiving sites. Eligible services business associate agreement and provided
include psychiatric services, professional the PHI is used only for communication
consultations, and office visits (Mueller, activities (OCR, HIPAA Privacy Guidance,
2001; AAFP, 2004). 2003). The DHHS advisory opinion states:
A communication is not “marketing” if it is made
Federal Health Insurance Portability
for case management or care coordination for the
and Accountability Act individual, or to direct or recommend alternative
treatments, therapies, health care providers, or
Virtually everyone involved in health settings of care to the individual . . . . For exam-
care and health research has been affected by ple, under this exception, it is not “marketing”
HIPAA. This wide-sweeping privacy law was when: (1) an endocrinologist (such as when deal-
originally intended to lead to “administrative ing with a diabetic patient) shares a patient’s medi-
cal record with several behavior management pro-
simplification” of health care transactions as grams to determine which program best suits the
well as protect patients’ privacy and right to ongoing needs of the individual patient (OCR,
leave one employer for another without inter- 2003).
ruption in health insurance. Most health plans
HIPAA and Contacts by the Media. Health
have found HIPAA to be anything but sim-
care providers may be asked by media rep-
ple or simplifying. This discussion will focus
resentatives for private health information on
exclusively on the sharing of private health
private or public record patients involved in
information (PHI).
a public event such as a police investigation.
HIPAA and Business Associate Agreements. While police and fire personnel are not bound
The Department of Health and Human Servi- by HIPAA, health care entities are required to
ces issued the final HIPAA privacy regulations honor a patient’s right to privacy. Members of
in December 2000 and these regulations have the press may go to great lengths to get a story,
slowly been phased in throughout the health including waiting in hospital hallways, calling
industry. Under most circumstances, health patients’ rooms, waiting outside facilities for
care providers are mandated to protect the patients or family as they are coming and go-
privacy of patients’ PHI. Ordinarily, patients ing, and contacting friends at home or at work.
also must consent to the release of any PHI Nevertheless, any health care provider with
and other health care providers, such as access to patient information may not share
DM companies should be asked to sign a that information with anyone not involved in
“Business Associate Agreement.” A model treatment, payment or health care operations
“Business Associate Agreement” can be (TPO) involving the patient. Most health care
accessed through the Office of Civil Rights at entities have adopted policies and standards
http://www.hhs.gov/ocr/hipaa/contractprov. for employees and medical staff to follow
html#1. The DHHS Office of Civil Rights and when contacted by members of the media.
Office of Continuing Review also have issued Other HIPAA considerations:
advisory standards clarifying that health care
r Privacy rule and cell phone use
providers may share PHI for purposes of r Communication regarding minors
treatment, payment or health care operations r When case managers call and are unable
(TPO), and that such information falls under
to talk directly to a patient
the exceptions to “marketing.” Certain com-
mon health care communications undertaken These areas are murky and if not cov-
for “case management or care coordination ered by state laws may have to be handled
for the individual or to direct alternative on an institutional basis through the establish-
treatments, therapies, health care providers, ment of policies. Some legal advisors do not
or setting of care to the individual” are not feel health matters should be communicated
by a health provider by cell phone, while oth- is illegal for a health plan or DM program to
ers argue that digital technology has advanced discriminate against a health plan member or
to the point where detection of messages and participant on the basis of gender, race, eth-
conversations is not possible. Communication nicity, religion, age, or disability. In addition,
directly with minors also should be a matter several states prohibit discrimination on the
of policy consideration. Many organizations basis of sexual orientation. These rights ap-
request authorization or consent to treat and ply to all aspects of patient care, including
communicate with minors as medically nec- DM. Many health care entities, as well as pri-
essary. vate and public programs require all new em-
ployees to receive training concerning patient
Consolidated Health Informatics Initiative rights and documented training of all employ-
ees at least annually. One example given by
This initiative was launched by the fed- the Department of Justice illustrates the re-
eral government in 2001 with a mandate to solve of the U.S. Government to prosecute
adopt integrated systems of exchanging ex- discriminatory behavior:
isting health information between all federal
agencies with health-related missions who are “An HMO that enrolls Medicaid patients tells a
required to exchange their health information Mexican American woman with cerebral palsy to
with other public or private entities. Federal come back another day for an appointment while
it provides immediate assistance to others.
officials believe that adopting systems that This example may be a violation of federal
“speak the same language” will reduce error laws that prohibit discrimination because of dis-
rates, improve patient safety and lower ad- ability as well as laws that prohibit discrimina-
ministrative costs. Thus, any agency that ex- tion because of national origin. If you believe
changes health-related information is required you have been discriminated against because you
have a disability you may contact the Disability
to adopt common messaging standards and ac- Rights Section at (800) 514-0301 (voice) or 800-
quire ability to transmit that information in a 514-0383 (TTY). You may also write to: Disabil-
way that maintains its meaning. The Consoli- ity Rights Section, P.O. Box 66738, Washington,
dated Health Informatics standards will affect D.C. 20035-6738” (U.S. Department of Justice,
health plans and DM programs by requiring 2004).
the adoption of vocabulary and messaging
adopted by the “Government-wide Health IT Role of Accreditation and Certification
Governance Council.” To date standards have in Diabetes DM
been adopted in the following domains:
r Laboratory result names Accreditation and Certification are two
r Messaging standards: includes schedul- methods through which DM programs and in-
ing, medical record/image management, dividual providers demonstrate professional
patient administration, observation re- competence and attainment of excellence in
porting, financial management, patient meeting DM standards and improving quality
care of care. Several organizations provide accred-
r Messaging standards: includes retail phar-
itation, and Table 23.3 lists prominent accred-
macy transactions iting/certification programs.
r Messaging standards: connectivity
r Messaging standards: includes image in- The National Committee for Quality As-
formation to workstations.
surance (NCQA) began offering accreditation
and certification for diabetes DM in 1991. Ac-
Discrimination Laws cording to the NCQA web site, a total of 21
organizations have been accredited by NCQA,
Under Title VII of the Civil Rights Act, and three are certified in disease specific areas.
ADEA and the ADA, and most state laws, it Nearly all health care organizations providing
TABLE 23.3. Accrediting Organizations practitioners and not patients. (NCQA’s Dis-
ease Management Accreditation and Certifi-
NCQA National Committee for Quality
cation Programs, 2004: Accessed 4/20/04).
Assurance
JCAHO Joint Commission for
Accreditation of Hospital According to the NCQA, “[a]ccredi-
Organizations tation is a rigorous and comprehensive evalu-
AAHC/URAC American Accreditation Health
ation process through which NCQA assesses
Care Commission/Utilization
Review and Accreditation the quality of the key systems and processes
Commission that define a health plan. Accreditation also
ABQAURP American Board of Quality includes an assessment of the care and ser-
Assurance and Utilization vice plans delivered in important areas . . . ”
Review Physicians
(NCQA, 2004). Being accredited signifies
ADA American Diabetes Association
AADE Association of Diabetic that a health plan meets “best practice” guide-
Educators lines, is in compliance with standards and pro-
tocol for disease specific care, and has proven,
through data, that it meets the benchmarks.
The Joint Commission for the Accred-
direct patient care are eligible, including:
itation of Health Organizations is primarily
(1) DM organizations; (2) HMOs, MCOs,
known for its accreditation of health care orga-
physician/provider organizations (PPOs), and
nizations that are in compliance with its stan-
behavioral health organizations; (3) Physician
dards. More recently, the JCAHO developed
organizations and physician groups, (4) Hos-
Disease Specific Care Certification Programs
pitals, (5) Pharmaceutical or Drug companies;
for health plans, DM service companies,
(6) Pharmacy benefit companies; and (7) Case
hospitals, and other organizations providing
Management or population management or-
health care. To achieve JCAHO certification,
ganizations (NCQA, 2004—brochure).
a DM program must show compliance with
The NCQA requires health plans and
consensus-based national standards, use of
health providers to evaluate and measure
those guidelines, and an organized approach
performance against at least two evidence-
to self-evaluation and permanence measure-
based clinical practice guidelines and demon-
ment. The JCAHO initial certification process
strate consistency with practice guidelines
requires an off-site and on-site evaluation.
in utilization (Gosfield, 1996, p. 196). The
Thereafter, to remain certified, organizations
NCQA’s DM Accreditation and Certification
must demonstrate that they are utilizing up-
Program principles and “best practices” in
dated guidelines and complying with applica-
chronic care management are available online
ble standards (JCAHO, accessed 4/20/04).
at: http://www.ncqa.org. The NCQA makes
The Utilization Review and Accredi-
three accreditation options available for or-
tation Committee is a nonprofit indepen-
ganizations depending upon the nature of the
dent organization that provides accreditation
health organization and their operation. These
and certification programs found in vari-
three options are:
ous health care settings. URAC provides 16
(a) Patient and practitioner oriented accreditation programs, including DM and
accreditation. For those organizations that case management. The organization also pro-
work with both patients and individual prac-
vides certification to vendors of DM services
titioners.
(b) Patient oriented accreditation. For
or claims management organizations—but
those organizations that work directly with who are not DM organizations. One of
patients but have no contact with practition- URAC’s strengths is its recognized exper-
ers. tise in HIPAA privacy and security rules
(c) Practitioner oriented accreditation. and implementation of Compliance Plans by
For those organizations that work only with an organization. The accreditation process
TABLE 23.4. Accreditation and Certification Organizations

Disease management
accreditation program Who is affected? Additional comments
JCAHO accreditation All health care organizations that JCAHO accreditation is institution
demonstrate compliance with specific—applying primarily to
hospitals and in-patient care
facilities.
JCAHO certification Health plans, DM service Disease-specific certification diabetes
companies, hospitals, and other certification requires implementation
health delivery organizations of the Wagner chronic care model
NCQA accreditation Organizations, health plans, Applies to health plans and
pharmaceutical companies. organizations offering disease
management. Disease specific
NCQA certification Hospitals health plans (if Requires peer review and credentialing
accredited by NCQA) of physicians
URAC accreditation All health plans. All health care Institutions apply for accreditation
providers who have access to
PHI including electronic
transmittal of PHI.
URAC certification Vendors of DM support services Applicable to vendors of electronic
applications and hardware.
ADA (diabetes Individual health providers, health A certified diabetes educator certificate
self-management organizations, regardless of is awarded recognizing health care
certification program) corporate status or all health professionals with expertise in
care providers and health care diabetes education, who has met
employers eligibility requirements and
successfully completed a certification
exam.
begins with a self-evaluation proceeding to management as an essential component of di-

review, on-site visit, and final review by an abetes care. The ADA is a nonprofit health
Accreditation Committee. A listing of the organization that provides diabetes research,
URAC accreditation programs can be found information, and advocacy and whose mission
at http://www.urac.org/prog. is to prevent and cure diabetes and to improve
The American Board of Quality As- the lives of all people affected by diabetes.
surance and Utilization Review Physicians The AADE is a multidisciplinary organization
(ABQA-URP) is an organization of interdis- whose core objective is to advance the prac-
ciplinary health care professionals dedicated tice of diabetes self-management training as
to providing health care education and certifi- a fundamental component of health care for
cation for physicians, nurses, and other health patients with diabetes.
care professionals. It provides accredited Table 23.4 provides a summary of DM
health education services and is sponsored accreditation and certification organizations.
by the American Medical Association
(AMA), the American Hospital Association
(AHA), and the Federation of State Medical CONCLUSION
Boards.
The American Diabetes Association and For a diabetes DM program to operate
the American Association of Diabetes Educa- effectively, leaders and administrators must
tors (AADE) provide certification in Diabetes take the time to acquaint themselves with all
Self-Management Education (DSME). Both laws and regulations as well as accreditation
the ADA and the AADE support team and certification requirements that may be
applicable. Failure to become familiar and fol- Department of Justice. (2004). Available at: http://
low applicable laws and regulations may not www.usdoj.gov/crt/legalinfo/natlorg-eng.htm.
Drug Improvement and Modernization Act (MMA).
only impact payment for services, but also
(2003). Amendment to Title XVIII, Section 1806
could subject your staff and organization to of Social Security Act. Subtitle C—Chronic Care
needless investigations and/or sanctions. This Improvement. Sec 721, Federal Register, December
chapter has provided only an overview of the 8, 2003. Public Law 108–173.
many laws that may be applicable to a given Gosfield, A. (1996). A Guide to Key Legal Issues in
Managed Care Quality. Vol. 2. Faulkner and Gray
program. Those who operate DM programs
Healthcare Information Center, Spencer Vibbert
would be well advised to invest the time and Publisher. New York, NY.
money in a full consultation with legal advi- Mueller, K.J. (2001). Benefits improvement and protec-
sors who can advise more specifically about tion act provisions: Where do we go from here?
both state laws and changes in federal laws RUPRI center for rural health policy analysis. Avail-
able at: www.rupri.org/healthpolicy. Accessed July
that may impact your organization.
27, 2004.
National Conference of State Legislators (NCSL).
Ac knowledgements. Funding for the (2004). State disease management program descrip-
Chronic Disease Management in Rural Areas tions. August, 2003 Available at: http://www.ncsl.
study was funded by grant # 5 U1C RH 00033 org/programs/health/StateDiseasemgmt1.htm. Ac-
through the Southwest Rural Health Research cessed March 25, 2004.
Center, the Office of Rural Health Policy and National Guideline Clearing House. (2004). Available at:
http://www.guideline.gov/. Accessed July 27, 2004.
the Health Resources Services Administra- NCQA. (2004). News: Medicare Bill Contains Important
tion (HRSA), US Department of Health and Quality Reporting, Pay-For-Performance Provi-
Human Services (HHS). sions, November 25, 2003. Available at: http://www.
ncqa.org/Communications/News/medicarestmt.htm.
Accessed July 27, 2004.
NCQA Disease Management Accreditation and Certifi-
REFERENCES cation Programs. (2004). Available at: http://www.
ncqa.org/Programs/Accreditation/Certification/
American Academy of Family Practitioners. (2004). DMAA/DM%20Brochure.pdf. Accessed April 20,
Telehealth discussion paper. Available at: http:// 2004.
www.aafp.org/x17527.xml. Accessed July 28, Office of Civil Rights. (2003). HIPAA Privacy Guidance.
2004. Sample Business Associate Contract Provi-
CMS (2003). Drug Improvement and Modernization Act, sions (Published in FR 67 No. 157, pp. 53182,
Social Security Act 108–173, US Department of 53264). Available at: http://www.hhs.gov/ocr/
Health and Human Services, Centers for Medicare hipaa/contractprov.html#1. Accessed March 14,
and Medicaid Services. 2005.
24
Economics
Jennifer Ryan
Chief Executive Officer, Chiricahua Community Health Centers, Inc., Elfrida, Arizona
The annual cost of diabetes (direct and in- three times those for people without the con-
direct) rose from $98 billion in 1997 to dition (World Health Organization [WHO],
$132 billion in 2002, according to a study 2002).
published by the American Diabetes Associ- An estimated 30 million people through-
ation (ADA). The direct medical care more out the world had diabetes in 1985 but by
than doubled in that time, from $44 billion 1995, this number reached 135 million. Esti-
in 1997 to $98.1 billion in 2002. “Diabetes mates indicate that the number will be closer
continues to be a huge financial burden on pa- to 300 million by the year 2025. The num-
tients, their families and society, a burden that ber of deaths related to the disease are on
continues to grow in parallel with the obe- the rise and often related to cardiovascular
sity and diabetes epidemics in this country. issues. An estimated 9% of the total global
We must all work to fight this disease that population will die from the disease and com-
touches so many of our daily lives” (Overbay, plications; many are thought to be premature
2004). deaths when people are still in the work force
Diabetes is a costly disease. The eco- (WHO, 2002).
nomic impact includes the quantifiable direct It has been estimated that diabetes af-
costs of medical care, along with the more fects more than16 million Americans. Al-
elusive indirect costs of lost productivity and though those diagnosed account for only 3.8%
the intangible social costs of pain and suffer- of the United States population, the disease
ing. Studies in India estimate that, for a low- is responsible for 5.8% of all personal health
income family with an adult with diabetes, as care expenditures (ADA, 2002). Type 2 dia-
much as 25% of family income may be de- betes is a preventable disease and some prac-
voted to that individual’s care. For families titioners now apply the modalities of eat-
in the Unites States with a child who has di- ing disorder treatment to their patients. With
abetes, the corresponding figure is 10%. The the rising costs of health care, primary and
total health care costs of a person with diabetes secondary diabetes prevention become more
in the United States are between twice and significant.
311
312 ECONOMICS
LITERATURE REVIEW These differences amounted to $104.86

per member per month or $1,294.32 per year.
Several studies on the costs of diabetes For the continuously enrolled patients in this
appeared in the late 1970s and increased dur- study, a savings of $4,035,689.70 per year in
ing the 1980s. Comparison among the eco- fewer claims were paid compared to the non-
nomic estimations is fairly consistent, but the program participants.
methodologies and baseline years differ. Ad- The Economic Costs of Diabetes in the
ditional studies followed in the 1990s parallel- U.S. in 2002 estimates the medical expendi-
ing the reduced reimbursement for health care tures for the U.S. population with and with-
providers as the country moved away from out diabetes by sex, age, race/ethnicity, types
indemnity fee-for-service health care plans of medical condition, and health care setting
to the managed care organizations. Diabetes (Hogan et al., 2003). Health care use and to-
Care, published by the ADA, is the leading tal health care expenditure attributable to di-
journal of clinical research that includes a peer abetes were estimated using etiological frac-
review process. tions and calculated based on national health
Currently published materials match dis- care survey data.
ease management models and outcomes. A This study found that the prevalence of
2002 report by Jaan Sidorov, Does diabetes diabetes increases with age and is higher
disease management save money and improve among certain racial and ethnic minority pop-
outcomes, presents a study comparing health ulations. If diabetes prevalence rates remain
care costs for patients who fulfilled health em- constant over time, based on U.S. Census
ployer data and information set (HEDIS) cri- Bureau population projections, the number
teria for diabetes and were in a health mainte- of people with diabetes could increase to
nance organization (HMO) Geisinger Health 14.5 million by 2010 and to 17.4 million by
Plan (GHP) sponsored disease-management 2020. The projected increases suggest that
program with those not in disease manage- the annual cost in 2002 dollars of diabetes
ment (Sidorov, 2002). could rise to an estimated $156 billion by
During a two-year period, 6,700 patients 2010 and to $192 billion by 2020. The ac-
fulfilling HEDIS criteria for the diagnosis of tual costs could be even higher if the cost of
diabetes for GHP, 3,118 (45.9%) who were health care rises faster than the cost of liv-
enrolled in the disease management program ing or if the complications increase prevalence
were compared to 3,681 who were not en- rates.
rolled. The following data were revealed: Among patients with diabetes examined
in a study from the Agency for Healthcare Re-
r Program patients incurred $394.62 per search Quality, 30% had two or more hospital
member per month in mean total claims compared stays that contributed to more than 50% of
to $502.48 for those not in disease management. total hospitalizations and total hospital costs
r The mean number of emergency room (the hospital cost per patient was nearly three
visits was 0.49 per patient for program participants times as high for patients who had multiple ad-
compared to 0.56 among the comparison group. missions). The researchers used 1999 Health-
r Program patients experienced a higher
care Cost and Utilization Project (HCUP) dis-
mean number of primary care office visits: 8.4 per
charge data for five states to identify 648,748
patient per year compared to 7.8 for nonprogram
individuals who had one or more hospitaliza-
patients.
r Program participants experienced favor- tions listing diabetes. The likelihood of hav-
able HEDIS scores: HbAlc, lipid, eye, and kidney ing multiple hospitalizations was higher for
screening were 96.6, 91.1, 79.1, and 68.5%, respec- elderly Hispanics (37%) and blacks (34%)
tively, compared to 83.8, 77.6, 64.9, and 39.3% for compared with whites (31%), as well as for
the other group. patients covered by Medicare or Medicaid and
ECONOMICS 313
those living in low-income areas. The authors on ambulance services; $3+ billion on hos-
conclude that clinical and policy interventions pital outpatient care; $4 billion on home
should be developed to target vulnerable pop- health care; half-a-billion on hospice care;
ulations (Hogan et al., 2003). $17.5 billion for outpatient medication and
supplies; and $40 billion to indirect costs due
to lost productivity. Senator Scoop Jackson’s
DIRECT COSTS OF DIABETES famous quip on the floors of Congress comes
to mind, “A billion here, a billion there, soon
Direct costs are divided into direct med- we’re talking about real money.” For dia-
ical costs and direct nonmedical costs. Direct betes costs, the real money two years ago was
medical costs are those resulting from the de- $132, 000,000, and projections for the near
livery of clinical services such as office visits, and distant future suggest it will rise at an
hospitalizations, medications, and health pro- increasing rate.
grams. Direct nonmedical costs derive from
activities such as transportation and the value
of time used for care. INDIRECT COSTS
From an economic perspective, the cost
of a service is different from the price of Indirect costs are largely related to a
that service. Price is a function of what the disability from the complications of dia-
marketplace will bear (in comparison to the betes rather than from the disease itself.
charges of other providers of the same or For example, macrovascular diabetes such as
like service). Cost is a function of the mul- retinopathy, nephropathy, and neuropathy are
tiple inputs required to produce the good or the leading cause of blindness, end stage re-
service-labor, materials, etc. Estimated costs nal diseases, and nontraumatic amputation
are less, often times much less, than the com- (National Institutes of Health, 1995).
mon price. For example, the current cost of an Indirect costs also include the value of
HbAlc in rural Arizona is $7.80 but the price is changes in the work force or the worth of
$14.00. This difference often skews the com- lost work time. Indirect costs are often dis-
parison data available unless the distinction is cussed in terms of productivity. Working
declared. age individuals with serious illness will cost
Direct medical costs and indirect expen- their employer more in terms of absenteeism
ditures attributable to diabetes in the year and medical costs than those without seri-
2002 were estimated at $132 billion by the ous morbidities. A 2002 study found that, in
ADA (Hogan et al., 2003). In a Position State- 1998, the employer’s mean annual per capita
ment, Economic Costs of Diabetes in the U.S. costs were higher for all diabetes beneficiaries
in 2002, direct medical expenditures totaled than for control subjects without the disease
$91.8 billion including $23.2 billion for dia- ($7,778 ± $16,176 versus $3,367 ± $8,783;
betes care, $24.6 billion for chronic compli- p < 0.0001), yielding an incremental cost of
cations attributable to diabetes, and $44.1 bil- $4,410 ± $18,407 associated with diabetes
lion for excess prevalence of general medical (Ramsey et al., 2002).
conditions. Another study examining the economic
This tabulated breakout of the dollar total impact of obesity discovered that the cost of
costs included institutional care cost of $54+ type 2 diabetes (attributable to poor weight
billion; hospital in-patient care of $40+ bil- management) was $12.7 billion in 1990 (Wolf
lion; nursing home care of $14 billion; and and Colditz, 1994). This figure included some,
outpatient care cost of $20+ billion. It also in- but not all the costs of the associated lost pro-
cluded $10 billion spent in physician offices; ductivity resulting from excess mortality, be-
$2 billion for emergency care; $146 million cause many are difficult to quantify.
314 ECONOMICS
More recent studies have examined the acquiring the skills to meet those goals and
costs to the individual and society of initial trouble shooting as problems arise require the
treatment, follow-up, and late treatment for patient to actively collaborate at every stage
type 1 diabetes. The costs of this disease peak (RWJF, 2004).
at diagnosis and again with the development
of complications. A consensus in the litera-
ture is that cost control is considerably more THE COSTS OF PREVENTING
difficult for type 1, but that intensive patient DIABETES
education, shortened hospital stays, mainte-
nance of good metabolic control, and mental The Diabetes Prevention Program (DPP)
health can reduce and contain costs (Simell has demonstrated that type 2 diabetes can
et al., 1996). be prevented (Diabetes Prevention Research
Group, 2002). The cost analysis performed
in the DPP revealed that the annual direct
SOCIAL COSTS costs of the metformin and lifestyle inter-
ventions averaged $1,000–$1,400 more than
Intangible costs are the economic value the placebo group the first year and about
of grief, pain, suffering, and other difficult to $700 each year thereafter. The cost of identi-
value costs for the patient and their families. fying patients with impaired glucose tolerance
Many people have no signs or symptoms until and the intervention was less than half the di-
the disease process is well underway. Symp- rect medical costs for the three-year period of
toms also can be so mild that they might not the study. The study also attempted to quan-
be noticed. More than 5 million people in the tify the direct nonmedical costs. Costs were
United States have type 2 diabetes and do not assigned to the value of physical activity per
know it (National Diabetes Information Clear- hour and another dollar value of leisure time.
inghouse, 2004). According to a recent study, Diabetes:
This study of 3,234 people at high risk for Disabling, Deadly and on the Rise, released
diabetes showed that a 5–7% weight loss can in 2004, the many complications of diabetes
delay and possibly prevent diabetes. The low- can be prevented (Gerberding, 2004):
cost intervention of diet and exercise for peo- r Eye disease and blindness. Regular eye
ple with increased thirst, increased hunger, fa-
exams and timely treatment could prevent up to
tigue, increased urination, weight loss, blurred 90% of diabetes-related blindness; only 64.2% of
vision, and sores that do not heal can have a people with diabetes received annual dilated eye
significant impact on intangible health care exams in 2002.
costs. r Kidney disease. About 42,813 people
Advances, the Robert Wood Johnson with diabetes develop kidney failure each year and
Foundation (RWJF) Quarterly Newsletter, over 100,000 are treated. Better control of blood
outlines 10 rules for health care reform—four pressure and blood glucose levels could reduce
of which seek to make the patient not the ob- diabetes-related kidney failure by about 50%.
r Amputations. About 82,000 peo-
ject of care but a care collaborator (RWJF,
2004). The concept of patient activation in ple have diabetes related leg, foot, or toe
amputations each year. Foot care programs that
relationship to the control of chronic illness
include regular examinations and patient education
is one of the keys to controlling the costs of could prevent up to 85% of these amputations.
health care. r Cardiovascular disease. Heart disease
RWJF’s $6.3 million, two-program na- and stroke cause about 65% of deaths among peo-
tional Diabetes Initiative places patient activa- ple with diabetes. The deaths could be reduced by
tion in the forefront of the campaign to combat 30% with improved care to control blood pressure,
the disease. The social control of setting goals, blood glucose, and blood cholesterol levels.
ECONOMICS 315
r Pregnancy complications. About 18,000 an expense center to a revenue center (Hall,

women with preexisting diabetes and about 2002). An expense center is a business unit
135,000 women with gestational diabetes give birth created to accumulate outflows of cash or
each year. Risks can be reduced with screenings other using up of assets or incurrence of li-
and diabetes care before, during, and after preg- abilities during a period from delivering or
nancy.
r Flu and pneumonia-related deaths. Each producing goods, rendering services or other
year, 10,000–30,000 people with diabetes die of
activities that constitute the entity’s ongoing
complications from the flu or pneumonia. They are major or central operations. A revenue center
roughly three times more likely to die of these com- is a business unit created to accumulate in-
plications than people without diabetes. flows of cash or other enhancements of assets
or settlements of its liabilities during a period
from delivering or producing goods, render-
HOW TO COMPUTE THE DIRECT ing services or other activities that constitute
AND INDIRECT COSTS OF the entity’s ongoing major or central opera-
TREATMENT tions.
This may be an optimistic view but we
The computation of either direct or indi- do know that optimal diabetes control is best
rect costs of the treatment of diabetes in a stan- achieved by a patient through a multidisci-
dardized form is difficult because the severity plinary approach from a team of providers and
of the disease determines the treatment, med- skilled workers (i.e., certified diabetes educa-
ications, and services required. Differences tors and behavioral health counselors). Cost
also exist in categories such as the price of savings are realized when the program out-
testing equipment (i.e., glucometers) and the comes are targeted and realized. Estimations
supplies (test strips). indicate that such costs can be reduced at 4, 10,
Prior to the 1970s, the United States 20, and 30% for each 1% reduction in HbA1c
health care system functioned primarily un- from 7% to 10%, respectively (Gilmer et al.,
der an indemnity insurance payment mecha- 1997). The standardized cost differences for
nism, with separation of health care delivery 1% change in HbA1c for 3,017 adults with
and financing. Premiums were collected and diabetes over a three-year period are illus-
providers were paid on a fee-for-service basis. trated by the following (Diabetes Care, 1997,
This structure resulted in a lack of incentives pp. 1847–1853).
for providers and consumers to use the health
Reduction in HbA1c levels, corresponded to a
care system efficiently. The passage of the savings measured in standardized costs. For ex-
HMO Act in 1973 revolutionized health care ample, in patients with diabetes, only, a change
delivery with the development of health main- from 10% to 9% HbA1c yielded a $1,200 sav-
tenance organizations as a means of reducing ings. From 9% to 8%, the savings was $900; from
costs. Managed care organizations have pro- 8% to 7% it was $600; and from 7% to 6% the
savings was $400. The rates of savings are pro-
liferated, capturing a large portion of the mar- portionally larger for patients with diabetes with
ket share formerly held by indemnity plans. hypertension, and more for patients with diabetes
More than 43% of the population is insured and heart disease. For patients with diabetes with
by some type of managed care plan (Tobin and hypertension and heart disease, a reduction from
Godley, 1997). The Balanced Budget Act of 10% to 9% yielded a $4,000 savings; 9% to 8%
saved $3000; 8% to 7% saved $2,200; and 7% to
1997 provides Medicare coverage for diabetes 6% saved $1,500.
and patient education.
According to some assessments, with the HbA1c level measurements are an excel-
development of well-organized Diabetes Dis- lent index of diabetes management in the pa-
ease Management Programs, there is poten- tient, and an excellent feedback mechanism
tial for providers to turn the programs from for the conscientious patient who manages
316 ECONOMICS
his or her diabetes by frequent blood glu- Diabetes Prevention Research Group. (2002). Reduction
cose measurement. Cost reduction does not in the incidence of type 2 diabetes with lifestyle
modification or metformin. N Engl J Med. 346:393–
stop with glycemic control. Managed care
403.
organizations have discovered that enrollees Gerberding, J.L. (2004). Diabetes: Disabling, Deadly, and
with diabetes have higher rates of cardiovas- on the Rise—At A Glance 2004. Centers for Disease
cular, eye, lower-extremity, and renal disease Control and Prevention, National Center for Chronic
compared to other enrollees. Prevention and Disease Prevention and Health Promotion. Available
at: http://www.cdc.gov/diabetes. Accessed August,
early treatment for these issues may translate
2004.
into further savings. Gilmer, T.P., O’Connor, P.J., Manning, W.G., and Rush,
The $132 billion-cost estimate is con- W.G. The cost to health plans of poor glycemic con-
servative and understates the true burden of trol. Diabetes Care 20:1847–1853.
diabetes. Diabetes prevention, early detec- Hall, D.E. (May, 2002). Business Plan Proposal for a
Diabetes Disease Management Program, Lancaster
tion, intensive treatment, and control can con-
Regional Medical Center (unpublished document).
tribute a significant cost saving to the overall National Diabetes Information Clearinghouse. (2004).
health care system, to the patients, and to their National Institute of Diabetes, Digestive, and Kid-
families. ney Diseases, Am I At Risk for Type 2 Diabetes?
Taking Steps to Lower the Risk of Getting Diabetes.
National Diabetes Information Clearinghouse, NIH
Publication 04-4805, April 2004.
Overbay, M. (2004). Study shows sharp rise in cost of
REFERENCES diabetes nationwide. American Diabetes Associa-
tion. Available at http://www.diabetes.org. Accessed
American Diabetes Association. (2002). Direct and Indi- August, 2004.
rect Costs of Diabetes. Available at: http://www. di- Ramsey, M.D., Summers, K.H., Leong, S.A, Birnbaum,
abetes.org/main/info/facts/impact/default2.jsp. Ac- H.G., Kemner, J.E., and Greenberg, P. Diabetes Care
cessed February 7, 2002. 25:23–29.
National Institute of Diabetes and Kidney Dis- The Robert Wood Johnson Foundation Newsletter Ad-
eases in American, 2nd ed. Available at http:// vances. Available at www.rwjf.org/publications/
care.diabetesjournals.org/cgi/reprint/26/3/917.pdf newsletter/advances2 2004.pdf
National Institute of Diabetes and Kidney Diseases in Sidorov, J. (2002). Diabetes Care 25:684–689.
America, 2nd ed. Harris, M.I., Cowie, C.C., Stem, Simell, T.T., Sintonen, H., and Hahl, J. (1996). Pharma-
M.P., Boyko, E.J., Reiber, G.E., Bennett, P.H., Eds. coEconomics 9(1):24–38.
Washington, D.C., U.S. Govt. Printing Office, 1995 Tobin, C., and Godley, K. (eds.). (1997). Navigating the
(NIH publ. no. 95-1468). Healthcare Financing System: A Guide for Diabetes
Jiang, H.D., Stryer, D., Friedman, B., and Andrews, R. Educators. Chicago, IL: American Association of
Multiple hospitalizations for patients with diabetes. Diabetes Educators.
Diabetes Care 26:1421–1426, 2003. Wolf, A.M., and Colditz, G.A. (1994). PharmacoEco-
American Diabetes Association: Economics costs of di- nomics 5(Suppl 1):34–37.
abetes in the U.S. In 2002. Diabetes Care 26:917, World Health Organization, Fact Sheet No. 236,
2003. September 2002. Available at: http://www.who.int/
(1997). The cost to health plans of poor glycemic control. mediacentre/factsheets/fs236/en/print.html. Acces-
Diabetes Care 20(12):1847–1853. sed July 22, 2004.
25
Funding
Donna Zazworsky
Carondolet Health Network, Tucson, Arizona; St. Elizabeth of Hungary Clinic, Tucson, Arizona; and Case Manager
Solutions, LLC, Tucson, Arizona
INTRODUCTION help position the program for short- and long-term

potential?
Establishing a diabetes disease man- 3. What are the sociodemographic, eco-
agement program involves careful planning. nomic, and cultural barriers of the target popula-
Not only must the program be shaped from tion?
a thorough-needs assessment and program-
design process, but it must also include After careful consideration of these as-
a strategic plan for funding and sustain- pects, a program design and funding strategy
ability. This chapter will provide informa- is developed. So often, programs are designed
tion on funding strategies and sources that and implemented because they are given fund-
can be considered wherever an organiza- ing for a project. This can be shortsided if the
tion may be along this continuum of disease “real” issue of needs, barriers, and long-term
management. sustainability are not addressed. Too often,
these programs are closed and the results can
be a negative public image of the program and
its affiliated organization. Therefore, a fund-
FUNDING STRATEGIES ing plan depends on several key elements:
Funding strategies for a diabetes dis- r the target population to be served,

ease management program is considered a r the organization’s incentives to provide a
part of the program design, expandability, and full or partial disease management program,
sustainability. Therefore, the following key r potential partners with this program,
r the continuum of care that the program
financial-related program issues must be con-
sidered when developing a financial plan. will encompass, and
r short- and long-term expectations, in-
1. Who is the target population(s) to be cluding sustainability.
served? And what are their needs?
2. What are the local, state, and national The following steps will incorporate these key
trend analyses for reimbursement issues that will elements into a funding plan.
317
318 FUNDING
Identify the Target Population and larger co-payments for the educational series.
Diabetes Care Needs Then the question is whether most patients can
afford—or feel that it is important enough to
It is critical to identify the target pop- pay the co-payments. In some way, this could
ulation for the diabetes disease management be a disincentive for the patient and the pro-
program in order to begin defining funding gram may not be able to maintain a certain
strategies. The targeting process will pro- volume to offset their costs. Therefore, it is
vide direction for reimbursement and funding critical to work out these details upfront and
needs in both short- and long-term perspec- include a clause regarding any type of reim-
tives. It will also guide the health care provider bursement or co-payment changes.
systems of the disease management program In another example, a primary care clinic
in policy reform to address long-term finan- is offered a “pay for performance” incentive
cial sustainability. program by their local health plan. In this case,
If the target population has health in- the clinic would receive a bonus for improved
surance: then the following questions will be HbA1cs over time. Like the other organiza-
helpful tion, a cost analysis process would serve as the
r What elements of diabetes care does the premise for implementing the type or types
health insurance cover: provider visits, group vis- of proven outcome practice models such as
its, 1:1 or group education visits by nursing and the “Planned Visit” or “Group Visit” models
dietitians, medication, supplies, and equipment? discussed in the case studies and “Chapter 6.”
r Does the plan require that educators be a Again, detailed discussions must be addressed
Certified Diabetes Educator (CDE) and that their with the health plan prior to entering into any
education program is ADA certified? arrangements, since appropriate staffing is-
r Does the individual have a co-payment
sues could be a financial burden rather than
with each of these elements? If so, how much is the
a benefit.
co-pay and could this be a barrier for the individual?
If the target population is uninsured, then
For example, one organization may only a different set of questions must be asked.
want to provide a specific service to an
r What is the uninsured target population’s
already-identified target population because
of a reimbursement initiative. This may be a diabetes needs? Is it for primary care, education,
local hospital that has been approached by a medications, supplies, and equipment?
r Are there specific cultural barriers that
health plan to provide a diabetes education
will need to be addressed in the funding strategies,
class to the plan’s enrollees. In this case, a
such as bilingual providers, educators, and materi-
cost analysis of the service would drive the als?
charges and lead to appropriate contract and r Will the uninsured individual be able to
funding arrangements. In other words, what is pay some type of co-payment? If so, what will they
cost of staff, materials and space . . . and then, be able to afford?
how much does the hospital need to charge
the plan? An uninsured population requires a more
An important issue of this case is if the community-based focus where a provider
plan decides to pass on some of the costs to organization or a provider coalition would
the patient. If the plan requires that health ed- take a proactive approach to influence the
ucators are CDEs and that the program is cer- health of a community or target population.
tified by the American Diabetes Association In this scenario, a population-driven model
(ADA), then the cost of the program will be would include a funding plan that lays a foun-
much higher in order to maintain these stan- dation to progressively build a full service
dards. In some cases, the health plan may pass diabetes chronic care management system
this higher cost onto the patient by requiring that addresses health promotion, disease
FUNDING 319
management, and acute care components. r Is outside/consulting needed?

The outcomes could then be capable of r Is there a billing function involved? Who
influencing health policy changes as a result will do this?
of demonstrated cost benefit analyses and For example, if the decision is to do dia-
clinical outcomes. betes education classes, then what are the data
Define the Diabetes Disease Management that need to be collected and does the organi-
System and Process zation have the software to support it. In most
cases, a simple excel program will sufficiently
The first aspect to consider in funding track data, but will the data entry require an
a disease management system and process is additional part-time or full-time position.
what type of program and services will be On the other hand, if the organization de-
implemented initially. It is important to decides to take a more extensive approach and
termine the infrastructure that will be needed establish a full diabetes disease management
to support the program, i.e., manpower, pub- system, then your organization may want to
licity, information system software and man- set up a registry with a more intensive ef-
power support, regular reports, etc. The fol- fort at clinical data. What data are important
lowing checklist provides general guidance in to collect—clinical, financial? How will this
developing a budget and identifying funding data be transferred from the visit to the reg-
support. istry? Who will manage the registry? What
type of reports will be generated, i.e., patient
lists, aggregate data, etc.? All of these compo-
Program/Services
nents must be factored into the funding pro-
r What is the scope of diabetes program or gram.
services that the organization has decided to do?
r Can the program be broken down into
Equipment and Supplies
separate components, i.e., manpower, equipment,
supplies, etc.? r Does the program/services require addi-
r Who is the target population? tional equipment (i.e., DCA machine) or supplies?
r How will the revenue be generated? r How will patients receive their equipment
r Does there need to be a research com- and supplies?
ponent? If so, does it require an Internal Review
Board process?
r What kind of development effort is Medications
needed? r Does the program/services need to cover
r Will the program/services need to go
medications?
through a legal review (i.e., consent forms, HIPAA, r Does the organization need to establish
etc.)? a Pharmacy Assistance Program? If so, who will
r Are there other agency/community part-
manage the program?
nerships that should be considered?
These are just a few questions, but criti-
Infrastructure Support cal to consider when building a full diabetes
r What type of manpower is needed in the disease management system and identifying
potential funding sources.
direct program/service delivery (nursing, dietitian
community health worker) and indirect (i.e., Med-
ical Director, clerical support)? Identify Funding Sources for Your
r What type of information must be col- Program and Services
lected?
r Who will manage the information (i.e., Matching the funding source(s) with the
collect, enter, and manage the data)? program and services requires a knowledge of
320 FUNDING
Partnerships Grants
Service SEHC YWCA CHN Grant 1 Grant 2 Grant 3 Primary
Care
Funding
$25,000 $25,000 $5000
1. Find and Assess X X
- ICD9 Analysis X X
- TriFit Diabetes
Health Risk
Assessment
(SEHC Registration and
YWCA Outreach)
- Mobile Podiatry
2. Stratify
- Known X
- Unknown X
3. Treat
a. Quarterly Clinic X X
Visits per Protocols
HbA1c X X
Glucometers X X
Glucometer Strips X X X
Insulin X
b. Program Manager X X
c. Clinical Educators
Clinic Nurse X X
Dietitian X X
e. Community Ed
Carondelet X
Community Classes
f. Education Material X X X X
g. Newsletter X
4. Train X
Staff X
Community Health X
Advisors (Promotoras)
5. Track
Registry X
Outreach X X X
Evaluation X X
FIGURE 25.1. St. Elizabeth’s diabetes disease management funding grid: Year 1.
“who are the potential funders” and “what are funding. In some cases, one-time purchases
they willing to fund.” It is helpful to develop a such as equipment can be easily funded by
Funding Grid that breaks down the program. local business or service groups such as
It can be drafted for a program that addresses the Rotary or Kiwanas Club. Other funding
manpower, supplies, publicity, etc. or it can might include grants, private donations, spe-
be for a system illustrated in Figure 25.1. cial taxes, or fundraising events.
The Funding Grid is a tool to help sort Here are a few options in funding. One
out what pieces of the program are being key rule to remember: it is vital that the pro-
cover/reimbursed and what elements need gram goals match with the funder’s goals. It is
FUNDING 321
a waste of time to submit to a funding agency of knowledge, but it also brings opportuni-
who only wants to fund programs in a certain ties for student learning experiences that will
geographic location. translate into volunteer manpower to an or-
ganization. This has also been an avenue to
obtain evaluation services and other research
FUND SOURCES opportunities that can demonstrate the out-
comes of your program and lead to quality
Government Agencies improvement.
Another positive aspect in working with
Government agencies grants can be bro-
a university is the Student Work Study Pro-
ken into three major categories: local, state,
gram. This program pays students for their
and federal government grants.
work experience and places students in iden-
tified organizations that they have an ar-
Local: County and City Block Grants
rangement with. In return, the organization
These are provided by the city and pays a small percentage of the student’s
county governmental entities, such as City salary.
Block Grants and health department grants.
These grants may be for new services, equip- Foundations
ment, building opportunities, or infrastruc-
ture. They have very specific guidelines Foundations are another resource for
requirements and may mandate attendance to funding programs and services. Many of the
a workshop prior to grant submission. professional foundations, such as the National
Kidney Foundation will offer grants for re-
State Grants search. Foundations can be found at a local,
state, or national level and are an important
State grants are available through the source of support for healthcare organiza-
state’s Governor’s Office, State Health De- tions. Here are a few tips to increase chances
partment, or other State agencies. Again, these of funding from a foundation:
grants have very specific guidelines and re-
porting requirements. r Be sure to match your objectives with the
foundations objectives. If the foundation is only
Federal Grants funding programs in a certain geographic region,
and your organization is outside of that region, do
Federal grants offer a broad range of op-
not waste your time.
portunities to support research, service, and r Establish a rapport early with the funding
program development. A resource list is pro- contact.
vided at the end of the chapter to identify key r Attend any meetings or conference calls
government granting agencies. It is always that are offered by the foundation to discuss the
helpful to have the support of your local state grant requirements.
senator or representative to facilitate grant r Follow the guidelines closely and answer
support. Contact their office and meet with the questions that are asked.
r Use charts, graphs, photos, or other
them or their health assistant to build knowl-
edge and support of your needs and efforts. attention-getting features in your proposal.
University (Co-sponsors) Faith-Based Grants
University partnerships are important. Faith-based grants may be available

Not only does the university offer a wealth through government and foundation sources.
322 FUNDING
Pharmaceutical the Student Nurses Association. Explore the

community.
Most pharmaceutical companies offer a In closing, funding sources are available,
number of financial support. Many companies but a strategic plan is critical to the long-term
have an indigent medication program, which viability of the program. It is difficult to keep
provides medications for free as long as a pa- asking agencies to continue to fund the same
tient qualifies financially. Another funding op- services—most funders will not get involved
portunity with pharmaceutical companies is if there is not a solid plan for sustainability.
their grant program. Contact the pharmaceu- Therefore, the new program or service must be
tical company directly or work with the local well thought out with their financial viability
representative to learn more about their fund- before seeking funding.
ing programs.
Diversify your Revenue Streams: “Don’t Put RESOURCES

All Your Eggs in One Basket.”
Kenner, C., and Walden, M. (2001). Grant Writing Tips
When establishing your revenue sources, for Nurses. Washington, DC: American Nurses As-
develop a variety of funding avenues. In other sociation.
words, do not put all your eggs in one bas-
ket. It is imperative to create a reimbursement Web Resources
mechanism through patient fees and/or con- General:
tracts with payers. If the program is depen-
Grants and Related Resources: www.lib.mus.edu/
dent solely on one or two grants, what happens
harris23/grants/federal.htm.
when those grants are finished? Grants Resources on the Internet: A Detailed Guide:
www.library.wisc.edu/libraries/Memor.
Include Fundraising As Part of Your Grants Web: www.infoserv.rttonet.psu.edu/gweb.htm.
Welcome to GrantsNet: www.grantsnet.org.
Program
Do not overlook the opportunity for Government Grants:

fundraising to help support your activities. HRSA Grants and Contracts: www.hrsa.dhhs.gov/
This can become a teambuilding experience grants.htm.
for the staff and patients. National Institute for Health (NIH) Guide Index:
www.med.nyu.edu/hih-guide.htm.
NIH: www.grants.nih.gov/grants/.
FUNDRAISING ACTIVITIES Centers for Disease Control and Prevention (CDC):
www.cdc.gov/od/pgo/forminfo.htm.
Fundraising also should be considered.
An organization can decide to hold their own Foundations:
fundraising activities or become the recipi- The Foundation Center: www.fdncenter.org.
ent of another agency’s fundraising activities. Bill and Melinda Gates Foundation: www.gatesfound-
For example, one organization has received ation.org.
an annual donation from a local professional National Foundation Funding Sources for Rural Health:
www.nal.usda.gov/ric/richs/foundat.htm.
women’s sorority. This sorority holds an an-
nual dinner-dance and auction. Their pro-
Faith-Based Grants
ceeds go to the indigent clinic for cancer
care. Some examples could include the local http://www.whitehouse.gov/government/fbci/grants-cata
medical auxiliary, the dental association, or log-index.html.
26
Tools for Getting Your Message Out

about Diabetes
Marketing/Public Relations, Social Marketing,
and Media Advocacy
Vicki B. Gaubeca
INTRODUCTION immensely in their approach, target audience,

and effect.
Communication is an important element
of change, whether at an interpersonal level Public Relations and Marketing
(patient–doctor) or at a community wide level.
Many prevention activities and public health This strategy is perhaps the most famil-
interventions utilize marketing, communica- iar. The main objective of this level of com-
tions, and public relations techniques to ac- munication is to inform.
complish their objectives. The initial goal is to get the message
It is important to distinguish the basic to a specific or general audience that a pro-
differences among the models of communi- gram (or product) exists. The ultimate goal
cation used by health professionals. There are might be to recruit participants for a study,
five general strategies of communication that to inform patients of new services, to pub-
are related to treatment and health promotion licize an accomplishment, or to get name
programs: recognition.
For example, a health care provider of
r Public relations and marketing.
r a diabetes complications prevention program
Social marketing. might utilize public relations strategies to in-
r Media Literacy.
r form the community about the program. They
Speaking Engagements.
r Media advocacy.
may contact a local reporter and tell them
about the program. The reporter then might
Although these strategies may look sim- interview key people and write a story; the
ilar in the ways they are executed, they vary story runs in the newspaper or is broadcast
323
324 TOOLS FOR GETTING YOUR MESSAGE OUT
on TV; and finally the provider’s phone rings instances, prohibitive for television. To maxi-
with calls from people interested in partici- mize your investment, you will want to decide
pating in the program. This example is public ahead of time who your target audience is and
relations (sometimes known as media rela- whether you want to use print or broadcast
tions) at its best. advertising. Another difference from public
Using the same example, the health relations activities is that you would be call-
provider may decide that the program has a ing the marketing/advertising department and
small advertising budget, so they contact the speaking to an account executive instead of a
marketing departments of their local media reporter.
representatives to find out how much an ad Creating brochures, special publications,
would cost. An ad is designed and placed and, and web sites also fall in the province of mar-
in turn, phone calls result from people inter- keting activities. The costs involved in the
ested in participating in the program. This production and distribution of these tools of
example illustrates the differences between marketing vary on size, colors used, quantity,
public relations (or media relations) and mar- dissemination method, etc. Again, deciding
keting activities. who your audience is and the best way to reach
Generally, in public relations, the place- them will help determine how much invest-
ment of a message is free (the time spent with ment is needed.
the reporter is the only real expense). How- Public relations and marketing efforts
ever, one cannot control how the reporter will can target internal or external audiences.
write the story, how long the story will be, Many large organizations (and even some
what quotes he or she will use, the angle of smaller ones) create newsletters or other
the story, or in what section or page the story modes of communication to inform their
will be placed. employees about company news that affect
The same is true of broadcast journalism. them personally. This audience would be
One cannot control where in the news report considered an internal audience. An organi-
the story will run. It could be aired as a “top zation may want to communicate items to an
of the news” story or it could wind up being a internal audience, but not want to publicize
“sound bite” or end of the news show “kicker.” this information to an external audience (i.e.,
A person might even agree to do an interview the general public). Examples of internal
for an evening news report and, because of marketing items would be brochures, special
another “late-breaking” news story, the story publications, and internal web sites that are
might air in the morning news show, which written to provide information specifically to
typically has fewer viewers, or none at all. employees.
In most cases, you can get a general feel Later in this chapter, we will discuss in
for the story during the interview with the re- detail the different tools of communication
porter. But it also is okay to ask upfront what and marketing and show examples of press
the angle is on the story. You also may influ- releases and public service announcements
ence the angle of the story if you contact the (PSAs). We also will discuss different mar-
reporter initially and “pitch” an angle. Later keting tools, such as brochures and web sites
on in this chapter, we will provide some tips and considerations to take into account when
on how to handle media interviews that will using these.
enhance the chances of your message being
placed prominently in the news. Social Marketing
In marketing, you have greater control
over the message and its placement; how- Social marketing is a term that bor-
ever, the cost of placing an ad can be high rows from marketing theories used in busi-
for newspapers and magazines, and in some ness and commercial settings. When used in
TOOLS FOR GETTING YOUR MESSAGE OUT 325
the prevention or health care setting, its major interpret media messages. Media literacy pro-
aim is to change individual health behaviors. fessionals that focus their work on this aspect
Communications at this level typically develop interventions that train target audi-
attempt not only to increase the awareness ences to interpret the messages they receive
of a target population about a certain health via the different modes of communication
issue, but also aim to motivate this audi- (i.e., newspapers, television, movies, etc.).
ence to change. A social marketing inter- Interventions presented by this aspect of
vention will sometimes utilize the four “P’s” media literacy range from the development of
of marketing (product, price, placement, and basic skills to identify the frames in which
promotion). messages are presented to the development of
For example, the product might be en- all-out conspiracy theories related to large me-
couraging people to start doing a 30-minute dia conglomerates aiming to allegedly brain-
walk in the mornings or to quit smoking. The wash consumers to a particular political view
respective price of each product would be the or product purchase.
target audience’s time commitment of 30 min- For example, these interventions show
utes or of dealing with the symptoms of nico- how photographs are cropped by print and
tine withdrawal. Placement of a walking or broadcast media to change actual events (e.g.,
tobacco cessation program might consider the a political rally that was attended by only
habits of people with sedentary lifestyles or 10 people will show a small group of peo-
who smoke and their exposure to media out- ple cropped tightly with the podium in front
lets. It may also include nontraditional place- of them to give the illusion that the rally was
ment venues like church bulletins, billboards, well attended) or they discuss how large cor-
grocery store bulletin boards, etc. Promotion porations mass distribute specialty items with
of either program will attempt to package the their company logo and tag line. Others will
program in its most sellable form. In health discuss how sex and sex appeal are weaved
promotion activities, it focuses on increasing into visual and text messages to sell a prod-
the perceived benefits of the activity. The tar- uct.
get audience then “gets” how important it is Some of the more moderate interven-
for their health, quality of life, and longevity tions can be helpful for many target audiences.
to engage in a morning walk or to quit Interventions that educate younger audiences
smoking. on how the media sometimes glamorizes, for
Unlike commercial marketing, which is example, smoking or alcohol consumption,
driven by the profit margins of an organiza- may help this audience decide not to take up
tion, social marketing is driven by the bene- these habits to emulate media icons.
fits obtained by a target group or “society” in The second aspect of media literacy is a
general. Common examples of social market- more practical one for health providers and
ing ads include antitobacco and antidrug TV health promotion professionals. It is based
ad campaigns geared toward teenagers, which on the theory that effective health commu-
attempt to steer them away from smoking or nications take into account the target audi-
using drugs. Another common example is ads ence’s culture, age, gender, ethnicity, socio-
on how wearing car seat belts can save lives economic status, regional differences, and so
during an automobile accident. on. The aim of health professionals that focus
on this aspect of media literacy is to create
Media Literacy communications that speak directly to the au-
dience they are trying to reach.
There are two main, distinct aspects of Activities under this aspect include
media literacy. The first looks at the capacity translations and back-translations (to ensure
of individuals and communities to read and these items are translated without changing
their meaning) and conducting focus groups to ing, and social marketing, but the biggest dif-
evaluate the success of the messaging or fram- ference is in its target audience: policy mak-
ing of the message in relation to the specific ers and community leaders. When gaining a
characteristics of the target audience (gender, placement (via advertising, news story, or edi-
ethnicity, etc.). torial), media advocacy succeeds when a new
policy or a change in policy is suggested.
Speaking Engagements Used effectively, media advocacy can re-
frame public debates; it can help shape new
The participation of health professionals laws that protect the health of individuals
in speaker’s bureaus, seminars, grand rounds, (such as no-smoking policies in restaurants
and conferences cannot be underestimated as or in the workplace); and it can help push leg-
an effective communications strategy. Often islators, for example, to fund neighborhood
these speaking engagements offer an oppor- renewal projects that include walking/cycling
tunity to raise awareness about a particular paths.
health or public health subject and to offer Media advocacy will play an ever in-
tips on better health management and disease creasing role in the fight against obesity in the
prevention. United States and the related high incidence
These engagements also offer an oppor- of type 2 diabetes. Some visionaries argue that
tunity for networking or getting a person’s media advocacy might ultimately help shape
name out as an expert in a particular subject. the environment we live in to make it incon-
No group is too smal or too large to not be venient for people to engage in an unhealthy
considered as an opportunity to get a message lifestyle.
out there. Groups like the Kiwanis Club, the However, it will probably take concerted
Knights of Columbus or other membership or- communication strategies at all levels to effect
ganizations are constantly seeking a speaker necessary lifestyle changes in the fight against
for their regular meetings. obesity and the higher incidence of chronic
To get the word out to these groups, conditions in this country.
some health organizations offer a directory The reduction in the prevalence in smok-
of speakers and topic areas to community ing serves as a good example of how the dif-
groups. Some organizations even have ded- ferent strategies of communication have been
icated staff who take calls from community used effectively:
members seeking speakers for their groups
and who match an organization’s experts to r At the public relations/marketing level
these requests. are the news stories providing information about
tobacco cessation programs, along with ads related
Media Advocacy to a smoker’s helpline or cessation program.
r At the social marketing level, are the news
More and more, health professionals stories and features about a smoker dying of em-
are moving toward media advocacy to effect physema or the TV ad campaigns targeting youth.
change. Media advocacy is about applying Both of these levels aim at the individual’s personal
pressure on policy makers and community ability to change behavior, but in the first the aim is
to inform and in the second, the aim is to encourage
leaders so that changes can occur at the policy
smokers to quit or youth to avoid starting the habit.
or environmental level. The philosophy be- r At the media literacy level, are the many
hind these efforts is that individual behavior studies that showed, for example, how tobacco
changes need to be supported by the environ- companies were specifically targeting women or
ment in which individuals coexist. youth and the consequent interventions that raised
Media advocacy uses the same modes of the public’s awareness of these tactics. Another
communication as public relations, market- example that fits the media literacy level, are the
tobacco cessation ads directed at particularly “vul- sages are developed, it is important to dissem-
nerable” groups, like ethnic minorities and youth. inate these to both your internal and external
r At the “speaking engagements” level, are
audiences.
the countless of forums and public presentations Let us say that you decide that your key
about the questionable tactics of large tobacco cor- messages are:
porations as well as those presentations elucidating
the detriments to health caused by tobacco prod- 1. We want to reduce the incidence of dia-
ucts. betes in the Hispanic/Latino population.
r At the media advocacy level are the edito- 2. We are the only program in northwestern
rials on smoking and news features that discuss the Atlantis doing this.
importance of changing or implementing a policy
(such as creating a smoke-free workplace or ban- If a reporter were to call anyone on your
ning smoking in restaurants). Editorials and news staff, they should all be able to include these
features help influence legislators and other policy two messages as part of their responses.
makers to sponsor bills or vote on a bill related to Communication tools used by this pro-
smoking. gram should contain this information some-
By looking at the success of the efforts where. In press releases or brochures, for ex-
against tobacco use and the methods utilized, ample, you can add a “tag paragraph” at the
one can develop a similar communication end that says “Program XXX is the only pro-
strategy for any health intervention, including gram in northwestern Atlantis aimed at pre-
those focusing on prevention or management venting diabetes among the Hispanic/Latino
of diabetes or any chronic condition. population.”
DEVELOPING KEY MESSAGES DRAWING ATTENTION TO

YOUR MESSAGE
One of the most important steps in de-
veloping effective communication strategies Once you have established what you
is figuring out exactly what you are trying to want to say, the next step is to determine
say. The identification of a few clear, key mes- the target audience and the best way to reach
sages and repeating them as often as necessary them.
is the best way to build an image campaign and Who do you want to hear your mes-
is a rationale behind large companies devel- sage? Are you trying to reach a particular
oping “tag lines” such as “Think Outside of cultural group, such as Hispanics or African
the Bun” (Taco Bell r
) or “Can You Hear Me Americans? There are several sources of in-
r
Now?” (Verizon ). formation that provide this information. A
Without the selection of a few key mes- quick search on the internet or in the refer-
sages (preferably one to three), you will con- ences section of a library usually results in a
fuse the audience you are trying to reach. plethora of information that can help deter-
You also may confuse the people who work mine how to reach a specific audience.
with you. Often organizations or programs Arbitronr
, for example, is a company
fail to inform their constituents of their goals that specializes in compiling demographic
in a clear, succinct manner. Key messages trends for U.S. radio listeners. Available
can serve as compass points for the direction free online, you can download and print a
of an agency or program and the efforts of report that will illustrate how many radio
the people who participate and work in these stations there are countrywide (more than
programs. 13,800 in 2004) and the listening patterns
Key messages can be found in a mission of Americans. The reports provide informa-
statement or prime directive. Once key mes- tion that ranges from the general, such as
the time of day Americans listen to the radio For theme-specific reports that ana-
most (during the morning commute time on lyze the consequences of marketing prac-
weekdays) and least (while most people sleep, tices and how these affect certain demo-
12–5 a.m.), and the gender and age of lis- graphics, the Federal Trade Commission of-
teners. Arbitron’s 2004 “Radio Today: How fers reports on violence in TV and films, na-
America Listens to Radio” illustrates many tional marketing practices, cigarette sales, ad-
details of the American listening patterns, vertising and promotion, weight-loss adver-
such as people’s favorite formats (teens pre- tising practices, false claims on spam and
fer music that is “current” while “oldies is the more.
format of choice for older baby boomers in the Similar demographic data exist for print
45–54 age group, followed closely by Adult readers. Most magazines and newspapers can
Contemporary/Smooth Jazz”). provide, on request, a synopsis of their de-
The report also can tell you items and mographics. Local TV and radio stations can
details you would not normally expect to see, do the same. Tracking this information is a
such as the fact that nearly “one-third of the useful tool for media outlets when they sell
people living in households planning to buy advertising space.
a new SUV are Adult Contemporary listen- After determining the audience you want
ers.” According to this report, 35% of this to reach and how, the other question you need
group also has gone in-line skating in the past to ask is why do you want to reach this partic-
12 months and about 29.1% have eaten at a ular audience? Is there a call to action in your
fast-food restaurant five times or more in the message? Do you, for example, want them
past 30 days. to participate in a study or contribute money
Arbitron also offers reports that describe to a cause? Or is your program part of a so-
a specific demographic, such as Hispanics or cial marketing strategy that aims to change the
African Americans. In the 2004 Edition of behavior of a target audience? For example,
“Hispanic Radio Today: How America Lis- you develop a marketing campaign that en-
tens to Radio,” Arbitron notes that of the more courages teenagers to steer away from using
than 13,800 radio stations in the United States, tobacco or to talk to their parents about safe
about 650 offer Hispanic formats. This report sex. The answer to this question is a primor-
provides station trends, age of listeners, hour- dial component of a key message.
by-hour data, overnight listening habits, lis- At this point, you should determine
tening locations, formats by region, favorite whether or not to disseminate this message us-
formats and more. ing marketing or public relations techniques
Another corporation that is dedicated to (or both). If you decide the former, then you
tracking audience habits is Nielsen Media need to get the attention of your target au-
Research, which is best known for its Nielsen dience by designing a publication, web site,
Ratings. This company not only measures ad, etc., that will effectively speak to that
trends in television (network, cable, and satel- audience (culturally, age-appropriate, literacy
lite) and radio audiences in the United States level, and so on). If you decide the latter, then
and worldwide, but also measures Internet you need to know how to get the attention of
usage. Available on their web site are re- media representatives.
ports and CDs on viewing trends (which in-
clude anything from average daily viewing Marketing Your Message
to VCR penetration in U.S. households), lo-
cal market reports (ranging in cost from $60 If you decide to use a marketing strategy,
to $1,300), and maps illustrating designated the size of your budget will play a key role
market areas (ranging in cost from $35 to in how you get the attention of your target
$550). audience.
The resources you have on-hand (budget, finding an interesting statistic helps sell the story.
creative staff, dissemination methods) need For example, “one of every two Pima Indians over
to match your objectives. For example, you the age of 35 has type 2 diabetes” is a remark-
cannot aim to change the lifestyle habits of able statistic that should prompt media coverage.
all community members in the United States, It is also valid to say “the first XX in the north-
ernmost region of Atlantis that specializes in nasal
when your program’s budget supports a slight
warts.”
reduction in smoking in two neighborhoods r The story needs to be timely, particularly
of Southside Atlantis. if you are writing a letter to the editor or a guest ed-
There are several marketing models you itorial. For example, when former U.S. President
can use to ensure that you are spending Ronald Reagan passed away, headline news sto-
your budget in the most effective way. Fo- ries related to Alzheimer’s disease permeated both
cus groups can help hone your messages and print and broadcast media for a week. Angles on
learn whether or not these messages are be- the story varied from the controversy and promise
ing heard the way you want them to be heard. of stem cell research to how to recognize and test
Pretest and posttest evaluations also are use- for Alzheimer’s and available resources for people
ful or you may choose to hire a consultant or affected by Alzheimer’s.
r Along with timeliness comes being re-
agency that specializes in evaluating the ef-
sponsive and available. Sometimes a reporter will
fects of program strategies. call your organization to speak to an “expert” on
In any program, it is important to have a story they are working on. If your organization
an evaluation component early in its design is large enough to have a public relations officer,
and implementation whether or not you decide reporters may call them directly. The public rela-
to use marketing or public relations strate- tions officer will call the experts at hand to see
gies. Measuring outcomes is key when you if they are available and willing to talk to the re-
are seeking to re-fund a program, to evalu- porters. This benefits the “experts” because they
ate its effectiveness, or to report back to the are not receiving a call directly from a reporter
community. without at least a few minutes to prepare for the in-
Later on in this chapter, you will see a de- terview. This also protects expert’s time if they are
not available to speak to the reporter. Public rela-
scription of the different tools used in market-
tions officers benefit the reporters because they will
ing (from print and broadcast ads to brochures know who in the organization can best answer the
and specialty items). questions.
Getting Your Message into the News

Press Releases
If you decide to follow a public relations
strategy, then your strategy shifts from sell- The most common tool used for dis-
ing the story directly to the target audience tributing information and garnering “free”
to selling your story to a reporter or news attention about an entity’s activities and ac-
editor. In the news business, the reporters complishments is the writing and distribu-
and editors are essentially the gatekeepers of tion of press releases. Press releases often
information. can result in a media story that carries an
The following characteristics make a important public health message to a wide
story sellable to a reporter/editor: audience.
When writing a release, remember to be
r The story needs to be interesting. Think factual. Do not exaggerate the points of your
of the old adage “dog bites man, no news, but story and do not use all caps or exclama-
man bites dog is news.” The story does not have tion marks. Many smaller media outlets will
to be a cure for cancer, but it needs a new angle to sometimes print your release verbatim, so try
it, like the “first” or “latest” in something. Often, to write it as if it were a news article. Read
newspapers to get a feel for what this writing Abbreviation of State)”, e.g., Feb. 9, 2004
looks like. (Paris, TX).
Keep press releases as short as possi- ◦ Contact information of the person
ble. Editors and reporters do not have the reporters can call for more information about
time to read through lengthy releases. One the subject of the release. Sometimes releases
will have two contact numbers, one for the
8.5 × 11 inch page is standard. Use a font
public relations representative who wrote the
that is at least 10 points in size. Use a letter- release and another for the person to contact
head for your release that has your organiza- who knows more about the subject of the re-
tion name and logo, address and main phone lease. For example, a release about a new
number. cancer clinical trial seeking participants will
There are several types of press releases list the number of the person to contact if re-
depending on the type of event/program you porters would like to interview the principal
want to publicize. (See sample releases in investigator on the study and another number
“Appendix”). for the general public to call if they wish to
participate in the study. In all cases, double-
r A calendar release announces a specific check phone numbers and e-mail addresses,
event that will happen in the community, such as before sending the release out.
a health fair, a lecture, or a seminar series. At a ◦ A lead paragraph (the first para-
minimum, this release should include: graph) that summarizes the story. Headlines
◦ Event Name (e.g., “Unhealthy are typically written from the lead paragraph.
Eaters Anonymous,” “Diabetes Health Fair,” If possible, summarize the “what, when,
“Cancer 5K Fun Walk/Run”). where, who, why, and how” in the lead para-
◦ Time (when the event is held). graph. If possible use a “hook” in the lead
◦ Location (where the event will be). paragraph, such as “study reveals for the first
◦ Fee or cost (if none, write “Free”). time, the benefits of cinnamon in the control
◦ Contact information (name and of diabetes.”
phone number of where to RSVP or who ◦ The body of the release elaborates
to contact for more information about the on the “what, when, where, who, why, and
event.) Double check phone numbers before how” and provides additional background in-
sending the calendar release out. formation. Unlike fiction or essay writing,
r A media advisory is typically used to an- where the writing builds up to the most im-
nounce a press conference or an event that is closed portant information and draws the reader in
to the public, but open for media coverage. Its for- slowly, a press release is written with the most
mat is similar to that of a calendar release and con- important information first. This is known as
tains the same minimum information listed above. an upside down pyramid structure of writ-
Print and broadcast media receive thousands of ing. The reason releases (as well as the news
press releases a day. Placing the words “Calendar stories that journalist write) are written this
Release” or “Media Advisory” at the beginning of way is because in trying to fit the story on
the release will quickly tell the recipient whether a page, an editor will cut the last paragraphs
the release needs to go to the calendar editor or first. Repeat contact information at the end
whether it is a story that needs to be assigned to a of the release.
reporter. ◦ Tag paragraphs are an optional part
r A general press release is the most com- of releases and are included as part of a gen-
monly used format used. It generally has six parts: eral image campaign for your organization
◦ A headline that summarizes what or program. These are usually one to three
the story is about. sentences that summarize the goals of your
◦ A date (date of when the press was program or organization and serve as a back-
written/released to the media and, if applica- ground to the reporter about your entity. Typ-
ble, a date of when an event that is the subject ically, the font is italicized on the tag para-
of the release happened or will happen) or a graph to distinguish it from the rest of the
dateline, usually in the format of “date (City, release.
Center the characters “—MORE—” on leases are appropriate if you would like cov-
the bottom of the page if the release contin- erage about a specific event or about a note-
ues. On the bottom of the last page, center worthy achievement by one of your program
the characters “—30—” or “###” to indicate members (i.e., an award or some other special
the end of the release. These symbols are an recognition).
industry standard and are expected by most However, if you want to encourage a
reporters and editors. larger feature or human interest story, you may
After sending a press release out, it is a decide to target specific newspapers, TV sta-
good idea to follow up with a phone call to tions, or reporters and contact them person-
ensure they have received the release. During ally. Sometimes, providing them with an “ex-
this call, simply state who you are and that you clusive” on your story increases your chances
are calling to make sure they have received the for getting a bigger placement of your story.
release. Use a “soft-sale” approach when you Making phone calls or sending a personal
do this. Usually what will happen is that they e-mail to a specific reporter also may result
will search through the pile on their desk to in a more in-depth human interest story, be-
see if they can find the release. If they cannot cause by talking to the reporter one-on-one
find it, offer to fax or e-mail it to them again. If you might be able to better illustrate the im-
they do find it, just say something to the effect portance of your story or show the reporter
of “Great! Just wanted to make sure you got the “passion” behind a story that cannot be
it.” conveyed on a release.
You may want to add an encouraging E-mails do not garner the immediate at-
line, such as “I personally was impressed with tention that a phone call will, but they are less
the results of this study and I just wanted to intrusive on a reporter’s time and often are the
make sure you knew about them.” But try to preferred method of contact. If you decide to
steer away from a hard sale approach or ask call or e-mail a reporter, be sure to find out
them if they will cover it. Whether a story gets which method they prefer.
covered or not is usually discussed in early Make sure you know about the topics
staff meetings. Stories that are “fast-breaking” that are covered by the reporter you call or
get top priority, followed by interesting sto- e-mail. If your story has a business angle, you
ries. Often, those “interesting stories” do not should call or e-mail a business reporter. If
pan out and reporters scramble to fill the news it is about health, talk to a health reporter.
with quick, easy stories. Often, this is where Nothing frustrates a reporter more than to get
your press release will come in. Forcing an story ideas that are outside of their coverage
answer early from an assignment editor might area. If the media outlet focuses on reach-
preclude your story from being placed. Your ing a specific audience (Hispanics, Catholics,
phone call, however, succeeded in bringing teenagers, sports enthusiasts, etc.), make sure
attention to your release and it also tells them that your story will interest their readers.
you have an “expert” in place if they should It also helps if you have read any
need one. recent articles written by the reporter or
watched/listened to any of their recent broad-
Phone Calls or E-Mails casts. You can even pitch your story as a
follow-up to one of these stories. Showing re-
Writing a press release and sending it porters that you are familiar with their work
out to several media outlets may result in one not only is flattering to them, but also makes
or two of these outlets picking up the story them more willing to listen to what you have
(sometimes running it verbatim) or, more of- to say.
ten, a reporter calling you to develop a more Use phone calls and e-mails sparingly.
in-depth story. Mass mailings of press re- Overwhelming a reporter with frequent phone
calls and e-mails can be a turnoff to them and To develop a crisis communication plan,
can place your credibility in jeopardy. you may need to bring together key people of
your organization to “dream up” worse case
Press Conferences scenarios and response plans. There is no way
to anticipate all crises that may befall your
Press conferences should be used at a organization. It could be a major accident, a
minimum and only when a story has elicited medical error, a disgruntled employee threat-
enough media interest that all parties involved ening to harm or harming other employees, an
benefit from a news conference. accounting fiasco or other corporate wrongdo-
Sometimes the number of media calls ing, an infectious disease and more. Depend-
received drives the need for a press confer- ing on the organization, simply practicing for
ence because it would be difficult to arrange the worst-case scenario may be enough or you
for separate interviews. For example, a patient may have to develop a manual containing a
who has received the latest state-of-the-art ar- specific crisis communication strategy.
tificial heart transplant or a celebrity patient
may get a lot of requests for interviews from
the media. Arranging a press conference, dur- TYPES OF MASS
ing which time many press members can in- COMMUNICATION/MEDIA
terview the patient at the same time not only
facilitates the interview process, but might be Each media type is driven by differ-
less cumbersome for the patient and physi- ent basic principles. The following section
cians. will describe the different types of media by
Press conferences also are typically used medium (i.e., broadcast, print, and Internet)
during a crisis, particularly when it is im- and include tools used for both marketing and
portant to get the same information out to communications.
a large group of media representatives and
it is fast-breaking news. Examples of these Broadcast Media
could be a large-scale disaster, a kidnapped
child, corporate wrongdoing, or announc- At its most elementary level, broadcast
ing study results that show sizeable implica- media, which includes television and radio, is
tions for the health of a certain population about filling time slots with news and advertis-
(e.g., the use of hormone replacement ther- ing. The biggest limitation to this medium is
apy and its potential negative side effects on time; hence, communications are short and to
women). the point. Radio news stories usually are 15–
30 seconds long; TV news stories are usually
Crisis Communication Plan between 1 and 3 minutes long. News stories on
public broadcast stations typically run longer
Every organization should have a crisis and are more in-depth, but have a smaller au-
communication plan that outlines what to do dience.
in the event of a disaster or crisis. When crises
strike, swift and precise communications— TV and Radio News
often in the midst of chaos—are demanded
by the media (who are acting on behalf TV and radio reporters are always on the
of the public). One of the most important hunt for that important “sound-bite” that is
components of a communication plan in- going to make their story. Reporters need “ex-
cludes identifying a key spokesperson and a perts” in the fields of research, particularly in
backup spokesperson in case this person is not the area of health, to add credibility to their
available. stories.
Reporters value experts who make them- and other times, they will expect the agency
selves available on short notice for an inter- to provide them.
view. They will go to these experts first when Both radio and TV PSAs are usually kept
working on the next story. As noted earlier, under a minute in length, with radio PSAs
one of the most important things to remem- sometimes being as short as 15 seconds.
ber when working with reporters it to make Larger fund-raising organizations, such
yourself available. as the American Diabetes Association or the
Like print news, topics for broadcast American Heart Association, will produce
news stories can include human interest fea- PSAs and distribute them to television and ra-
tures and commentaries. Some stories are a dio stations nationwide. Whether or not they
complete “package” that include reporter in- get aired depends a lot on whether or not the
troductions and segues, sound bites from ex- associations buy air time. Although not com-
perts, and “b-roll,” which are action shots mon, some stations will air the “canned” PSAs
used to illustrate a story (people walking to fill time slots that were not successfully sold
down a hallway or street, walking into a lab, to a business for advertising.
running, etc.). Because of the nature of the Before investing the time and expense
medium, TV news stories demand that inter- of producing a PSA on your own, you should
view topics be visual. TV reporters and pro- meet with target broadcast station account ex-
ducers are constantly seeking innovative set- ecutives to discuss the availability of air time
tings for interviews (office interviews with and their willingness to sponsor these. Be-
a bookcase in the background are simply fore you meet with them, however, determine
overused). And they like any kind of props your target audience, because a station might
or graphics you can provide to illustrate the agree to sponsor your PSAs, but run these at
story. 3 a.m., when most of your target audience is
Unlike the print media, which is open asleep.
to printing guest editorials, broadcast me-
dia rarely offers an opportunity for commen- Video News Releases
tary from people who are not staff mem-
bers. Instead they offer a sundry of formats Video news releases (VNRs) differ from
for round-table discussions or on-set inter- PSAs in that they are preproduced news sto-
views/talk shows. ries that are packaged and distributed by agen-
cies to television stations nationwide. VNRs
Public Service Announcements are the video version of a wire story and are
usually about “nonbreaking” news, such as a
Many radio and TV stations assign a health topic or business tip.
certain percentage of their air time, usually Agencies that produce VNRs will cover
not during prime time, to designated chari- the cost of producing and distributing these
ties and public events. Each radio and TV sta- stories in exchange for interviewing the “ex-
tion decides how to allot this differently. Some perts” of your organization. If a local TV sta-
take requests from area agencies year round tion airs a VNR, they pay a fee to the agency.
and others decide what fund-raising events or For the agency, it is a way of making money.
causes they will sponsor for a year. For the TV station, it is a way to fill air time,
Typically this sponsorship includes the and for you, it is a way to get free publicity
production of a PSA. A writer, a narrator and potentially on a national level.
voice “talent” are required for radio PSAs. A The only consideration about using
writer, cameraman, “talent” (i.e., actor), and VNRs is that your story has to be something
a narrator are required for a TV PSA. Some- that affects a national audience. A story about
times the stations will donate all of these roles a new vaccine against the common cold would
interest them, but a story about a local health r Have established relationships with local
fair, would not. broadcast stations.
r Know what media outlets to use when try-
ing to reach a certain demographic group.
Radio News Releases r Know when to schedule the ads and how
often.
More affordable to produce and dis-
tribute are radio news releases. These are
tape cassettes or compact discs with two to Print Media
three radio news reports and include narra-
At its most elementary level, print media
tion, interviews, sound bites, and scripts. Ra-
is about filling space with news and advertis-
dio stations that are short on reporters (or have
ing. The biggest limitation to this medium is
none) use these to fill air space. These can
space; stories have to fit within the columns
be sent to local, statewide, or national radio
of an assigned page.
stations.
Considerations to take into account when
producing radio news releases is having ac- Newspaper and Magazine Articles
cess to recording and sound editing equip-
ment or a radio booth as well as cassette and Most articles in print are considered
CD reproduction equipment. As with VNRs, straight news stories (i.e., articles that re-
it is difficult to track the placement of these port the news) or features (i.e., articles that
stories. have a human interest angle and are writ-
ten more in-depth about the subject). Straight
news stories contain factual information and
Television and Radio Advertising cover the “what, when, where, who, why, and
how” questions that reporters are trained to
Radio and television advertising can ask. Human feature stories have a more in-
be very expensive, especially on national timate dimension but still try to remain ob-
networks. Running a television ad during jective. Straight news stories are also con-
the Super Bowl, for example, can cost you sidered “fast-breaking,” meaning that they
millions for a few minutes. However, pur- are happening at the moment or in recent
chasing air time on local radio, television time; whereas human feature stories typically
stations, and cable networks can be more have a timeframe, but are not necessarily
affordable. timely.
Most organizations that purchase televi-
sion and radio ads work through an advertis-
ing agency. Using an advertising agency may Opinion Editorials/Letters to the Editor
seem to add to the costs, but in the long run,
Opinion editorials and letters to the ed-
using good agencies will save you money and
itor are excellent tools for disseminating an
your ads will have a larger effect on the audi-
important message to a newspaper’s or mag-
ence you are trying to reach.
azine’s readership. Placement is not guaran-
Advantages to using advertising agen-
teed, but one does control the message, al-
cies include they:
though not to the extent of paid advertising
r Typically have a creative department that because editorials are still edited by the news-
can come up with an ad concept and produce these paper or magazine.
in-house. Both opinion editorials and letters to
r Know where to find the talent for these the editor should address timely issues. Di-
ads. rect reference to a recent event or article
greatly enhances the chances of being pub- 8-page, 12-page, 16-page, and so on). Talk
lished. Word counts should be kept to up a with prospective printers about the best for-
maximum of 250 for letters to the editor and mat to use.
500 for opinion editorials.
Also remember to keep scientific and Print Ads
technical jargon out of submissions to
newspapers. In other words, write the editorial Subscriptions account for only a small
or letter in layperson’s terms. percentage of the revenue made by newspa-
Most newspapers also will publish their per and magazines. Profits are made by selling
own editorials that represent their official advertising space. This also is true for broad-
point of view. Not many people know this, cast media, however, the space a newspaper
but a group or an individual can arrange a or magazine has is more flexible. You can-
meeting with the editorial board and “pitch” not create more time, but you can create more
a particular point of view. The editorial board pages. Because of this, the number of pages
will then discuss the topic and collaborate on and space available for news stories is often
an editorial that agrees or disagrees with the determined by advertising.
group’s or the individual’s point of view; or Fees for ads are determined by its size
they may decide to not write one on the topic and calculated by columnar inch. Some print
altogether. media will provide fees for 1/8-, 1/4-, 1/2- or
full-page ads. Most newspapers and maga-
zines offer a discount to nonprofit organiza-
Newsletters
tions, requiring only that these organizations
Newsletters are typically used for an show them a copy of their 501(3) (c) status.
“internal” audience. The mailing list usu- Most print ads need to be provided as
ally includes people who have been identi- “camera-ready art,” meaning that they are
fied as being part of a certain group. Ex- in the appropriate dimensions and are clean
amples include alumni, resellers, program enough to be photographed for printing.
participants, consumers, company employ- Some newspapers and magazines will
ees, financial donors, sports enthusiasts, hik- have in-house creative departments that can
ers, travelers, seniors, Catholics, and many create ads according to your needs. If you have
more. the budget for a larger print ad campaign, you
The cost of producing newsletters varies may want to work with an advertising agency.
depending on the number of pages and if color They can be invaluable in helping come up
is used. Many organizations will save costs by with an ad concept, design and production, as
producing a one-page, double sided newslet- well as having an effective distribution system
ter that is photocopied on 81/ 2 × 11 inch pain place.
per. A larger version can be photocopied onto
17 × 11 inch paper and folded, effectively Other Print Media and Communication
creating a four-page newsletter. Tools
A larger budget will allow more col-
ors, ranging from a “spot” color to four-color There is a wide range of print media op-
newsletters. tions for disseminating your message, includ-
If you decide to go with a commercial ing brochures, postcards, business reply cards,
printer, the number of pages in a newsletter flyers, and posters.
is often determined by how the offset presses At some point in the design of a publica-
cut, collate, and fold these. Typically, the num- tion you will need to consider the specifica-
ber of pages grows in sets of four (i.e., 4-page, tions in Table 26.1:
TABLE 26.1. Print Specifications

Specification Choices Comments
Paper grades Bond Bond paper is commonly used in photocopy machines and for
(listed choices 8.5 × 11 business letters.
are the most
commonly
used)
Coated This paper literally has a coating on in that improves ink
absorption on the page. Choices include a dull or glossy
coating or coating on one or both sides of the paper.
Text This paper offers many choices of different colors and textures
and is commonly used for flyers, brochures, and pamphlets.
Book Typically used for textbooks and books. This paper is cheaper
than text and offers a wider variety in weight and bulk.
Cover Coated and text paper are made in heavier weights in matching
colors and are used as a cover sheet for brochures, pamphlets,
reports, etc.
Newsprint Used mostly for printing newspapers.
Lightweight (e.g., Specialty grades used for bridal announcements, etc. Because
onion) of their weight, these papers can save on postage.
Colors Black or one color One color printing should cost the same, whether it is black or
another color.
One color (usually Spot color means that a different color is used in specific
black), plus elements on a page (e.g., the headings, borders, boxes, lines,
spot color or other graphic elements). The color on these elements will
be different from the text. Two plates (one for each color) are
needed for spot-color printing.
Four-color (cyan, Four-color printing, which is the most expensive, involves the
yellow, use of four industry hues: cyan (reflects blue and green light,
magenta, black) absorbs red light), yellow (reflects red and green light,
absorbs blue light), magenta (reflects blue and red, absorbs
green light), and black.
Note: In addition to charging a fee for each plate (one for each
color), some commercial printers will charge a nominal fee
(known as a “press wash” fee) for when they clean the
printing equipment between ink colors.
Screens Screens are an area on a page (usually a box shape or a
silhouette) that uses a color that is scaled back to allow text
to be printed on top. A 10% screen reflects black text well; a
50% or higher color screen reflects reverse-text (i.e., white
text) well.
Half-tones and In addition to four-color printing, photographs can be printed as
Duo-tones a black and white half-tone or by using a color and black,
known as a duo-tone. Printing a half-tone or a duo-tone is
more cost effective than printing a four-color photograph.
Paper size Standard and Printers offer a variety of sizes for publications, ranging from
custom standard sizes to custom sizes. Standard sizes are typically
more inexpensive than custom sizes.
Folds Standard and Folds are used most commonly in trifold and accordion type
custom brochures. If you use a heavy stock, such as a cover paper,
the paper might need to be scored before it is folded
automatically. Some printers will charge an extra fee for
scoring.
Binding Saddle stitch A saddle stitch is a staple along the center fold of a publication.
The back of the staple is on the outside cover. The pages and
a cover are folded and placed on a saddle. It is then stapled
two to three times on its center fold, making a booklet.
Side-stitch When a publication is too bulky for a saddle-stitch, a side-stitch

can be used. A side-stitch is basically two to three staples
along the left edge of the pages, binding them together.
Sometimes a tape adhesive is used to hide the staples.
Spiral There are two types of spiral binding. In one, a spiral wire is
woven through several holes down the side of a publication.
In another, a binding machine makes many rectangular holes
in a line along the left side of a publication. Then a plastic
spiral is opened with the same machine and its “teeth” are fed
through the holes.
Adhesive A glue is used to bind all the papers along the left-hand edge.
To reinforce the edge, a cloth tape is usually added.
Pockets and Custom, including A feature in some publications, including folders, is pockets in
inserts business card which inserts can be placed. Generally, the pockets will
size require trimming, scoring, and folding.
Inserts for the pockets can be printed at the same time or as
needed. A popular design is the use of step or staggered
inserts, these are different sizes of paper that follow the same
design as the brochure or folder and whose headings are
staggered.
The biggest advantage of using step inserts is that it increases
the shelf life of the publication. If an update is needed, you
simply update the relevant inserts, pull the old ones, and
replace them with the new ones.
A considerable disadvantage to these is that as years go by and
some items are printed more than once, you wind up having
an uneven number of different inserts. Having a need for
eight inserts of different sizes and quantities may cost you
more in the long run than simply updating and printing an
entire eight-page brochure.
Another common specification is cutting corner lines to insert a
business card. These cuts are fairly inexpensive and the
advantage is that anyone can place their business card in
these precut slots.
Perforations Custom Many publications will have a card with a call to action on it.
Commonly you will see a dotted line with scissors telling a
person where to cut the card, so they may fill out a form and
return. Some people argue that asking a person to find a pair
of scissors may deter them from sending in the card.
Commercial printers can add perforations along the edge of the
card, so that all they would need to do is tear along the edge.
It also helps if you add a business reply card on the back with a
postage permit. See more on business reply cards below.
Brochures folds, named that way because they have three

panels (front and back). Technically, however,
A general brochure outlining the mis- they only have two parallel folds in them.
sion, history, programs, and contact informa- Brochures can be simple black and white
tion can be used for providing orientation copies, black and a spot color or full-fledged
and information about your organization to four-color glossies, depending on the size of
prospective customers, program participants, your budget and the quantity you need. You
students, benefactors, or the general public. may decide to use photographs, graphics, or
Brochures can be designed in all shapes and tables to better convey your message in a
sizes. The most common brochures are tri- succinct manner.
Large print runs (500+) will sometimes These cards usually have a form on one
give you a better price break than if you print side and the address of your organization
a short run (<150). Get at least three esti- preprinted on the other side, along with a
mates from different printers to get the most postage permit number and bar code, allow-
cost-effective rate. You will be surprised to ing the recipient to fill out the form and send
see how much these estimates vary on type of it back to you without costing them postage.
paper, colors and coatings, number of folds, Most direct-mail campaigns and busi-
binding, and custom specifications (such as ness reply cards strategies expect no more
inserts, ragged edges, perforated cards, etc.). than a four to six percent return. Phone
Make sure the date of when you pro- call follow-ups will often generate more re-
duced the brochure is printed on it somewhere sponses, but are labor intensive.
inconspicuously (in month/year format). Also
include an address and phone number of Public Advertising
where readers can get more information about
your organization. Billboards and ads on park benches and
buses can be a cost-effective form of advertis-
Flyers and Posters ing. Locations of billboards and park benches
will affect the cost as well, with busier streets
Flyers and posters are typically one-
having the highest fees. Some billboard com-
sided announcements. Flyers can be useful
panies will donate the space of a billboard
to hand out at different locations and can be
(usually the locations with the least traffic)
used to announce programs or special events.
but will request the nonprofit event or agency
Posters and flyers can be placed on walls or
to pay production costs.
bulletin boards in establishments that allow it.
Keep the text on flyers and posters as
simple as possible and with the most impor- Specialty Items
tant information written in a succinct manner.
Make sure you have a phone number and ad- Sometimes just getting the logo, phone
dress on the flyer or poster where someone number, and tag line of your company or
can get more information or respond. Dou- program out there is the most cost-effective
ble check phone numbers on flyers before dis- marketing. Some of the most popular spe-
tributing these. cialty items include pens, water bottles, sticky
pads, key chains, and note pads. Price breaks
Special Publications are offered as quantities go up. There are nu-
merous corporations that offer specialty items
You may decide to create a publication and who are willing to send customers cata-
that serves only an immediate need, such as an logues where one can pick out a favorite spe-
invitation card with an RSVP card for a special cialty item.
event or a direct-mail advertising piece. The
design and distribution of these will vary on Internet and E-Mails
what you are trying to accomplish (subscrip-
tion renewal, meeting reminder, gauge interest A whole new world of public rela-
in a program, etc.). The cost will vary depend- tions and marketing opportunities has opened
ing on the design and the quantity. up with the advent of Internet and elec-
tronic messaging technologies. In the last few
Business Reply Cards decades:
Some brochures, flyers, newsletters, etc., r Newspapers and magazines have created
may contain a business reply card insert. online versions of their publications, most still
maintaining the production and distribution of the E-News

paper versions as well.
r Television and radio news, along with There are at least two options for “e-
wire news (such as Associated Press and United news.” One is to send out memo-like an-
Press International) have created online news web nouncements on an as-needed basis to a list-
sites. serv. The second is to compile and format an-
r Many organizations have created e-news
nouncements into an e-newsletter that is sent
and e-magazines that are electronically distributed to a listserv on a monthly or other regular basis.
via an electronic mailing list of subscribers.
r Organizations have created their own Advantages to the first are that it is more
timely and specific to an issue. A disadvantage
web site, many of them replacing newsletters and
brochures and thereby saving them money while is that recipients may tire of receiving many
still disseminating necessary information. e-mails they feel they have no time to read.
Advantages to the second option include
a concise way of communicating news in
Internet
a semi-timely fashion (not as timely as in-
The advantages of using web sites are dividual e-mail announcements). Disadvan-
many, including tages include that it requires more time to for-
mat and has a high risk of repeating already
r More flexibility in using color, pho- disseminated information (i.e., high risk for
tographs, and graphics. It really does not matter duplication of effort and e-mails). To avoid
how many colors you use on a web site, it will duplication, a “gatekeeper” role would have to
cost you the same. However, do keep web sites as be created to ensure that individual messages
simple as possible. If your web site is memory- that should be part of the e-newsletter are not
intensive, some users, especially those who access
sent out separately. In addition, a mechanism
the Internet via dial-up modems, will have trou-
for collecting newsworthy items needs to be
ble loading the pages of your web site onto their
computers. established.
r The possibility of updating information E-newsletters should contain no more
in a matter of minutes. than 10 items with hypertext links to relevant
r Unlimited number of subsites/web pages. web sites. To shorten the length of an e-news,
Unlike a publication, which is limited in size by some organizations provide a headline with a
budget constraints, a web site can have an unlim- short paragraph of the story, with a hyperlink
ited number of subsites and options. The only real text that jumps to more details about the story
limitation is the memory capacity of the server on on a web site. Other organizations summa-
which the web site resides. rize as much as possible in their e-news and
Disadvantages to web sites include: include hyperlink texts only as-needed or for
those readers who want more than the basic
r Vulnerability to outside computer hack- information. More and more e-mail users can
ers. Be sure to include strong firewalls and update read HTML, so incorporate graphics into e-
virus detection software frequently to protect the news. For photographs be sure to use JPEGs
server and other computers. or GIFs, because these are smaller files (than
r Many organizations underestimate the la-
BMPs, TIFFS, PNGs, etc.) and run less of a
bor and skill involved in creating and maintaining chance of bogging down the user’s e-mail sys-
web sites. It often is necessary to dedicate person-
tem.
nel to maintain and continuously update the infor-
mation on a web site.
r Despite its popularity, Internet access is
Monitoring and Tracking Placements
still limited. If your target audience falls in a group
marginalized by the latest information technology, One way to track effective communica-
it would not make sense for you to build a web site. tion strategies is to ask people how they heard
about a specific program or organization when sition. But for regular communications, it is
they call or visit. best to identify and train spokespeople by their
Another way is to monitor the number of area of expertise.
news stories in print or broadcast media. It is Having a cadre of trained spokespersons
difficult to track the placement of radio news who feel comfortable speaking with the me-
stories, because it is difficult to monitor all dia and who know the techniques of get-
radio stations and there are few organizations ting their message across effectively can be
that monitor these. Local television news sto- crucial in an image campaign and during a
ries are easier to monitor, because there are crisis.
fewer of them. In addition, many medium to If, for example, the media is writing a
large cities have television news monitoring story about the possibility of fraud by one
organizations. For a subscription fee, they will of the accountants in your organization, then
fax every morning the topics covered on local having a chief financial officer prepared to an-
TV news programs. They also can provide na- swer these questions can make a difference.
tional news broadcasts lists as well, although A well-trained, savvy spokesperson also can
many national broadcast media (including na- turn the prospect of endless dogging by the
tional public radio stations) offer scripts on- paparazzi and front-page headlines into a two-
line for free or for a fee (if they are in the inch, ho-hum story buried in the business sec-
archives). tion. Providing information to a reporter is
Newspapers are much easier to track. always better than a “no comment.”
Clipping services hire people to read through If, in another example, a reporter is writ-
stacks of newspapers and clip articles containing a story about an unusually high inci-
ing key words. The advent of the Internet has dence of nose warts in southern Chile and you
also made clips easier to track. You can pro- happen to have an expert on nose warts on
gram some Internet search engines to notify hand, then you have effectively garnered some
you via email if key words come up in news free publicity for your organization. You can
articles published on the web (which many capitalize even more on this media opportu-
times will have a paper edition as well). Most nity, by having the nose wart expert weave
of the search engines on the Internet are free; your organization’s key messages into his or
however, accessing some articles may cost a her answers.
subscription or per-article fee. If your program is conducting a study
In addition, many newspapers offer on nose warts and you do not have the re-
archives of their prior editions online. Typi- sources to contact news outlets yourself, but
cally reading a current issue is free, but read- your organization is big enough to have a
ing archived issues will cost you a fee or sub- public relations officer, inform these officers
scription. Most of the archived issues offer a of your expertise. Then when a story come
search engine. ups in the media related to your area of re-
search or expertise, they will know to contact
you.
IDENTIFYING AND TRAINING As you have probably surmised by read-
SPOKESPERSONS ing this chapter, there are different ways and
levels of selling a story. You can either do it
Although ideally everyone in an organi- yourself directly, or you can ask a PR/media
zation can serve as a spokesperson, it some- relations person or a reporter to do it for you.
times is best to identify and train a pool of The answer will reside in the resources you
spokespersons. have at hand. If you doubt your writing abil-
For crisis communications, it is best to ities or if you feel unsure about contacting
identify and train a person in a leadership po- reporters directly, seek out the resources you
might have in the community or in your orga-

Technical Jargon Substitute
nization to accomplish your objectives. Amblyopia Lazy eye
Listed below are tips to follow before, Surgical Operation
during and after an interview. intervention
Physician Doctor
Meds Medicines
Oncology Cancer
Media Tips HbA1c Average blood sugar level
Preparing for an Interview

r When a reporter calls you, always find out
what kind of deadline he or she is facing. If they r Be brief! We live in the age of the sound
leave a voice message, call back right away. bite. Television and radio stories may use only a
r Ask for the reporter’s name and the me- 10–30 second cut. Even print reporters look for
dia organization for which he or she is reporting. short, snappy quotes.
However, it is best not to play favorites when de- r Be colorful—tell stories and anecdotes
ciding whether or not to grant an interview to a that illustrate your point; give examples. Be
specific reporter. It may seem like a good idea in friendly and positive.
the short run, but in the long run it will damage your r Do not ramble, state message and restate
relationship with reporters and may come back to it whenever opportunity arises.
haunt you. Even if the reporter has disappointed r Remember you can direct the spin of the
you in the past, be as cooperative as possible. story. You can say “that is the wrong question. What
r Think of two to three main points you you should be asking is . . . .” Or “I think the key
would like to make about your subject. Gather point to this story might be . . . .”
facts, figures, and anecdotes to support your points. r Speak in complete thoughts. The re-
Try to anticipate questions the reporter might ask porter’s question may be edited out and your re-
and have responses ready. The tougher your antici- sponse should stand on its own.
pated questions, the more comfortable you will be r Do not overestimate a reporter’s knowl-
during the interview. edge of your subject. When a reporter bases a
r Have printed materials to support your in- question on information you believe is incorrect,
formation whenever possible to help the reporter do not hesitate to set the record straight (in a
minimize errors. If time allows, offer to fax or mail friendly manner). Offer background information
the reporter printed information in advance of the where necessary.
interview. r If you do not understand a question, ask
r If a reporter calls asking your response to for clarification rather than talking around it. If you
the results of a recently published story, it is okay do not have the answer, say so. Tell the reporter
to ask the reporter to see a copy of the study. If the where to find the information, if possible. Or say
reporter is working on a very tight deadline, ask the that you will find the answer and get back to them
reporter to summarize the main points of the study (remember to follow through).
over the phone. r Never say, “No comment.” Instead, if you
r Be aware that reporters’ schedules are cannot or do not choose to answer, explain briefly.
determined by the “breaking” news of the day. For example, “It is our policy not to discuss law-
Do not be offended if an interview gets can- suits currently in litigation” or “I can’t answer that
celed or rescheduled because a more urgent story because I haven’t seen the research paper you are
arises. referring to.” If the latter is true, ask the reporter
if they have time for you to quickly review the re-
search paper; after which you can provide them
During the Interview with a better answer.
r Avoid saying things “off the record.” Re-
r Avoid academic or technical jargon; ex- porters may or may not honor this, and it annoys
plain special terms if you must use them. A few them. If you do not want to hear it on the evening
examples: news, you had better not say it.
r Be honest. Do not try to conceal negative r Do not expect the reporter to announce
information; rather, let your interviewer know what when the camera is on, just assume that it is always
you are doing to solve a problem. rolling.
r If appropriate, give the “call-to-action”
phone number or other contact information (this
is particularly helpful if you are trying to recruit After the Interview
participants for a study). r In most instances you will not have the
opportunity to check over the reporter’s story be-
Tips on Broadcast Media fore it appears. However, you can ask questions
at the end of an interview to test for comprehen-
r For television interviews, wear solid-
sion. For example, you might inquire, “What do
color clothing (blue is best). Stripes, plaids, or other you think is the main story angle here?”
designs can cause problems with color TV pictures. r You may want to ask when a story will
Avoid large, dangling, or reflective jewelry. Avoid appear. The reporter may not have an answer, but
red or white. if he does he will be happy to tell you.
r Sit on back of jacket/blazer, button up if r Give the reporter your business card to
possible. Make sure jacket/blazer does not bunch make sure your name and title are spelled correctly.
up, sit erect, leaning slightly forward. Avoid tight r If you feel after reflecting on an interview
clothing or, if wearing a skirt, short hemlines. that you misspoke or gave incorrect information,
r Place feet flat on the floor.
call the reporter as soon as possible and let him or
r Look in a mirror, if possible, just before
her know. Similarly, you can call with additional in-
going on camera. The reporter may not tell you formation if you forgot to make an important point.
that your collar is folded over or your hair is out of r Give positive feedback to reporters, if
place. merited, after a story appears. Like the rest of us,
r Choose a location where you can screen
they usually hear only complaints and rarely get a
out extraneous noises. Hold your calls and turn off call or note to say they have done a good job.
your computer, if possible. Avoid rooms with loud
background hums from refrigerators or air condi-
tioning or heating units. SPECIAL CONSIDERATIONS FOR
r Find out in advance whether the interview
HEALTH ORGANIZATIONS
is edited or “live.” If you agree to a live interview,
be sure you are comfortable thinking on your feet
IRB and Study Participants
and responding off the cuff.
r In edited interviews, do not answer ques-
If a program or study involves human
tions too quickly; pause briefly before answering.
subjects, investigators may be required to ob-
This helps the reporter get a “clean” sound bite and
also has the added benefit of allowing you time to
tain approval of their study design from the or-
think out your answer. ganization’s institutional review board (IRB)
r In edited interviews, it is OK to stop and or human subjects committee. This approval,
start over again if you do not like the way you however, does not mean that investigators
worded your answer. have a blanket approval on the press releases
r In a TV interview, look at the reporter and and ads they use to recruit study participants.
not the camera. The only exception is in a satellite If you are working on such a study, be
interview, when the reporter or anchor may not be sure to obtain approval on any collateral you
on location. If you are uncertain where to look, ask. use for recruitment, including releases, ads,
r Stay stationary in front of radio or TV
brochures, flyers, etc.
microphones and avoid sitting in a chair that rocks
or spins. Wandering around or rocking in your chair
can cause the recorded volume to rise and fall. HIPAA Regulations
r Be aware of and avoid nervous habits such
as pen tapping that can interfere with the interview. The Health Insurance Portability and
Do not cross arms. Accountability Act (HIPAA) of 1996 (which
went into effect April 14, 2003) contains spe- patient. But the reporter must provide the pa-
cific regulations on how health care profes- tient’s complete name. If the reporter cannot
sionals can share information about a patient’s provide a name, the hospital cannot release
health, including guidelines on how a health- any information that will identify the patient.
care organization releases information about HIPAA also requires the hospital ob-
a patient’s health to the media. Many hospi- tain written authorization from the patient
tals have public information officers or pub- or patient’s family before the media can ap-
lic relations officers whose jobs are to an- proach them for an interview.
swer calls from media representatives on top-
ics ranging from the names and conditions of
auto accident victims to the conditions of pa- FURTHER READING
tients who have received an unusual procedure
or who were diagnosed with an uncommon Ailes, R. Dealing Effectively with the Media.
disease. Bennett, P., and Calman, K. (eds.). Risk Communication
Most hospitals carry a continually up- and Public Health.
dated list of patient’s names, their room num- Bensley, R.J., and Brookins-Fisher, J. (eds.). Community
Health Education Methods: A Practical Guide.
bers and their conditions. If the patient has not
Brown, L. Your Public Best.
requested that this information be restricted or Nelson, D.E., Brownson, R.C., Remington, P.L., and
that their name be excluded from the list, the Parvanta, C. (eds.). Communicating Public Health
hospital may release the general condition of a Information Effectively: A Guide for Practitioners.
APPENDIX
Sample Releases
MEDIA ADVISORY
Event: Groundbreaking Event for Major University, seminar presented by John Doe Hall of
Biomedical Research
Date/Time: Friday, November 7, 4 to 5:30 PM
Place: Intersection of Big City America Avenue and Small City Street
Rsvp: Although the event is open to the public, we ask individuals planning to attend the
ceremony to please RSVP by Oct. 31 by calling (333) 999-2222.
Editors Please Note: Reporters are encouraged to attend/cover this event. A riser will be
available for videographers and photographers, and officials and scientists will be available for
interviews. Press kits also will be available.
From: Vicki Gaubeca, (333) 999-1212 Oct. 14, 2004
A new era in scientific discovery, collaborative research and health education is set to
begin at the University of America when a major facility breaks ground Friday, November 7,
4 PM., at the intersection of Big City America Avenue and Small City Street.
In addition to addressing the University’s severe shortage of research space, the John Doe
Hall of Biomedical Research will ensure it serves an even greater role in the “biomedical revo-
lution” and should spur significant economic development in our region. The project also will
provide new facilities to educate much-needed professionals in public health, pharmacy, and
nursing.
The event is scheduled to feature brief remarks by University President Jane Doe, recog-
nition of several donors and dignitaries. Project-related posters and displays will be exhibited
and festivities will include entertainment, food, and refreshments.
At a time when funding from the National Institutes of Health (NIH) has doubled, a recent
space-needs assessment by Hallelujah & Associates found that the university currently has a
deficit of 266,254 square feet of research laboratory space.
Last session, the State Legislature passed House Bill 3456, which gives the state univer-
sities bonding authorization for $30 million for research facilities, allowing the University to
proceed with construction. The money will be well spent: each dollar invested in biomedical
research is estimated to have a six-fold multiplier effect.
Estimated completion date for John Doe Hall of Biomedical Research will be June 2005.
###
Calendar Release
Event: Community-Based Chronic Disease Prevention: Why Promotoras are Successful. A

public health seminar presented by Juana Lopez, Promotora, Duncan, Ariz., Mary Hawkins,
Rustic College of Public Health.
When: Tuesday, September 30; NOON to 1 PM
Where: Kasper Auditorium, Arizona Center 3440 N. Vista Ave.
Fee: Free and open to the public.
Editors Please Note: Media are welcome to cover this event. For more information, call Vicki
B. Gaubeca, (333) 999-1212 or Jena Franks, (333) 222-4444, ext. 2233.
From: Vicki B. Gaubeca, (333) 999-1212 Aug. 15, 2004
The Rustic College of Public Health invites the public to attend Community-Based Chronic
Disease Prevention: Why Promotoras are Successful.
This public health seminar will be presented by Juana Lopez, promotora, and Mary
Hawkins, MPH, MA, director, Data Collection and Recruitment for Community Based Pro-
grams, both are with the Center for Community Health Promotion at the Rustic College of
Public Health. Ms. Lopez, who lives and works in Duncan, Ariz., dedicates her efforts in
prevention programs for chronic diseases, such as diabetes.
The seminar is part of the Engaging Our Communities Public Health Seminar Series
that brings together experts from around Arizona and the nation to discuss the most salient
public health issues. Presentations focus on local, state, national or global public health topics,
including those from other disciplines that may affect public health. The free seminars are set
for every first, third, and fifth (if applicable) Tuesday of the month in Kasper Auditorium in
the Arizona Center, 3440 N. Vista, noon to 1 PM.
Continuing Education credits are offered. The seminar series is open to the public. For
more information, please call Jena Franks, professional development coordinator (333) 222-
4444, ext. 2233.
###
Rustic College of Public Health Receives Grant to Study Effects of Teas on Lung
Cancer and Oxidative Stress
From: Vicki B. Gaubeca, (333) 999-1212 June 4, 2004

Researchers at the Rustic College of Public Health have been awarded a grant totaling
$4.6 million over four years to study the effects of tea on preventing disease. The study will
look at preventing lung cancer among former heavy smokers and minimizing oxidative stress,
a naturally occurring reaction in the human body that, when enhanced, may contribute to lung
cancer, cardiovascular diseases, diabetes, and other chronic diseases.
The study, funded by the U.S. Department of Alternative Medicine, is looking at the
effects of green and black tea on minimizing oxidative stress in smokers and former smokers.
Smoking enhances oxidative stress and may lead to tissue damage even after people cease
smoking. Participants in this study should have some form of chronic obstructive pulmonary
disease (COPD).
“The overall goal is to reduce the incidence of tobacco-related diseases by establish-
ing an efficient and feasible intervention approach for patients with COPD,” explains Stuart
Venezuela, MD, MPH, director of the Division of Health Promotion Sciences at the Rustic
College of Public Health and principal investigator on the study. “These individuals are at a
particularly high risk for lung cancer.”
Although tea studies have not conclusively shown that tea will prevent cancers, prelimi-
nary results indicate potential benefits. “Tea compounds can inhibit the transformation process
at many checkpoints and both green tea or its extracts may be equally effective in preventing
cancer in humans,” explains Dr. Venezuela.
Participants interested in volunteering for the study should call, Norma Monique, at the
Tea Studies’ office, Rustic College of Public Health, 333-8787, ext. 1244.
---
Established by the Rustic Board of Regents in February 1919, the Rustic College of Public
Health is the first public health college in Mid-Atlantis. The Rustic College of Public Health’s
mission is to promote the health of individuals and communities with a special emphasis on
diverse populations.
###
Case Study 1
Diabetes Disease Management Program
Donna Zazworsky1,2 and James Dumbauld1

1 St. Elizabeth of Hungary Clinic, Tucson, Arizona;
2 Case Manager Solutions, LLC, Tucson, Arizona; Carondelet Health Network, Tucson, Arizona
St. Elizabeth of Hungary Clinic (SEHC) r Early identification system (risk assess-
established a proactive diabetes disease man- ment and stratification)
r Practice guidelines and protocols
agement program in 2000 to respond to the
r Behavior education (staff and patient—
alarming numbers of patients with diabetes
being treated at the clinic. The clinic’s pro- 1:1 and group)
r Tracking system (data management
gram offers a bilingual continuing care ap-
systems).
proach to population-based management (see
Figure 1) by integrating health promotion, SEHC adapted the FAST Approach to
disease management, and acute episodic care Disease Management (Lamb and Zazworsky,
through culturally sensitive activities. 2000) as their operational methodology for
addressing diabetes care within the clinic.
This model includes the above components
in a comprehensive and systematic approach
A PROACTIVE DIABETES
identified below:
DISEASE MANAGEMENT
r Find. Identify the patients at the time of
PROGRAM
enrollment (proactive) or through database query-
In order to address the special needs of ing (retroactive);
r Assess. All patients are assessed through
diabetes prevention, early detection and man-
a standardized risk assessment;
aging diabetes of the clinic’s population and r Stratify. Patients are stratified into low-,
the community it serves, the clinic adapted moderate-, and high-risk categories in order to re-
a disease management framework to guide ceive appropriate interventions; and
their efforts. A Proactive Disease Manage- r Treat, train, and track. All patients re-
ment System incorporates the following com- ceive medical treatment and self-care educa-
ponents (Eichert and Patterson, 1998): tion based on their level of risk and treatment
347
348 CASE STUDY 1
Health Risk Primary Disease

Appraisal Prevention Management
Screening
Medical Mgmt. TARGET POPULATION
Monitoring Risk
Acute Assessment
Early Referral
Episodic Monitoring
Medical Mgmt.
Risk Assess for Self Care Ed
Readmission Coordination
Social Support Communication
Support Services
(Acute Care, HH, Rehab)
FIGURE 1. St. Elizabeth of Hungary Clinic’s Healthcare Delivery Model.
guidelines. In addition, these patients are tracked 3. Develop self-care education guidelines
in a database to monitor adherence to the disease and programs for patients according to risk cate-
management protocols. gories (Figure 3).
Treat
ACTION PLAN
1. Develop and implement treatment guide-
Find lines and protocols. Train staff on guidelines and
protocols.
1. Identify all new patients at the time of 2. Train providers and staff on guidelines
enrollment to the clinic and administer the Diabetes and protocols.
TriFitc Health Risk Appraisal.
2. Identify active SEHC patients diagnosed
with diabetes. Train
1. Develop and implement education guide-
Assess lines and programs for patients.
2. Train staff on guidelines and material.
1. Perform assessments during eligibility/
enrollment.
2. Audit charts with diabetes risk grid for Track
HbA1c, blood pressure, ldl, microalbumin, foot
score, and retinopathy. 1. Track the following information:
a. Patient outcomes (service vis-

Stratify its, adherence to treatment, and HbA1C
results);
1. Place patients into low-, moderate-, and b. Cost outcomes (hospitalizations,
high-risk interventions. complications, and service utilization);
2. Develop treatment guidelines and c. Patient and provider satisfaction;
protocols for providers (Figure 2). d. Patient referrals and feedback.
CASE STUDY 1 349

St. Elizabeth
of Hungary Clinic
Diabetes Quality Indicators: Clinical
140 W. Speedway Blvd
Patient: __________________________________________ DOB: _________________
Tucson, AZ 85705-7698
(520) 628-7871 MR# ___________________________ Provider: _________________________________
Frequency Baseline 3 mo 6 mo 9 mo 1 year
Date/Initials
C=Completed
FS Blood Glucose R or F qvisit
Assessment
HbA1c quarterly
Blood Pressure < 130/80 qvisit
Re=Referred
Urine Protein Dip Annual
Height Annual
Weight qvisit
F=Fasting
Body Mass Index (BMI) qvisit
Chol/TG <200/200 Annual

Lab
HDL/LDL >45/<100 Annual
R= Random
Micro Protein Annual
(If protein dip negative)
Bun/Creatinine Annual
Oral Agents Y or N qvisit
SME= Self-Management Education Referral

Insulin Y or N qvisit
Interventions
ACE Inhibitor if hypertensive Y or N qvisit
ACE Inhibitor if proteinuric Y or N qvisit
Statin Y or N qvisit
ASA Y or N qvisit
Vaccines
Specify (ie. flu, pneumonia, etc) Annual
Full Physical Exam Y or N Annual
Eye Exam Re or C Annual

PE
Foot Exam Re or C qvisit
SMBG and records S or SME qvisit

S= Satisfactory
Meal Plan S or SME qvisit

Self Care
Physical Activity S or SME qvisit
Medication Instruction S or SME qvisit
Tobacco Cessation S or SME qvisit
This flow sheet indicates recommended services to be provided in the continuing care of persons with diabetes. The frequency of
each service is a recommendation from the American Diabetes Association. Document values where indicated. Any discussions
with patients or significant others should be documented in the “notes” section in date order.
Signature initials Signature initials
INITIAL WORK An alarming gap was noted in the ADA stan-

dard and what patients were able to afford and
The initial work focused on a chart audit perform. There were a number of barriers in
to identify clinic system and process needs. cost and clinic processes. Therefore, initial
350 CASE STUDY 1
Preliminary Diabetes Intervention Model
Low Risk (Potential Risk)
Clinic Visits + Education
Moderate Risk (Diabetes-Controlled)
Clinic Visits + Education (1:1 and/or Group) + Certified Diabetes Educator (CDE) Consult
High Risk (Diabetes-Uncontrolled)
Clinic Visits + Education + CDE Consult + Community Nurse Case Manager/Promotora
FIGURE 3. Patients with Diabetes Intervention Grid.
efforts were to obtain the necessary equip- activities through a number of programs and
ment and funding and simultaneously devel- partnerships.
oping clinic protocols for providers and staff. r Diabetes health-risk appraisals to the
community. SEHC partners with the YWCA
promotoras to offer a proactive approach to early
FINDINGS
detection. The promotoras administer the TriFitc
computerized diabetes health risk appraisal to the
The following descriptions provide a general public at health fairs, community events,
brief overview of the programs and systems church gatherings, and other community activi-
that have been developed. As a result of these ties. Individuals are mailed their results in ap-
programs and services, the clinic has demon- proximately 1 week with an accompanying letter
strated an increase in patients achieving quar- explaining their need for certain follow-up depend-
terly and annual requirements as well as an ing on their results. People who are identified as
improvement in health status indicators. From high-risk for diabetes or as diabetic receive a phone
June 2001 through June 2004, the clinic has call from the promotora. If people do not have
seen a reduction of patients who have HbA1cs health insurance, the promotora works to connect
them with a community provider who provides care
greater than 9%. This went from 32.9% down
for the uninsured.
to 18.3%. Another promising improvement is r Diabetes health-risk appraisals to SEHC
in those patients who have HbA1cs less than new registrants. The Diabetes TriFitc Health Risk
7%. That number increased from 22.6% to Appraisal is administered to new patients register-
35.3% in those 3 years. This was based on ing for clinic services. The computerized results
a total of 371 patients who had two or more are then posted in their chart for the provider to
HbA1cs with a first and last HbA1c. review at their first visit. The provider may decide
to do a plasma insulin test to identify early predi-
abetes through insulin resistance. If the individual
ST. ELIZABETH OF HUNGARY is diagnosed with this prediabetes condition, the
CLINIC CONTINUUM provider will provide education on diet and exer-
cise, make a nutrition and/or nursing referral and
Health Promotion may even start a medication regime. A nurse tracks
all “high-risk for diabetes” and “self-identified di-
Outreach efforts are proactive and pro- abetics” and sends letters to those who have not
vide early identification and prevention made their first appointment.
CASE STUDY 1 351
r Mobile podiatry. SEHC’s Mobile Podia- r Medication and glucometer supplies sup-
try Unit travels to 10 senior sites monthly to pro- port. The clinic offers special programs to help
vide podiatry outreach to the low-income elderly. patients maintain medication compliance. Patients
More than 100 people receive this basic podiatry can become involved in the clinics Pharmaceu-
service. Many of these individuals have diabetes tical Advocacy Program and receive many of
and desperately need this preventive service, since their medications free through pharmaceutical pro-
basic podiatry is no longer a covered benefit under grams coordinated by clinic. Also, a special In-
Medicare. Individuals are referred to podiatrists in sulin Program offers free insulin to bridge patients
the community if further needs are identified. This while they wait to get on the Pharmacy Advocacy
year, SEHC received funds to help those with spe- Program.
cial diabetes footwear needs. r Glucometer strips program. Glucometer
strips are now available through a low cost, incen-
Disease Management tive program. The patients sign an agreement (see
Figure 4) to participate in a self-management pro-
The clinic offers the following diabetes gram that includes regular testing and exercising.
disease management efforts based on an The patient is given a monthly log, passport, and
initial risk assessment that helps to guide Patient Diabetes MAP.
r Open access. This is an informal clinic
the provider and determine an intervention
process where the diabetes nurses encourage pa-
scheme:
tients with diabetes to call or stop by if they have
r Quarterly provider diabetes visits. All pa- a problem. The nurse will work them into the doc-
tients diagnosed with diabetes are automatically tor/NP if necessary.
r Diabetes day group visit. This is a once
placed on the evidence-based guideline, called the
Diabetes Clinical Flow Sheet (see Figure 3). This a month clinic where a group of 8–10 patients are
flow sheet follows the recommendations estab- scheduled. They are selected based on risk, indi-
lished by the American Diabetes Association. Re- vidual need, and their ability to learn better in a
ferrals are made accordingly. group format. The provider and nurse discuss who
r Prediabetes program. Patients who have would be best to attend. The group visit lasts ap-
been identified as high-risk potential for diabetes proximately three hours and includes: a retinopathy
through their health-risk appraisal are referred to exam by the ophthalmologist, foot evaluation by
the provider for further testing. If appropriate, a the podiatrist, group education by the nurse and nu-
serum insulin test may be performed. If the patient tritionist, and primary care visit with the PCP. This
is identified to have the prediabetes, the provider is all documented on a Group Visit Form (Refer
initiates the Prediabetes Clinical Flow Sheet (see to Case Study 5 for complete description of this
Chapter 13). Patients can be referred to 1:1 or group program on other examples).
education classes.
r Community Nurse Case Management and
r Nutrition counseling. A dietitian, who is YWCA promotora home visits. This service is avail-
also a Certified Diabetes Educator (CDE), provides able to individuals who are having difficulty man-
1:1 diet instruction based on their learning needs aging their diabetes and are unable to come to
and level of readiness. The CDE dietitian utilizes the clinic regularly. The Community Nurse Case
a number of different educational tools that may Manager and YWCA promotora provide an ini-
include a personalized laminated food pyramid, tial home visit to complete a needs assessment
food models, brochures, and many other individual and develop a mutually agreed upon plan of ac-
handouts. tion. The individual and YWCA promotora estab-
r Nursing education. Specially trained di- lish regular a time for regular visits to monitor the
abetes nurses offer 1:1 education and counseling person’s progress and report back to the diabetes
on lifestyle, self-management, and glucometer use. team.
All newly diagnosed individuals must be seen by
r Diabetes patient registry. The SEHC
the nurse in order to obtain a glucometer. The Diabetes Registry has been specifically designed
nurses utilize the Patient Diabetes MAP (see Chap- to track patient data related to demographics, visit
ter 12) as their teaching tool and documentation types, patient data, medications, supplies, and risk
form. level.
352 CASE STUDY 1
FIGURE 4. St. Elizabeth of Hungary Clinic.
r Diabetes health care team conferences. r Diabetes update newsletter. This bilin-
Once a month, the diabetes team meets to present gual quarterly newsletter promotes healthy lifestyle
cases and discuss a multidisciplinary plan of action tips, calendar of events, and success stories for pa-
for each case. This is also the time that the team tients with diabetes and their families.
will review and Continuous Quality Improvement
items based on the PDCA (Plan–Do–Check–Act)
process.
r Carondelet diabetes education classes. Acute Episodic Care
Offered by Carondelet Health Network’s Parish
Nurse Program, this free seven-week education se- The clinic offers a triage service for pa-
ries covers nutrition, exercise, stress management, tients who have immediate medical needs.
blood sugar control, and a supermarket tour. The clinic also promotes an “Open Access”
CASE STUDY 1 353
philosophy with the diabetes nurses to pro- or face-to-face questions and concerns when they
mote early identification of problems. arise. This process has also expedited immediate
medical intervention when needed to reduce fur-
ther complications.
3. Telemedicine. St. Elizabeth of Hungary
BARRIER REDUCTION
Clinic has been involved in the Arizona
STRATEGIES Telemedicine Program since 2000 through the tel-
eradiology program. We will begin a teleophthal-
St. Elizabeth continuously works to re- mology with an ophthalmologist who provides this
duce patient barriers that may interfere with service. This will enable our patients with diabetes
successful diabetes self-management. The to have their annual retinopathy exam during their
following strategies have been or will be im- PCP visit through a “Store and Forward” capacity.
plemented:
1. On-site HbA1c finger-stick tests that are
performed at the time of the PCP visit. This strat-
REFERENCES
egy has dramatically improved the management of
diabetes by reducing time and cost barriers for the Eichert, J.H., and Patterson, R.B. (1998). Factors affect-
ing the success of disease management. J. Oncol
patient. The patient can receive their HbA1c re-
Management 7(1):15–18.
sults within 6 minutes and have their medications
Lamb, G., and Zazworsky, D. (2000). Improving out-
adjusted at the same visit. comes fast. Advance for Post-Acute Care 3(1):
2. Open access visits with the nurse. This 28–29.
strategy empowers patients to openly and proac- www.ama-assn.org/ama/pub/category/3798.html. Di-
tively pursue self-management success by knowing abetes guidelines recommended by the AMA,
that the nurse will be able to respond to telephone JCAHO & NCQA.
Case Study 2
Carle’s Diabetes Management Program
Christine Kucera,1 John Stoll,2 Cindy Fraser,1

James C. Leonard,3 and Paul Shelton1
1 Health Systems Research Center, Carle Foundation, Urbana, Illinois;
2 Medical Director of Primary Care and Pediatric Sub-Specialties, General Internal Medicine,
Carle Clinic Association, Urbana, Illinois; and
3 Carle Foundation, Urbana, Illinois
Diabetes mellitus (DM) is a chronic disease et al., 2002). The most pressing problem in
increasing in epidemic proportions. It is esti- DM care is the poor translation of this accu-
mated that approximately 16 million Amer- mulated knowledge into routine clinical prac-
icans have DM and 200,000 each year die tice (Berger and Muhlhauser, 1999). These
from its complications (Boyle et al., 2001). pressing reasons provided strong motivation
Diagnosed cases of DM are expected to in- and incentive for the Carle health care system
crease dramatically in coming years, primar- to make patients with DM a priority focus for
ily related to our eating behavior (obesity) the organization. The purpose of this chapter
and sedentary lifestyle (lack of physical ac- is to present an overview of the Carle diabetes
tivity; Flegal et al., 2002). Diabetes melli- management program and our achievements
tus has its greatest effects on the elderly; to date.
one in five adults, 65 and older, has diabetes
(Modkad et al., 2001) and approximately 66%
of diabetes-related expenditures are for the
care of the elderly (Basile, 2000). THE CARLE HEALTH CARE
Over the past 30 years, DM care has been SYSTEM
at the forefront of the changes in disease man-
agement (Griffin, 2001). The majority of pa- The Carle organizations (Carle Clinic
tients with DM are inadequately treated de- Association, Carle Foundation, Health Al-
spite the proliferation of medical guidelines liance Medical Plans), located in Urbana, Illi-
specifying optimal management of the disease nois, are a vertically integrated health care
and there are wide variations in care (Saaddine system that serve as the regional medical
355
356 CASE STUDY 2
center for over eight million individuals living doing it.” The only way to do this was to give
in urban and mostly rural areas of east cen- individual physicians and their staff specific
tral Illinois and western Indiana. The Carle information that was accurate, patient specific
Clinic Association is a multispecialty, physi- and “actionable.”
cian group practice, with over 280 physicians Carle’s diabetes management program
representing 50 medical and surgical special- consists of the following components:
ties and subspecialties, including 120 primary
(1) Patient registry. The diabetes registry,
care physicians (PCPs), and a substantial am-
which contains approximately 10,000 active pa-
bulatory nursing component. Carle’s deliv-
tients, is updated on a monthly basis and includes
ery system provides primary care through a all individuals who have been treated at Carle with
network of nine branch clinics. The branch at least two contacts related to their diabetes care
clinics provide access to health services us- (i.e., physician visits, hospitalizations, eye or foot
ing networks of local practitioners and com- exams, and laboratory tests) during the past 18
munity service providers to create smaller months. The registry contains the following patient
“hubs” of service within a 30-mile radius information: name, date of birth, age, gender, in-
of the branch. The main campus, located surance status, PCP name, medical specialty and
in Urbana, is the primary referral and spe- practice location, date the patient was diagnosed
cialty care center. The Carle Foundation owns with DM, termination date, and reason from the
registry.
the 295-bed Carle Foundation Hospital and
(2) Evidenced-based clinical guidelines.
other related health care services and is af-
Guidelines from the American Diabetes Associ-
filiated with the University of Illinois Col- ation (ADA) facilitate patient management and
lege of Medicine. Health Alliance Medical care (American Diabetes Association, 2003). The
Plans (HAMP) is a managed care organiza- guidelines are reviewed and updated on a yearly ba-
tion (MCO) owned by Carle Clinic Associ- sis (American Diabetes Association, 2004) and are
ation and is the largest MCO in downstate available online to all physicians and staff through
Illinois. Carle’s intranet system. Signed standing orders are
in place to facilitate laboratory testing. When a pa-
tient is scheduled for a PCP visit, they are also
CARLE’S DIABETES scheduled for laboratory testing so the PCP will
have the latest results.
MANAGEMENT PROGRAM
(3) Diabetes self-management education
program. Both group and individual classes are of-
The overall purpose of the program is fered at four of Carle’s branch clinics and focus
to educate and update PCPs and RNs on on nutrition, exercise, medication, and self-testing.
evidence-based clinical guidelines to improve All classes are taught by certified RNs, dietitians,
management of patients with diabetes within and endocrinologists. Over 1,200 individuals a year
Carle’s primary care network. The program is participate in this program.
designed to help clinicians focus on individual (4) Inpatient self-management program.
patients as well as facilitate a population- Carle’s inpatient education program has a twofold
based approach that provides specific purpose. The first is to keep Carle Founda-
feedback on their entire panel of patients with tion Hospital staff, especially RNs and Family
Practice physician residents, updated on policy
diabetes. Although most of the individual
and procedures and diabetic treatment protocols.
program components existed within the Carle The second is to educate and refer newly diag-
system for a long time, it was decided to nosed hospitalized patients or patients hospital-
formalize the program on a system wide ized with complications to the self-management
basis in 1999 as a major quality improvement education program or to the endocrinologist. Over
initiative. The program’s overriding theme 300 patients a year are seen in the inpatient
is “if you’re not measuring it you’re not setting.
CASE STUDY 2 357
(5) Referral. Patients who have glycemic reasons for this. First, it was decided that all
levels that are severely uncontrolled are referred program training had to be done at the site
to endocrinologists for specialized care. level and it took a lot of time and effort to
(6) Program outcomes and reporting. Spe- schedule and complete multiple training ses-
cific outcomes, at both the individual patient and sions at Carle’s nine different clinics. It was a
physician level, are based on the guidelines for
challenge to complete the training with as lit-
monitoring and glycemic (HbA1c) and lipid con-
trol (low-density lipoprotein [LDL]) levels. HbA1c
tle disruption as possible to extremely busy
values should be monitored at least twice a year clinical practices. Second, in order to pro-
and LDL values at least once a year. Therapeutic vide feedback that was specific to individual
HbA1c control should be below 7% and LDL con- physicians, it had to be accurate. Considerable
trol below 100% (Carle has taken a conservative ap- time was spent on developing and cleaning up
proach to calculating outcomes and a missing lab- the patient registry. In the Carle system, only
oratory value is considered not in control). Blood MCO members have to designate a PCP, so
pressure control and yearly eye examinations also physicians and their staff had to review and
were considered for disease management outcomes verify their patient panels and indicate which
but they could not be easily accessed electronically patients were deceased or otherwise not theirs.
so were not included.
Most physicians cooperated in this task but
(7) Reports are distributed to individual
physicians and clinic administration on a quarterly
not all were timely returning the information.
basis (April, July, October, and January). Individ- At the end of the second year, we felt this pro-
ual physician reports contain the following infor- cess resulted in data that were more than 90%
mation: accurate.
r Physician name, medical specialty,
Implementation occurred in several
and practice location; stages over the two-year period. First, a
r Total number of active patients with
kick-off meeting was held with all PCPs to in-
diabetes;
r Calculated HbA1c status: number troduce and inform them about the program,
and percent of patients who in the past 6
the guidelines being used for care manage-
months have no laboratory value, number and ment, and outcomes that were going to be
percent who have severely uncontrolled val- measured. Second, initial training was con-
ues (>9.5); number and percent who are un- ducted for physicians, office staff, and RNs
controlled, and number and percent who are with emphasis placed on regular ordering of
controlled. laboratory tests according to the guidelines
r Calculated LDL control status: and attaining HbA1c control. This training
number and percent of patients who in the took approximately 1 year to complete.
past 13 months have no laboratory value, At the same time, individual physician
number and percent who are uncontrolled, reports, described above, were being devel-
and number and percent who are controlled.
r HbA1c and LDL statistics are pro- oped, modified, and refined. By the second
vided comparing an individual physician with
year, the reports were distributed to all PCPs
their peers within their medical division on a quarterly basis. When these reports were
(Adult Medicine or Family Practice), by their first rolled out, training and one-on-one sup-
medical specialty and practice location, and port was given to physicians and RNs to assist
the organization overall. them in identifying their patients who were
r Patient information includes a new not being tested according to the guidelines
patient icon, patient name, age, HbA1c and (noncompliant) and to identify those patients
LDL testing dates and results. who were severely uncontrolled. The train-
See Figure 1 for a sample report. ing sequence was the same, first in the larger
Program rollout took approximately 2 urban clinics and then in the smaller rural
years to finalize. There were primarily two branches.
358 CASE STUDY 2
FIGURE 1. Individual physician report.

CASE STUDY 2 359
PROGRAM OUTCOMES ditions by PCPs because of patient nonad-

herence to treatment regimens, a conscious
In January 2001, with comfort that the decision based on patient age and comorbid
patient registry information was 90% accu- illness, lack of trained staff, and lack of con-
rate, Carle established a baseline of patient de- sultative assistance and follow-up (Larme and
mographics and program outcomes. The typi- Pugh, 2002). This is compounded because
cal patient in the registry is 62 years old, 53% self-management plays such a central role in
are 65 years or older, 52% are female, and 30% care (Schechter and Walker, 2002) and until
have health insurance through Carle’s MCO. there is a cure for diabetes these behaviors
The average Carle PCP has approximately must be done for a lifetime.
111 patients with diabetes on his/her panel, Carle’s diabetes management program
although there is wide variation per physician, was founded on the theme “if you’re not mea-
especially for those who have practiced at suring it you’re not doing it.” Carle has a sys-
Carle for over 15 years. Throughout the Carle tem in place that provides regular feedback to
system, 28% of patients were in glycemic con- PCPs on the glycemic and lipid control of their
trol, 34% had not had their HbA1ctested ac- patients with diabetes. The system is not per-
cording to the guidelines, 20% were in lipid fect and not all physicians are convinced that
control, and 48% had not had their LDL tested the outcomes being measured and reported
according to the guidelines. After three years, are the best way to change or improve care.
glycemic control increased by 13% to 41%, However, the results the system has attained
lipid control increased by 12–32%, and lack are worth the continued efforts to improve the
of HbA1c and LDL testing decreased by 7% primary care delivered to our patients with di-
and 22%, respectively, to 27%. abetes.
The positive movement of these out-
comes is encouraging, especially when
Ac knowledgement. This program is
viewed from a system-wide basis. While there
funded with support from the Carle Founda-
remains room for continued improvement,
tion Hospital.
glycemic and lipid control has increased while
noncompliance had decreased; these results
are similar to other published interventions
that have attempted to improve the manage- REFERENCES
ment of diabetes in primary care settings
(Renders et al., 2001). Glycemic and lipid American Diabetes Association. (2003). Clinical prac-
control outcomes are now key performance tice recommendations. Diabetes Care 26(Suppl 1):
S1–S156.
indicators for both Adult Medicine and Fam-
American Diabetes Association. (2004). Clinical prac-
ily Practice, and achievable yearly bench- tice recommendations. Diabetes Care 27(Suppl 1):
marks for both medical divisions and individ- S1–S150.
ual physicians are being tracked. Carle will Basile, F. (2000). The increasing prevalence of dia-
soon add nephropathy monitoring to our pro- betes and its economic burden. Am J Manag Care
6(Suppl):S1007–S1018.
gram outcomes.
Berger, M., and Muhlhauser, I. (1999). Diabetes care
and patient-oriented outcomes. JAMA 281:1676–
1678.
CONCLUSION Boyle, J.P., Honeycutt, A.A., Venkat Narayan, K.M.,
Hoerger, T.J., Geiss, L.S., Chen, H., and Thompson,
T.J. (2001). Projection of diabetes burden through
Improving health outcomes for individ-
2050. Diabetes Care 24:1936–1940.
uals with diabetes is a challenging process. Flegal, K.M., Carroll, M.D., Ogden, C.L., and Johnson,
Diabetes is a chronic illness that is gener- C.L. (2002). Prevalence and trends in obesity among
ally considered harder to treat than other con- US adults, 1999–2000. JAMA 288:1723–1727.
360 CASE STUDY 2
Griffin, S.J. (2001). The management of diabetes: Moving Interventions to improve the management of dia-
beyond registration, recall, and regular review. BMJ betes in primary care, outpatients, and community
323:946–947. settings: A systematic review. Diabetes Care 24:
Larme, A.C., and Pugh, J.A. (2002). Evidence-based 1821–1833.
guidelines meet the real world: The case of diabetes Saaddine, J.B., Engelgau, M.M., Beckles, G.L., Gregg,
care. Diabetes Care 24:1728–1733. E.W., Thompson, T.J., and Venkat Narayan K.M.
Modkad, A.H., Bowman, B.A., Ford, E.S., Vinicor F., (2002). A diabetes report card for the United States:
Marks, J.S., and Koplan, J.P. (2001). The continu- Quality of care in the 1990s. Ann Intern Med
ing epidemics of obesity and diabetes in the United 136:565–574.
States. JAMA 286:1195–1200. Schechter, C.B., and Walker, E.A. (2002). Improving ad-
Renders, C.M., Valk, G.D., Griffin, S.J., Wagner, E.H., herence to diabetes self-management recommenda-
Eijk, J.T.M.E., and Assendelft, W.J.J. (2001). tions. Diabetes Spectrum 15:170–175.
Case Study 3
The Scott and White Experience—Chronic
Disease Management on a Shoe String
Barbalee Symm and Michael Reis

Department of Family and Community Medicine, Texas A&M University System HSC College of Medicine,
Scott and White Memorial Hospital, Temple, Texas 76504
THE BEGINNINGS PROBLEMS, PROGRESS, AND

LESSONS LEARNED
It was a good year—1999. One of our
Scott and White Medical Directors had been First, three of the RNs hired were se-
sent elsewhere to learn about Chronic Dis- lected because they were in-house employees
ease Management (CDM) and implement from other departments that had just down-
a pilot CDM program at Scott and White sized. We were in a nursing shortage, and it
through the Scott and White Health Plan seemed to be the best decision, at the time.
(SWHP). None of these three nurses is still with the
Scott and White is an integrated health program. However, one nurse was hired from
care system composed of a 450-bed hospi- within the clinic where she would work as the
tal, a 500-physician multispecialty clinic, and CDM nurse. There was already a strong work-
a 186,000-member HMO, with 15 regional ing relationship and a good deal of trust be-
clinics. The appointed leader, one of SWHP’s tween that nurse and the physician staff. This
medical directors, was young, energetic, and ideal situation has blossomed beautifully. The
authoritative. Without much ado, four RNs nurse has earned her CDE credentials and the
were hired, and a physician champion was ap- highest esteem of the physicians with whom
pointed at each clinic where the nurses would she works.
be assigned. Each nurse was given a laptop
computer and BOOM—we were in business. Lessons learned. A preexisting, good working
Patients were identified by SWHP data or by relationship between the doctors and the nurse
rendered the best working situation. If time con-
physicians. The nurses were expected to as-
straints were not an issue, we might have done
sess the patients’ status and implement a plan better to select nurses based on background, ex-
of proactive care. perience, and communication skill level.
361
362 CASE STUDY 3
Next, none of the nurses had computer physicians wanted to try group visits. Nurses
skills, and at the best, had minimal key board- developed their own protocols, and the physi-
ing skills. This reflects the picture of most cians in their own areas signed them. All of
of our organization at that time. Computer those protocols varied. Our philosophy was
skills had never been a prerequisite for hir- to operate on a shoestring and do whatever
ing nurses and very few nurses had com- was necessary to get the job done. This was
puter access. We began with a simple Excel not necessarily a bad thing; because we knew
spreadsheet to collect data. It was traumatic from the beginning, we would learn by doing.
for the nurses when we moved into an Ac-
cess database because they had to learn new Lessons learned. Physicians must trust a nurse’s
skills. The first Access database was very lim- judgment before they will be willing to sign a
protocol. Even when a protocol is available, they
ited. Within 6 months, we moved into a much appreciate close oversight of the nurse’s work. A
more complex Access database that was net- standardized protocol is nice. An education ses-
worked so that all CDM patients’ data would sion of two hours is how we routinely schedule
be in the same database—another traumatic a patient with newly diagnosed diabetes now. Pa-
experience to the nurses. Today, the com- tients newly diagnosed, those with recent hospi-
talizations, ER visits, or major changes in med-
puter changes are a little more easily inte- ications or co-morbidities require the most time
grated, and our nursing staff has developed and intervention. We still do not have absolute
good computer user skills. In a related is- numbers but we believe one nurse can handle be-
sue, at the beginning, a clerical support per- tween 400 and 800 patients, depending on inten-
son was to be assigned to each nurse to assist sity. This is where patient stratification becomes
important.
with data entry. Those positions were elimi-
nated before they were ever filled. However,
for 6 months, we were able to hire one clerical
support person to assist all four nurses. She ro- PROGRESS AND SUCCESS
tated daily, and besides doing data entry, did
other tasks such as assemble patient education Our goals were to improve the quality of
materials. care and to decrease cost of care. Our evalua-
tion measures for the care rendered to patients
Lessons learned. Many nurses have not had the
with diabetes related to HbA1c improvements
opportunity or need to develop computer skills.
Data entry is a huge issue. Our organization did and cost of care. Evaluation measures for the
not support the idea that nursing time should care rendered to patients with congestive heart
not be spent on data entry. Until organizations failure were hospital days and cost of care. In
have a perfect electronic medical record that au- measuring improvement in HbA1c, we exam-
tomatically aggregates data on specified patients,
ined the number of HbA1c tests for a year.
this should be an early consideration in program
planning. Then we examined values for the first and
last test during the time period. At that time,
Next, there was differing practice among we considered a value of ≥9.5 “out of con-
the clinics. Some doctors trusted their nurses a trol.” Measures for patients in our database
great deal, and the nurse developed substantial included: number and percentage of patients
skills. Others had a hard time establishing with one HbA1c; number and percentage of
that level of trust. Some physicians wanted to patients with two or more HbA1c who were
maintain total control, and did not rely on the either improved or in control versus number
nurse at all. Our nurses offered care to pa- and percentage of patients out of control or un-
tients with diabetes and patients with conges- measured; hospitalizations and hospital days;
tive heart failure. We had no idea how many and ER visits. In regard to our HbA1c mea-
patients a nurse could handle, or how much sures, our Information Systems department
time it would take to educate a patient. Some was able to identify a control group of patients
CASE STUDY 3 363
How many patients had at least 2 HgbA1C tests

ordered 9-2001 to 9-2002?
1219 CDM Patients 1219 Controls
2 or more 2 or more
831 303
None or 1 None or 1
617 1145
Number of HgbA1c tests done

CDM compared to S&W control patients matched by age (within 3 years),
gender, and diagnosis of DM
p < 0.0001
FIGURE 1. SWHP patients with diabetes with 2 or more HbA1c tests in one year.
with diabetes based on matching age within Lessons learned. Early results demonstrated suc-
3 years, sex, and diagnosis of diabetes—but cess, but the organization did not necessar-
ily receive the results as believable. However,
no access to CDM. We have repeated the mea-
later results of cost effectiveness and return-
sures at least annually and we show wonderful on-investment analysis prepared by an objective
results (see Figures 1–4 that demonstrate care person not associated with CDM in any way
delivered September 2001–September 2002). (a SWHP actuary) were considered valid.
How many patients had a lab value that was

improved or was < 9.5?
1219 CDM Patients 1219 Controls
Improved or < 9.5 Improved or < 9.5
935 303
>=9.5 or unmeasured >=9.5 or unmeasured

284 916
Improvement
CDM compared to S&W control patients matched by age (within 3
years), gender, and diagnosis of DM
p < 0.0001
FIGURE 2. SWHP patients with diabetes with improvement between September, 2001 and September, 2002.
364 CASE STUDY 3
Total Hospital Days and Hospital Days With DM in Top 5 Dx

9-2001 to 9-2002
Per 1000 SWHP Members with DM
Total Hospital Days per 1000 DM Hospital Days per 1000

2500 120
1982 96
2000 100
1341 80
1500
60
1000 38
40
500
20
0 0
Non CDM CDM Non CDM CDM
FIGURE 3. Hospitalization rates for SWHP members with diabetes September, 2001 to September, 2002.
NEXT STEPS 4 RNs and computers for them. Four nurses

have been used to care for SWHP members in
Ours is a work-in-progress. SWHP’s five clinics, and the results demonstrate suc-
CDM program was initiated as a quality im- cess. Since the program has been deemed suc-
provement process in pilot format. The in- cessful, SWHP will roll the program out to
vestment cost was the salary and benefits of all SWHP members. Careful consideration is
Decreased Total Cost PMPM - DM

Total Cost PMPM
1400
$1,158
1200
$965
1000
800
600
400
200
0
Non CDM CDM
$193 PMPM Difference 9-2001 to 9-2002
FIGURE 4. Difference PMPM cost of care based on charges for CMD and non-CDM SWHP member with diabetes.
CASE STUDY 3 365
currently being given to the most cost effec- are being evaluated. Of particular interest,
tive way to implement CDM across the entire though our program was not standardized, we
186,000 membership. Along with computa- still demonstrated significant patient improve-
tions of requirements to continue and expand ments and decreased the cost of care substan-
the program internally, commercial programs tially.
Case Study 4
Nutrition Survival Skills for Diabetes—A
Personal Experience
Annette I. Peery
Department of Adult Health Nursing, School of Nursing, East Carolina University,
Greenville, North Carolina
Practice guidelines for diabetes recommend not seen or heard from again for 9 months,
that patients be referred to a dietitian for when they come to the clinic as a walk-in for
medical nutrition therapy (MNT) within the an acute problem, and see a provider they have
first month after diagnosis. However, more never seen before. Sounds familiar? We saw
often than not, reality prevents this from this scenario repeated time and time again in
occurring—the reality of not having enough our family practice group.
dietitians or dietitian appointments, and The Family Practice Center is located
the reality that patients do not always keep in a rural county in the southeastern United
their appointments. These realities also hold States. The clinic serves as a training site for
true for having patients in to see a diabetes 36 family practice residents and provides care
educator. to a traditionally underserved, mostly minor-
In practice, physicians and physician ex- ity, population. As the aforementioned prob-
tenders are limited in the amount of time they lem was prevalent in our practice, we felt we
have for patient education, including nutri- needed to intervene. The diabetes educator
tion. Therefore, they may often tell the patient and team of two dietitians and one nutrition-
“nutrition is important in controlling your di- ist worked together to develop a patient ed-
abetes. Do not eat any sweets and we will ucation handout entitled “Nutrition Survival
make an appointment for you to see a dieti- Skills for Diabetes” (Figure 1).
tian who will tell you about your diet.” The The handout was developed to serve
patient leaves with no nutrition education or three main purposes: (1) provide a one-sided,
guidance, an appointment with a dietitian for one-page, low reading level handout for our
2 months later, and a follow-up appointment patients; (2) give providers a guideline, or
with the physician in 4 weeks. The patient is outline, to follow, to provide patients with
367
368 CASE STUDY 4
Nutrition Survival Skills

For
Diabetes
Important!!! Please Read!!!
Having diabetes does not mean that you can no longer enjoy good food, or that everything you
eat “tastes bad.” It does not mean that you cannot have foods that are sweet.
What it does mean, is that you will need to be more aware of what you do eat and how much you
eat. Your doctor or dietitian can help you to develop a plan that is right for you and fits into your
life style, but until that time, the following are some “survival skills” that may help you to gain
better control of your diabetes and blood sugars.
Survival Skills
Foods to eat – low fat, high fiber foods and artificially sweetened beverages (not
sweetened with sugar)
Drink all you want of diet sodas, tea, coffee or Kool-Aid either unsweetened or
sweetened with an artificial sweetener such as Sweet ‘N Low, Equal, saccharin or
Splenda
Do not drink sugar sweetened beverages such as regular sodas, Gatorade, sugar
sweetened tea, coffee or Kool-Aid, Hi-C, Hawaiian Punch
Limit your fruit juice (orange, grapefruit, apple, grape, cranberry) to 1⁄2 cup every day with
a meal until you receive more specific instructions from your doctor or dietitian
Do not eat concentrated sweets. These include candy, cookies, cakes and pies. Your
doctor or dietitian may help you add occasional small amounts of these back into your
diet at a later time
Eat at least 3 different times throughout the day and about the same amount at each time.
That is, do no skip a meal and then eat twice as much at the next meal. This will make it
hard to control your diabetes and it may make you feel bad.
Cut back on your serving sizes. A serving size is 1⁄2 cup fruit, vegetables, pasta or rice; 3
to 4 ounces of meat (about the size of a deck of cards); 1⁄2 cup fruit juice; 1 cup of milk; 1
slice of regular white bread; a medium apple or orange; 15 to 20 seedless grapes; 1⁄2 of a
medium banana.
Try to avoid alcohol until you discuss it with your doctor or dietitian.
Remember!!! Just because a food says it is “dietetic,” “sugar free,” “fat free” or “low
fat” does not mean that it is low calorie or that it will not cause your blood sugar to go up.
Do not rush out to buy these often more expensive foods – talk to your doctor or
dietitian!
Eastern Carolina Family Practice Center

Annette Peery, MSN, RN, CDE
FIGURE 1. Nutrition survival skills for diabetes.
important nutrition education in a concise education points that have a major impact
manner; and (3) implement the handout as on glycemic control. Whenever possible, we
an educational tool for family practice resi- stated items in the positive rather than the
dents. The handout focuses on key nutrition negative (i.e. “do not . . . ”). The handout also
CASE STUDY 4 369
focuses on problems we consistently encoun- r What time do you eat dinner? What do
tered in our patient population—portion sizes you usually eat? What do you usually drink with
and beverages. dinner?
r Do you usually eat or drink anything be-
As an illustration, we worked with one
patient who could not figure out why her blood tween lunch and dinner? If so, what?
r Do you usually eat or drink anything be-
sugars were always elevated. Upon further as-
tween supper and bedtime? If so, what?
sessment and questioning, we found that she r When you are thirsty, what do you drink?
believed fruit juice to be a “healthy” beverage r Do you ever drink sodas? What kind?
and was drinking one gallon per day. Another How often?
patient came in one morning for education r Tell me about your daily activity. What
and had an elevated blood sugar. He seemed do you do everyday for physical activity?
shocked about this, especially since he had
not yet had breakfast. When questioned about These, and other, questions assist in learn-
whether or not he had a snack the evening being about the patient’s typical dietary habits
and their daily routine. While this is only a
fore, he stated that he had a bag of fries. Well,
small portion of assessment, it is extremely
in our minds, that meant an order of fries from
important. After learning more about the pa-
a fast food restaurant. When questioned about
tient, you will quickly find many ways that
whether this was a regular or large order, he
they might improve their nutrition and their
responded “neither.” The patient had eaten a
family sized bag of frozen fries. glycemic control, but keep in mind, the pa-
In our practice, this handout is used by all tient will become overwhelmed if you try to
providers to assist them in remembering what make too many changes. Try involving your
to tell the patient about nutrition and diabetes, patient by saying, “from everything you’ve
and is given to patients to take home. Patients told me, I think there are some things that you
are encouraged to post the handout on their might consider doing that would help to im-
refrigerator as a reminder of these “survival prove your blood sugars. Some of these things
skills” that may have a tremendous impact on are . . . . Of all the things I listed, which two
their well-being. do you think you could do between now and
Personal experience and using this hand- when I see you next?” This approach empow-
out helped this diabetes educator to develop a ers the patient and puts them in control, as op-
series of questions to ask to assess the patient’s posed to the paternalistic approach of telling
routines and dietary habits. These questions patients “this is what you have to do.”
include: Above all, remember that diabetes is
a chronic condition and therefore requires
r What time do you get up in the morning? chronic education.
Do you eat breakfast? If yes, what time do you
eat? What do you usually eat for breakfast? What
Acknowledgments. The author would
do you usually drink for breakfast? If you drink
coffee, what do you put in it?
like to acknowledge Kathryn M. Kolasa, PhD,
r What do you usually eat for lunch? What RD, LDN, Linda Walker, RD, LDN, and
time do you eat lunch? What do you usually drink Amanda McKee, Nutritionist, of the Eastern
with lunch? Carolina Family Practice Center, Greenville,
r Do you usually eat or drink anything be- North Carolina, for their input and review of
tween breakfast and lunch? If so, what? the “Nutrition Survival Skills for Diabetes.”
Case Study 5
Diabetes Continuing Care Clinic Group Visits
for the Uninsured—A Case Study of Three
Community Health Centers
Donna Zazworsky,1 James Dumbauld,2 Charmaine Trujillo,3

Cecelia Hofberger,3 and Juanita Peterman4
1 Carondelet Health Network, Tucson, Arizona; St. Elizabeth of Hungary Clinic, Tucson, Arizona; and
Case Manager Solutions LLC, Tucson, Arizona
2 Department of Family Medicine, St. Elizabeth of Hungary Clinic, Tucson, Arizona; and University of Arizona,
Phoenix, Arizona
3 Mountain Park Health Center, Phoenix, Arizona
4 Clinica Adelante Inc., Phoenix, Arizona
INTRODUCTION how the initially defined format can be applied

and modified to appropriately fit the prac-
The Continuing Care Clinic (CCC) tice and patient needs of different populations
model is a relatively new approach to chronic served.
disease management. Also known as the A detailed Continuing Care Clinic
group visit model, the CCC was originally Group Visit Manual can be downloaded
established by the Group Health Cooperative from the Improving Chronic Care Website
of Puget Sound (Wagner, 1998), demonstrat- (www.improvingchroniccare.org) under the
ing a positive methodology that leveraged the Critical Tools section. This section includes
planned visit protocol format with group ed- detailed timelines and formats with sample
ucation and support. Ultimately the outcomes patient letters and job descriptions of team
are improved disease management and en- members. It is notes that the key elements of
hanced self-care abilities. a CCC Group Visit include:
In 2003, three community health centers
in Arizona participated in the Arizona Depart- 1. Contact with the primary care team
ment of Health Services pilot project to apply 2. Patient education and coaching
the CCC model to patients who were unin- 3. Medication management
sured and served by the three clinics. The CCC 4. Self-management support
model discussed in this case study exemplifies 5. Routine clinical/preventive care
371
372 CASE STUDY 5
6. Periodic health assessments (i.e., annual Table 1 compares the programs and dis-
foot exam, retinopathy exam, nutrition counseling, cusses their preliminary results after provid-
psychosocial counseling, laboratory work) (Group ing the CCC for one year.
Health Cooperative, 2001).
PLAN-DO-STUDY-ACT CASE STUDIES
Each clinic adapted the continuous qual- St. Elizabeth of Hungary Clinic
ity improvement process of Plan, Do, Study,
St. Elizabeth has designed their group
Act or otherwise referred to as PDSA. Every
visits with the primary purpose to increase
month, each clinic team performed PDSA cy-
accessibility to annual exams and to provide
cles to improve processes. Included in each
diabetes education to more patients through
clinic description is a sample of their PDSA
a “one-stop shopping” format. The clinic had
cycle activities. For more information on the
a low rate of patients completing their annual
PDSA process refer to Chapter 3.
exams for retinopathy and foot. Therefore, the
medical director designed a monthly Diabetes
ARIZONA DEPARTMENT Day.
OF HEALTH SERVICES The special day became known as the
PILOT PROJECT Diabetes Day Group Visit (DDGV) and was
scheduled for the third Friday of every month.
The Arizona Department of Health Ser- Patients were referred from clinic providers
vices received a grant from the ASPE to im- and nurses based on any of the following three
plement the CCC model within two federally criterion:
qualified community health centers. ADHS r the patient had an HbA1c greater than
funded a third community health center that 8%;
had more than a year experience in deliver- r the individual had difficulty completing
ing group visits within the uninsured frame- their annual exams; or
work. Clinica Adelante, Mountain Park and r the patient was newly diagnosed with di-
St. Elizabeth of Hungary Clinic participated abetes.
in the project. The following summaries de-
Patients were usually asked to attend the
scribe the different CCC models adapted by
DDGV at the time of their quarterly planned
each clinic.
visit with their provider. Their name was
placed on a list with others. Usually 15–20
CONCLUSION people would be referred and approximately
10–15 would actually attend. An administra-
The pilot program was successful in im- tive fee of $20 is charged for the entire 3-hour
proving patient diabetes status as measured by program, which included an ophthalmologist
the HbA1c (Results can be obtained through and podiatrist visits. It is coded as a Group
the Primary Care Services of the Arizona De- Visit.
partment of Health Services). In addition, all The program process is as follows:
three clinics demonstrated improvement in
1. When patients check in they receive a
documentation of self-management goals and clipboard with the various visit forms and are in-
completion of annual requirements. As a re- structed to the waiting area where they will receive
sult of the pilot project work, a workshop was a visual acuity exam and then have eye drops in-
given to other community health centers to stilled for dilation later in the morning. Annual in-
share the experiences and lessons learned. fluenza vaccines are given at this time during the
CASE STUDY 5 373
TABLE 1. Comparison of ADHS Continuing Care Clinic Pilot Programs

St. Elizabeth of Hungary
Clinic Diabetes Day Mountain Park Health
Group Visit Center Clinica Adelante
Program A different group attends Groups are identified and Groups are identified and
description the monthly Diabetes the same groups meet the same group meets
Day Group Visit. Group once every 3 months. every 3 months. Group
size = 10–12. Takes Group size = 25 size =7–12
3 hours and
documented on Group
Visit Form.
Patients Tobacco tax eligible Uninsured patients with Uninsured (TT) and
(uninsured) adults with diabetes chosen from Insured (very few)
type 2 diabetes HbA1c existing PECS registry
>8, newly diagnosed,
difficulty obtaining
annual exams. New
group every month.
Cost $20 admin fee for 3-hour $25 fee $20.00 for provider visit
group visit
Setting Clinic conference room Clinic Clinic
for education classes
and dedicated area for
1:1 exams and checkout
Comments on Patients move from room Patient stays in exam Setting is very small, need
setting to room. Need to keep room and providers a larger class room.
patients together and rotate
utilize staff to facilitate
flow, so not to lose them
Goals Complete annual exams Complete annual exams Complete quarterly exam.
improve Improve HbA1c, LDL,
and BP
HbA1c, LDL, and BP Focus is on the HbA1c
Complete specialist and Improve national
class referrals collaborative indicators
Complete Review self-management
self-management goals goals and revise as
and follow-up plan with necessary.
promotoras
Motivate patient to attend
group classes
Intervention Diabetes nurse educators Provider Nurse practitioner
staffing and CDE Dietitian for
classes (English and
Spanish)
PCP Pharmacist Endocrinologist
Pharmacist Diabetes Case Manager RN
Ophthalmologist Dietitian Dietitian
Podiatrist Dentist MA
Promotoras Behavioral health Senior leader
2 Support staff Senior leader Support staff
Senior leader
(Cont.)
374 CASE STUDY 5
TABLE 1. (Continued)
St. Elizabeth of Hungary
Clinic Diabetes Day Mountain Park Health
Group Visit Center Clinica Adelante
Interventions The Basics of Diabetes Nutrition video Diet, exercise, and stress
topics and Nutrition management
Self-management goals 1:1 visits with provider, Vitals and BMI
dietitian, nurse case
manager, behavioral
health
Group snacks Group lunch and Medication review
socialization
General eye exam Foot exam
Retinopathy exam Laboratory work
Foot exam Group lunch
Medication review
Referrals to specialists
and 7-week classes
Flu shots
Lab when necessary
Results 98–100% receive annual Improved HbA1cs and Not available at this time.
exams lipids
100% complete 100% complete Total # participating
self-management goals self-management goals (POF-167)
78% agree to referral to 50 patients have
classes participated in all 3
visits
30% no show rate
More than 100 patients
have participated in
DDGV in past
11 months.
Citation Lamb, G., and Zazworsky, National Collaborative
D. (2002). Disease Literature (list serve
Management. In Cesta: literature)
The Case Manager’s
Survival Guide:
Winning Strategies for
Clinical Practice, 2nd
ed., St. Louis, Mosby.
Zazworsky, D. (2002).
Disease Management in
Managed Care. In
Cesta: The Nurse’s
Guide to Managed
Care. St. Louis, Mosby.
Site contacts Donna Zazworsky Charmaine Trujillo Juanita Peterman
donnazaz@aol.com ctrujillo@mphc-az.com jpeterman
@clinicaadelante.com
James Dumbauld, DO
drjamesd@ccs-soaz.org
Additional Difficult tracking results Patients who have not
Comments in one-time group visits participated in the
due to patients not classes tend to be the
returning to clinic for 3 patients who do not
or 6 month follow-up follow-up on a
visits consistent basis.
CASE STUDY 5 375
TABLE 2. St. Elizabeth of Hungary Clinic Diabetes Group Visit Flow Chart
DIABETES GROUP DAY
Check-In Registration
Paperwork /Clipboard
Visual Acuity – Anterior Chamber Evaluation
Eye Drops
English Spanish
Diabetes Class – Diabetes Class –

Nurse Nurse
Nutrition Class Nutrition Class

Self-management Goal Self-management Goal
Snack
Eye Examination Foot Examination
Provider and Pharmacy Wrap –Up

♦ Review Self-management Goals
♦ Review Medicine List
♦ Complete Encounter Form
♦ Complete Referral Forms
Promotoras
♦ Class Referrals
♦ Strip Program Referrals
♦ Self-management Follow-Up Appt
Check-Out/Business Office
appropriate time of the year. Table 2 describes the and 5) to simplify the process. There is room to
flow of the group visit. write other self-management goals.
2. Then patients are directed to the edu- 4. Individuals are given a healthy snack,
cation room. They are divided into two groups: then directed to the exam rooms to receive their
English or Spanish speaking. individual annual exams.
3. Each group receives educational sessions 5. Each person receives an individual exam
on the basics of diabetes and nutrition by the from the ophthalmologist and podiatrist on the
Diabetes Nurse Educators and Dietitian. At the DDGV Form. Clinic staff serve as translators when
end of the sessions, each patient is given a self- needed (see Table 6).
management goal form and asked to complete it. 6. Each person then has an exit interview
The form is in a checklist format (see Tables 4 with the Primary Care Provider who reviews the
376 CASE STUDY 5
TABLE 3. St. Elizabeth of Hungary Clinic Diabetes Day Group Visit Job Responsibilities
Clinic Clinic
diabetes diabetes
RN project nurse nurse
PCP lead (English) (Spanish) Dietitian QA RN
Refer patients Contact Send Refer patients Teach class Satisfaction

podiatrist reminder to complete evaluation
staff self-management
goals
Contact eye Data Coordinate Teach class Diabetes day Education
doctor oversight case (Spanish) menu/snacks evaluation
conference
Formulate, CQI oversight Teach class Implement Refer patients Assist with
communi- (English) care plan QI, PDSA
cate plan and
of care for Promotoras
patients
Flow master Flow master Flow master

Scheduler 1 2 3 (Volunteer) Pharmacist Promotora
Call/remind Direct Direct Assist patient Review meds with Patient

patients patients patients flow PCP and patient checkout
Keep Administer Assist Make Follow-up
attendance eye drops podiatrist recommendations ‘no-shows’
list
Give patients Assist eye Follow-up
clipboard doctor SMG
with Flow
Chart
results and self-management goals, and completes Outcomes

referral forms as needed. The PCP signs off on the
self-management goals or makes adjustments with The DDGV evaluation process focuses
the patients based on the patient’s medical needs. on three areas: clinical, quality, and financial.
The referrals may include further follow-up with
The clinical parameters looked at the
an ophthalmologist, podiatrist, dietitian, and/or
issue of how many people were receiving
nurse.
7. Finally, the person is directed to the Pro- annual exams for retinopathy and foot exams
motora table. Here the Promotora and the patient and identifying self-management goals.
complete any other paperwork, agree on a time Approximately 98% of the patients who
when the Promortora can call to see how their self- attend the DDGV completed their annual
management goals are progressing, and to enroll exams. Hundred percentage of the patients
the patient and family into the group classes. completed self-management goals. It also
should be noted that 78% of the patients who
attended DDGV agreed to attend the 7-week
Each person has specific responsibilities be- educational series and 50% of those patients
fore, during, and after the DDGV. Table 3 de- actually completed the classes (see Tables 5
fines these activities. and 6).
The providers and staff document on the The quality measures looked at patient
DDGV form (Table 4) and this becomes part satisfaction. Table 7 illustrates patient satis-
of the patient’s record. faction outcomes for DDGV.
CASE STUDY 5 377
TABLE 4. St. Elizabeth of Hungary Clinic Diabetes Quality Indicators

Spanish
English
DIABETES DAY
Patient’s Name Date
Address D.O.B.
Age Sex Chart No.
Home Phone
Date of Last Exam
Foot Neuropathy Screening Exam
General Diabetes Class Diabetes Nutrition Class
Retinopathy Screening Exam

VA VA
Ophthalmoscopy Dilated c
Disc
Vessels
Macula
Retina
378 CASE STUDY 5
TABLE 5. Self-Management Tool
ST. ELIZABETH OF HUNGARY

SELF-MANAGEMENT SUPPORT TOOL
HEALTHY CHANGES PLAN
Patient Name: MR #
Telephone Number: Date:
Please initial and place an in the box next to one self-management goal that you agree to follow. This goal will be
evaluated on your next monthly visit to the clinic.
Initial
❑ I will lose about 1–2 pounds this month.
❑ I will eat foods containing carbohydrate in moderation at regular times every day.
❑ I will eat 3 or more servings of vegetables each day.
❑ I will limit my servings of fat to 2 or 3 each day.

❑ I will not skip meals.
❑ I will do some type of exercise (physical activity) for a total of 15–30 minutes,
3–5 times per week (includes walking, stair climbing, running, and swimming).
I agree to have St. Elizabeth contact me by telephone calls or mail. Yes |− −

−| No |−|
Patient Signature indicates agreement to do the selected goal. It also grants permission for follow-up
telephone calls or to send mail).
Patient Signature: Date:

Reviewer Signature: Date:
Restrictions: Yes G No G Comment
Care Provider Signature: Date:

Weekly Telephone Contact:
Date: Time: Provider Name:



Three Month Follow-up Appointment:
Date: Time:
The financial outcomes were examined because we are talking about the uninsured
from a cost burden perspective. In other with no real reimbursement incentive. There-
words, what did it cost to run a DDGV fore, the incentive is to improve access to
and how many patients are needed to at- care and enhance patient adherence and mo-
tend to make it worthwhile for the clinic. tivation to pursue further self-management
There is not a true breakeven point here, activities.
CASE STUDY 5 379
TABLE 6. Self-Management Tool in Spanish
ST. ELIZABETH OF HUNGARY CLINIC

INSTRUMENTO DE APOYO PARA EL AUTOCUIDADO
PLAN DE CAMBIOS SANOS
Nombre del Paciente: MR #
Numero Telefónico: Fecha:
Ponga sus iniciales en la caja junto a una de las metas que usted se compromete a seguir. Esta meta será evaluada
en su próxima cita.
Inicial
❑ Voy a perder de 1 a 2 libras este mes.
❑ Voy a comer comidas que contienen carbohidratos en moderación y a horas regulares del dı́a.
❑ Voy a comer 3 o mas porciones de vegetales al dı́a.
❑ Voy a limitarme a de 2 o 3 grasas al dı́a.

❑ NO me saltare comidas en el dı́a
❑ Haré algún tipo de ejercicio (actividad fı́sica) por lo menos de 15 a 30 minutos,
3–5 dı́as por semana (incluye caminar, subir y bajar escalera, nadar, o correr).
Otorgo mi permiso para que la Clı́nica Sta. Elizabeth me hable por teléfono o me mande una carta por
correo. Si.❑No.❑
(Al firmar este documento, usted se compromete a seguir una de las metas. También le da permiso a la clı́nica
de llamarle por teléfono o contactarlo/a por correo.)
Firma del paciente: Fecha:

Firma del Evaluador: Fecha:
Firma del Proveedor: Fecha:

Llamada semanal:
Fecha: Hora: Nombre del proveedor:

Llamada semanal:
Llamada semanal:
Próxima Cita durante tres meses:
Fecha: Hora:
Cost Breakdown of $20/patient for an administrative fee barely

offsets any of the costs. Since there is an unin-
The clinic estimates that an average cost sured population, there is no reimbursement
for the clinic is approximately $600–$1000 and the “one-stop shopping” philosophy is an
for 3 hours every month. This would include advantage for both patients and providers. The
the costs related to staffing the clinic, prepara- outcomes related to completed annual exams
tion, and follow-up time. The average revenue and increased likelihood of participation in
380 CASE STUDY 5
TABLE 7. St. E’s Diabetes Day r Clinic staff members were comfortable in
Group Visit Patient Satisfaction one-to-one teaching scenarios, but must develop
Survey Results new skill sets to manage the larger group visit
format.
Response r Be prepared for New Patient Shows—
Question score people read the quarterly newsletter and just
Information presented clearly 2.8 showed up.
r DDGV serves as a motivator into group
Learned new information 2.9
Going to change eating habits 2.9 education classes.
Enjoyed DDGV 3.0
Mountain Park Health Center

group education classes are important. There-
fore, it is imperative that the focus on atten- Mountain Park Health Center (MPHC)
dance be addressed to keep the cost per patient is a nonprofit community health center that
between $50 and $70. has been providing comprehensive primary
In an insurance reimbursement or pay- care services to the greater Phoenix metropoli-
for-performance framework, the group visit tan area since 1980. Mountain Park Health
is a very positive approach to achieve clinical, Center has health center sites in four loca-
quality, and financial outcomes. tions: South Phoenix, Maryvale, Tolleson, and
East Phoenix. Services offered include pri-
mary medical care, dental care, pharmacy ser-
PDSA Cycles vices, nutrition counseling, behavioral health
services and community-based tobacco pre-
A major effort of the clinic PDSA pro- vention, and cessation services. In 2003, the
cess improvement focused on attendance (Ta- MPHC provided primary health care ser-
ble 8). The DDGV consistently experienced a vices to more than 38,000 individuals, com-
50% “no show” rate. Although this was alarm- prising more than 120,000 patient visits. To
ing, the promotora phone follow-up of the date, more than 1,500 individuals with dia-
“no shows” regularly reported family crisis betes have been enrolled in the health cen-
or they did not think it was necessary right ter’s diabetes program. Efforts to improve
now (Table 9). Some patients reported trans- the health care and health status for pa-
portation or financial issues as a barrier, so tients with diabetes have included the de-
we established a scholarship program. Now, velopment of the CCC, successful use of
when the promotoras do the reminder calls the tele-ophthalmology retinal screening pro-
prior to the group visit, they explore potential gram, and the development of a diabetes case
problems and have the option to offer schol- management program. Classes also are of-
arship vouchers. The end result has taught the fered for patients with diabetes in English and
team they need to schedule 20–25 people in Spanish.
order to have 10–12 attend. Mountain Park Health Center adapted
the group visit model that is defined in the
Lessons Learned Group Visit manual. Under the leadership of
the Quality Director, MPHC organized a CCC
As a result of the DDGV, the following Care Team that included: a pharmacist, nu-
lessons were learned: tritionist, behavioral health specialist, physi-
r Even when patients are administered eye cian, RN, and MA to do the retinal screening.
drops to dilate their pupils, they will still be active The team also established checklists, assess-
participants in the group education process. ment tools, and documentation forms. The
CASE STUDY 5 381
TABLE 8. Process Improvement Form: PDSA
St. Elizabeth of Hungry

Act Plan
PDSA Form
Study Do
Team: Donna, Chris, Linda, Paula, Mary, Catherine, Belen, Yvonne
CHRONIC CARE MODEL COMPONENT: Self-Management Support
Community Linkages Organization of the Healthcare Delivery System
Problem: Poor Self-Management Goal Documentation

Objectives of the Test
Plan:
1) Develop a self-management tool for the patient provider to document self-management goals
on Diabetes Day Group Visit (DDGV).
DO:
1) Create a tool with the multidisciplinary team

2) Train the promotoras and providers on the use of the tool
3) Administer the tool at the DDGV scheduled for September 12, 2003
4) Analyze the results
Study:
1) 100% of DDVG patients completed a mutually set (patient and provider) SMG
Act:
1) Implement the tool at every DDGV

2) Create a PSDA on SMG follow-up
team also hired a part-time Diabetes Case The CCC Care Team held numerous
Manager to provide one-on-one education and planning meetings to organize the flow of
self-management coaching at the time of the the group visit, develop forms and determine
group visit as well as follow-up on patients the educational format. The Team Leader
after the clinic. also contacted local sales representatives from
TABLE 9. St Elizabeth of HungaryDiabetes Telephone Visit Log for Promotoras (Visit Code 99371)
382
Patient Name MR # Date Caller Logged Hospitalized Reason for Comments

Initials in Since Last Follow-Up Inquiry M-Patient Moved
database Clinic SMG – TD-Telephone
(Y or N) Visit/Call? Self-management disconnected NA-No
(Y or N) Yes goal L – Reminder to answer (p 3 tries)
requires a complete logs AR- D-Deceased
comment in pts Appointment DNC-Do not
chart reminder O- Other contact/pt request
(please specify) H-Currently
hospitalized O- Other
(please specify)
CASE STUDY 5
Callers Signature: Callers

Signature:
Callers Signature: Callers
Signature:
CASE STUDY 5 383
pharmaceutical companies to provide lunch placed in a room and each provider floats
on the CCC Day. through the exam room on 15-minute inter-
To begin, eligible patients were identi- vals. The lead RN tracks the patients through
fied from their patient registry. Each patient the process, making sure that each provider
was notified about the new CCC opportunity. has seen the patient. One advantage of this
If they agreed to participate, the patient was process is that it is the provider who ro-
scheduled for the CCC. Prior to the day, a data tates rooms, not the patient. After all patients
entry staff member keeps track of patients that have been seen through the provider rota-
are in clinic and organizes the schedule. She tions, they are given lunch and participate in
pulls the charts and runs the super-bills the a group session that includes a video on the
day before clinic. PACE Nutrition Program with time for group
On the day of the CCC, the Medi- discussion.
cal Assistant triages patients and, if needed, The following three forms are examples
does a HbAlc and checks cholesterol before adapted for the Mountain Park Health Center
putting patient in the room. They are then Continuing Care Clinic.
Patient Behavioral Health Questionnaire
In the past 2 weeks have you: (Circle patient answer)

1. Had little interest or pleasure in doing things. Yes No
2. Felt depressed or hopeless. Yes No
3. Had trouble falling/staying asleep, or slept too much Yes No
4. Felt tired or had little energy? Yes No
5. Experienced a noticeable change in appetite Yes No
6. Had trouble concentrating on things? Yes No
7. Had thoughts of harming yourself? Yes No
Over the past 6 months, have you experienced excessive worry and anxiety? YES NO
If yes, please ask about the following and circle those that apply.
Does your anxiety or worry include: restlessness, fatigue, difficulty concentrating,

irritability, or muscle tension?
1. Have had nightmares about it or thought about it when you did not want to?
YES NO
2. Tried hard not to think about it or went out of your way to avoid situations that reminded
you of it? YES NO
3. Were constantly on guard, watchful, or easily startled? YES NO
4. Felt numb or detached from others, activities, or your surroundings? YES NO
Do you currently, or have you ever had problems with alcohol or drug use? YES NO
If available at Mountain Park Health Center, would you pursue specialty assistance for
these difficulties? YES NO
384 CASE STUDY 5
DIABETES CONTINUING CARE CLINIC

PROVIDER CHECK SHEET
PROVIDER
PHARMACIST
DIABETES CASE MANAGER
DIETICIAN
DENTIST
BEHAVIORAL HEALTH
RN
PROGRESS NOTES FOR CONTINUING CARE CLINIC

MOUNTAIN PARK HEALTH CENTER
DATE: MEDICAL RECORD:

PATIENT NAME: D.O.B.:
DIABETIC EDUCATOR:
Provider Signature:
PHARMACY:
Provider Signature:
BEHAVIORAL HEALTH:
Provider Signature:
NUTRITION
Provider Signature:
DENTAL:
(SEE DENTAL SCREENING FORM)
CASE STUDY 5 385
Clinica Adelante, Inc. r Nutritionist/CDE,

r Medical Assistant,
Clinica Adelante, Inc (CAI) is a com- r Provider,
munity and migrant health center dedicated r RN,
to providing primary care services to all resi- r Administrative Assistant, and
r Senior Leader.
dents of western Maricopa County and its ru-
ral communities. Primary and specialty health Below is a Flow Chart of Clinica Adelante’s
care services are provided at Clinica Ade- Continuing Clinic.
lante’s community health centers in Surprise,
Buckeye, Gila Bend, Mesa, Sun City West,
and Wickenburg. PDSA Cycles
Clinica’s Diabetes Continuing Care Over the year, the CCC Team performed
Clinic (CCC) was offered to patients with di- the PDSA cycles on a number of different pro-
abetes who were identified by providers as cess improvement aspects.
high-risk individuals who would most likely
r Business cards. The team tested using
benefit from a group visit. The clinic consisted
of three components over a 3-hour timeframe: business cards to provide continuity of commu-
nication between patients and staff. This worked
1. Medical: A planned diabetes visit was well and was implemented throughout the clinic.
performed by the endocrinologist r Ophthalmology vouchers. Each patient
2. Social: Peer support was experienced as who participated in the Group Visits received a
part of the educational and group support process. voucher to go to an ophthalmologist for their annual
3. Educational: Participating patients re- retinopathy exam. CAI subsidized the cost of the
ceived group and individual education on nutrition, visit to increase the compliance rate of annual reti-
self-management, and physical needs. nal exams. Unfortunately the cost was prohibitive
and did not reduce the no-show rate. Other options
The following staff members were part of the are being tested.
CCC Team: r Medication lists. A medication list was
r Medical Records, developed to encourage that a medication re-
r Front Desk, view was completed with each visit. The medical
CCC Flow Diagram

Patient signs in at front desk
Diet, exercise, &
stress management
To Class
Vitals, BMI, Review Meds,
Foot exam, Assessment,
MA takes to Provider Flowsheet & Labwork
Self-Management and
Provider takes to RN prescribed education
Patient goes back to Education room

for Q&A and lunch
386 CASE STUDY 5
assistants initiate the review and providers check r Clinical perspective: We learned
for accuracy and sign off on the form. that cultural diversity plays an important role
r Patient reminders. The administrative as- in providing care and education.
sistant, through use of the data registry, provides 4. Loss of provider staff for clinical day. We
staff with reports that indicate those patients who learned that we needed to change the day of the
are due or overdue for a visit. Team members use CCC to a day when walk-ins were less heavy. Ini-
the list to call patients to remind them of the need tially, we held the classes on a Monday morning.
for follow-up. This created a heavy work load for providers not
r Voice mail box/E-mail notifications. This involved with the CCC.
PDSA was initiated to provide feedback from spe-
cialists about patients who “no-showed”. The pro- To paraphrase the National Collabora-
cess worked, however, we have not continued to tive’s motto under the Bureau of Primary
use it due to time and cost factors. Health care (Health and Human Services),
r Flow sheets. This was a multicyle PDSA. changing practices does change lives for ev-
The end result was a flow sheet that incorporated eryone involved. It is evident by our improved
one year of quarterly visits, correlated with data functional and clinical outcomes that the con-
entry flow, provided an area for the patient to sign cept of the CCC is a valuable framework from
off acknowledging receipt of a patient education which both patients and staff benefit.
folder, and reminded the provider to check for other
chronic disease flow sheets.
Acknowledgements. We would like to ac-
knowledge the Arizona Department of Health
Lessons Learned Services, Patricia Tarango, Director, ADHS
Primary Care Services and Gordon Jensen,
1. Large team structure. Initially the team
was too large, consensus was difficult to obtain.
AHDS Primary Care Services for leadership,
In the future, we will start with a smaller cross- funding, and encouragement to explore new
functional team. models of care for the uninsured.
2. Communication. Members of the team
came from different beliefs and interests on how
the CCC should be created and managed. Change REFERENCES
came about slowly.
3. Cultural diversity. Conducting a Continuing Care Clinic Handbook for
r Patient perspective: Patient com-
Practice Teams. (March 5, 2001). Center for
ments reflect that they preferred a class that Health Studies, Group Health Cooperative of Puget
is facilitated in their native language. We no- Sound
ticed improved participation and outcomes Wagner, E.H. (1998). Chronic disease management:
when classes were separated into Spanish and What will it take to improve care for chronic illness?
English. Eff Clin Pract 1:2–4.
Case Study 6
A Hospital Case Study in Diabetes
Management—Carondelet Health Network
Rose Marie Manchon

Diabetes Care Centers, Carondelet Health Network, Tucson, Arizona
HISTORY Today, the Carondelet Health Network

serves a diversity of clients—Anglo, Latino,
Carondelet Health Network (CHN), a Native American, and Black Americans, re-
member of Ascension Health, is the oldest and flecting the population of Southern Arizona.
largest not-for-profit health care provider in As is noted in the literature on diabetes, the
Southern Arizona. Carondelet serves the com- highest prevalence is in the Latino, Native
munity with multiple inpatient and outpatient American, and Black communities. This di-
facilities. Presently, the Carondelet Health versity in Pima County presents unique chal-
Network is made up of St. Mary’s Hospital lenges for health care providers. Diabetes is
on the west side of Tucson, St. Joseph’s the 4th leading cause of death among Na-
Hospital on the east side, Holy Cross Hospital tive Americans; the 5th leading cause of death
in the border town of Nogales, AZ, and the among Latinos; and 4th leading cause of death
outpatient Medical Mall of Green Valley, among Black Americans (Arizona Depart-
AZ. ment of Health Services [ADHS], 2003). The
Carondelet St. Mary’s Hospital began Anglo community is certainly contributing to
in the 1880s when the Sisters of St. Joseph the growth and widespread concerns about di-
of Carondelet came to the area to provide abetes; however, the ratio of developing the
education and health care to a then remote disease is almost twice as high among non-
area. The Sisters built the hospital to con- Anglos (ADHS, 2003).
tinue their philosophy of caring for all per- The CHN sits in the pocket of an area
sons and fulfilling the mission of the Roman with a high prevalence of diabetes and di-
Catholic Church through St. Mary’s Hospital, abetes related diseases. Over the last few
St. Joseph’s Hospital, Holy Cross Hospital, years, Pima County has estimated 44,235
and Green Valley Medical Mall. people with diabetes: the largest age group
387
388 CASE STUDY 6
being the 45–64 group with 18,133 (ADHS, structured series of classes for clients referred
2003). by their physician and was more effectively
This case study will describe the inpa- managed.
tient and outpatient programs at St. Mary’s Both inpatient programs were not for-
and St. Joseph’s Hospitals specifically. Refer malized in the early years and were sporadic
to Appendix 1 for a profile of the clients and at best. The outpatient programs, with the
annual program outcomes. advantage of ADA Recognition Award were
In the late 1980s, Carondelet followed blossoming. Endocrinologists, Internists, and
through with their commitment by beginning Family Practitioners began referring at a reg-
a Diabetes Care Center (DCC) at St. Joseph’s ular pace. The Obstetricians began sending
Hospital that served inpatients and outpa- their gestational diabetes patients to the pro-
tients. This Center was devoted to the edu- gram in their early pregnancy, and Pediatri-
cation and improvement of lifestyles of those cians recognized the unique knowledge and
with diabetes. The DCC also focused on edu- skills of the CDEs with children.
cation for the staff of the hospitals and other Strong relationships built through good
outpatient facilities. Early on, CHN recog- communications were the underlying factor to
nized the need to help the people in Southern the success of the outpatient programs. The
Arizona learn about and live with diabetes and physicians trusted the veracity of the edu-
to respond to working toward prevention of cational assessment and recommendations of
the disease. the CDEs and were willing to work collabo-
ratively. The nurses and dietitians considered
each client as a unique individual with differ-
OUTPATIENT AND INPATIENT ent lifestyles and different coping skills. This
ISSUES individualization remains today as a corner-
stone and most respected aspect of the Caron-
The Diabetes Care Center at St. Joseph’s delet Diabetes Care Centers.
Hospital started outpatient classes; the DCC Because of the magnitude of the inpa-
nurses studied for certification exams, and im- tient referrals with new or out-of-control dia-
plemented statistical measures to apply for the betes, the limited staff of the DCCs was over-
American Diabetes Association Recognition whelmed and could no longer accommodate
Program. As the nurses received their Cer- inpatients with appropriate education during
tified Diabetes Educator (CDE) credentials, their stay. St. Mary’s Hospital instituted a
the program moved forward with an increased Nurse Resource Program to address this prob-
numbers of clients. Soon after, the center ap- lem. The Nurse Resource Program included a
plied for and received the American Diabetes seminar 2–3 times a year to update and reed-
Association (ADA) Recognition Award. St. ucate nurses and health care providers on the
Mary’s Hospital followed in the early 1990s newest and most current information on the
with a separate DCC to accommodate those care of the person with diabetes. Each unit or
on the west side of town and was granted the department sent representatives to the sem-
Recognition Award in the early 1990s. inars to learn about diabetes and serve as a
Originally, in both DCCs, educators han- resource person to that unit. The response to
dled inpatients diagnosed with diabetes or the classes was always amazing—nurses, di-
with diabetes as co-morbidity on a refer- etitians, and other health care workers were vi-
ral basis and by daily assessment of the tally interested in learning about diabetes. The
admissions list of newly admitted patients Nurse Resource Program was creative and ef-
These were loosely organized inpatient pro- fective for a period of time. Gaps in service
grams that worked only when DCC personnel occurred when the resource person moved on
was not stretched to the limit. On the other to other jobs. The hospital units were slow to
hand, the outpatient programs provided a recognize that the special resource nurse was
CASE STUDY 6 389
no longer available. Over time, very few units Outpatient programs have been the
retained the resource nurse, leaving the hos- largest and most successful programs address-
pital wide diabetes education program as an ing diabetes care that Carondelet offers. It is a
episodic event. recognized fact that outpatient education with
CDEs as instructors is the best way to affect
the lives and behaviors of those with diabetes.
INPATIENT CASE MANAGEMENT
STAFFING
Many discussions and consequent exper-
iments occurred at both St. Mary’s and St.
The DCC staff at both hospitals is staffed
Joseph’s Hospitals. At St. Joseph’s Hospital,
with CDEs, qualified registered nurses and
the DCC educators and staff supported the
registered dietitians, administrative support
Diabetes Case Manager (DCM) model as the
personnel, and an office coordinator. Cur-
appropriate way to handle inpatients with di-
rently, the DCC’s Program Coordinator po-
abetes. Ideally, the DCM is a combination
sition is filled by a full time CDE, an aca-
case manager and diabetes educator. Duties
demically prepared and experienced educa-
include: (a) client risk assessment, (b) coordi-
tor (ADA, 2004), replacing the former man-
nation of comprehensive care, (c) meeting im-
ager who was a Clinical Nurse Specialist with
mediate diabetes education needs, (d) assist-
graduate credits in management. The Program
ing clients in identifying necessary lifestyle
Manager is responsible for the efficacy and
changes, (e) problem solving with clients, (f)
coordination of the education program. The
linking clients with providers, and (g) en-
diabetes team is led and advised by a manda-
rolling clients in an outpatient program (Hos-
tory advisory committee headed by the Pro-
pital Case Management, 2000).
gram Manager. An endocrinologist, with spe-
The DCM, a full time, dedicated educa-
cialization in diabetes management, as well
tor (preferably a CDE), uses the DCCs as an
as all members of the advisory committee, is
education resource and for backup coverage.
available to the staff for questions and advice
Because educators are available, this model
on an as-needed basis.
works well in providing survival skills to the
newly diagnosed and refreshers to the patient
with diabetes who is out of control. STRUCTURE AND CONTENT
The outpatient DCCs accumulated a
plethora of booklets, instructional tapes, The DCCs, as recognized education pro-
handouts, diets, general, and specific infor- grams, follows the curriculum recommended
mation on diabetes that the inpatient DCM by the ADA. The curriculum and content
has available. Ideally, the DCM would be part must address: (a) diabetes disease process,
of the Diabetes Center as a regular Full Time (b) nutrition, (c) physical activity, (d) medi-
Equivalent (FTE); however, it works well if cations, (e) monitoring/using results, (f) acute
the educator is under the Nursing Depart- and chronic complications, (g) goal setting
ment with collaborative ties to the Diabetes and problem solving, (h) psychosocial ad-
Centers. justment, and (i) preconception care, preg-
While St. Joseph’s Hospital pilots the nancy, and gestational diabetes mellitus—
DCM position, St. Mary’s will reinstitute the GDM (ADA, 2004).
Nurse Resource Program for another trial, In addition to the regular classes that
correcting problems that were identified in the follow the ADA content and curriculum re-
last seminars. The Nurse Resource Program quirements, St. Mary’s Hospital conducts a
will reach for a wider audience—including weekly general overview diabetes class—in
all team members of the diabetes management English and in Spanish—to the public, free of
group. charge. The bilingual classes are headed by
390 CASE STUDY 6
a registered nurse who has met the necessary program. Of course, the staff often calls for
continuing education units (CEUs) to be eli- the client.
gible to teach in the Recognized Centers. The
class attracts people with diabetes and/or in-
BUDGET ISSUES
terested family members from the community.
The outpatient class structure has
Each year when the budget was set, the
changed over the years to accommodate the
focus was on FTEs needed to carry out the
numbers of referrals, the changes in insurance
program. Obviously, diabetes education is a
reimbursement or co-payment, and to take full
labor-intensive effort. Supplies included in
advantage of the team teaching talents of the
the budget increased as the number of en-
staff. Four years ago, the class structure was
rolled clients increased. In fiscal year 2002–
six, one and a half hour classes divided by
2003, both St. Mary’s and St Joseph’s Dia-
content, and one follow-up visit as part of the
betes Care Centers accommodated 6,051 class
series. The maximum number in those classes
attendees. This was a jump from 4,641 atten-
was 6–8 clients with one instructor. Today the
dees in 2001–2002. At one time, an HbA1c
DCCs offer 4-hour-long classes with a max-
was done on each client to compare the “be-
imum number of 10–12 clients and two in-
fore” and “after”; however, as our numbers
structors. The content is more integrated and
grew and time span of class shortened, it be-
addresses burning questions on the first visit.
came too difficult to continue. Now, the de-
A registered nurse and dietitian, both CDEs,
partment depends on the physician’s office to
teach each class. The classes are formatted to
give the HbA1c results both prior to and after
accommodate the lengthy time span by adding
the series.
regular breaks, group interaction, chair exer-
The most expensive supplies were the
cises, and even light dancing.
testing strips and cartridges needed for the
All materials used at the centers are
occasional HbA1c measurement. General of-
ADA-approved, the power point and slide pre-
fice supplies and laboratory services were in-
sentations are offered by the American Asso-
cluded as was money to support the attendance
ciation of Diabetes Educators (AADE). Phar-
of the staff at conferences and specific CEU
maceutical companies that produce drugs to
offerings that were needed in order to retain
control diabetes are generous with their edu-
the ADA Recognition.
cational material.
Anyone can make referrals to the
program—patient, family member, or con- RECOGNIZED PROGRAM
cerned health care provider. However, a physi-
cian order is needed to enroll the client and Recognition by the ADA was a very
begin instruction. Referral forms are sent to important step for the Carondelet Diabetes
area physicians, nurse educators, case man- Care Centers for many reasons. As a result
agers, and office referral nurses for their use. of being ADA recognized, the program set-
Most insurance programs do cover up was a systematic process in delivering ed-
diabetes education. However, in the last few ucation and monitoring for each person en-
years, insurance companies have offered rolled. The National Standards for Diabetes
menus to the employers and it is the em- Self Management Education (ADA, 2004)
ployer’s choice as to whether or not diabetes outlines the content and curriculum, staffing
education will be covered. Medicare covers and qualifications necessary to deliver a top
diabetes education with a physician order. quality program. As the standards are put into
The physician’s referral nurse is often asked place, the program takes form as an orga-
to check on coverage, or the client is asked to nized, salient program. Information on the
call and inquire, especially about the expected ADA Recognition status can be retrieved from
co-payments as they progress through the the ADA Web site www.diabetes.org.
CASE STUDY 6 391
Recognition is a necessary designation impressive. Community partners included:

for Medicare reimbursement on diabetes ed- Carondelet Community Trust, El Pueblo
ucation. Health Center, St. Elizabeth’s of Hungary
Community Health Center, Mel and Enid
Zuckerman College of Public Health, Canyon
CARONDELET FOUNDATION Ranch, University of Arizona College of
GRANT Nursing, El Pueblo Fitness Center, and the
local Young Women’s Christian Association
In October 2001, the Carondelet Foun- (YWCA).
dation’s Parish Nurse Program received a The staff developed a series of classes
$600,000 federal appropriations grant that that addressed the basic content of the ADA
was designated for diabetes education for an recognized classes. They offered behavioral
underserved community in the St. Mary’s strategies that would build capacity in the
Hospital catchment area. The overall aim of participant. Grocery store tours, walking pro-
the grant was to give those with diabetes the grams, passes for the graduates to the local
knowledge and skills to control the disease fitness center, a diabetes empowerment card,
and avoid long-term complications (Caron- and support groups were among the activities
delet Foundation Community Diabetes Pro- tied in to the program.
gram, 2004). Because the Carondelet Parish The total number served was 350. About
Nurse Program and the DCCs shared the same 75% of those graduated by attending at least
manager, staff members from both programs 4 out of 5 pertinent classes. A third of the
were involved in the grant. The grant even- participants took part in a 6-month follow-up
tually was approved for 3 years, enabling the questionnaire (Carondelet Foundation Com-
grant workers to become deeply involved in munity Diabetes Program, 2004). Program
the community. results demonstrate the classes immediately
The grant was modeled after the Promo- impacted the health of the participants. The
toras Model used by the Mel and Enid Zuck- measures used to evaluate were: HbA1c,
erman College of Public Health in several blood pressure, random blood sugar, and
border health grants. Promotoras are Com- weight. At the end of the program, the results
munity Health Workers (CHW) chosen from were reported as follows:
the local, ethnic community, who have met r Average random blood sugar decreased
education requirements and are supported by 26 points—187 to 161.
the American Public Health Association. The r Average random blood sugar decreased
CHW’s conduct outreach, participate in the 49 points among those with HbA1c >6.9.
r Average weight decreased by 3.3 lbs.
education classes and do individual and group
r Among those with elevated blood pres-
follow-up of enrolled clients (Carondelet
Foundation Community Diabetes Program, sure, the systolic decreased by 5.2 and the diastolic
by 18.8.
2004) r After 6 months, the HbA1c dropped 1.2%
The planning and development of the
from 8.8 to 7.6 among the high-risk population
program took 4–6 months, laying out the di- (Carondelet Foundation Report, 2004).
rection that the staff would take and began
to lay the groundwork for partnering with the
community, for developing needed policies, SUMMARY
curriculum, and forms.
The staff worked hard at creating part- The Carondelet Diabetes Care Centers
ners in the community to help with imple- continue to adapt to the needs of their clients
menting prevention strategies and supporting and the institution. As a member of Ascen-
lifestyle changes for the community. The sion Health, Carondelet has committed to
cooperation and willingness to help was the goal of providing health care access to
392 CASE STUDY 6
all. The Diabetes Program is an example of noneducated. The challenge and the goal of
the outreach to all levels of clients—high or the Sisters of St. Joseph of Carondelet con-
low risk, insured or noninsured, educated or tinue through these outreach efforts.
APPENDIX 1
Profile of Clients Served—January 1, 2003—to December 22, 2003

St. Joseph’s St. Mary’s
Age group
18 years or younger 0 0% 1 0%
19–44 203 29% 212 24%
45–64 306 43% 417 47%
65 years and over 177 25% 220 25%
Unspecified 12 0% 30 0%
Total 698 880
Gender
Females 418 59% 576 65%
Males 247 35% 295 33%
Total 698 880
Ethnicity
American Indian 0 0% 8 0%
Asian 15 2% 11 1%
African-American 28 4% 27 3%
Hispanic 140 20% 451 51%
White/Caucasian 499 71% 349 39%
Total 698 880
Diabetes type
Gestational 99 14% 101 11%
Type 1 3 0% 7 0%
Type 2—insulin 10 1% 88 10%
Type 2—noninsulin 585 83% 677 76%
Other 1 0% 1 0%
Unknown 0 0% 6 0%
Total 698 880
Treatment type
Combination 524 75% 422 56%
Diet only 75 11% 238 31%
Insulin 12 2% 35 5%
Oral 2 0% 41 5%
Total 698 759
Hemoglobin A1c 92 patients had 2 A1c levels recorded 70 patients had 2 A1c levels recorded
Average time 1 7.76 7.89
Average time 2 6.45 6.55
Percentage of change 16.88% decrease 17.03% decrease
Body mass index 269 patients had 5 weights recorded 288 patients had 5 weights recorded
Average BMI time 1 32.70 32.60
345 Patients had 4 weights recorded 425 Patients had 4 weights recorded
Source: Carondelet Diabetes Care Centers Annual Statistics Report (2004).
CASE STUDY 6 393
REFERENCES Managing the diabetic patient. Part II: Case managers

can make a difference in diabetes continuum of care.
Hosp Case Manag (United States). January, 2000;
American Diabetes Association, Inc. (2004). National
8(1):1–6, 15–16.
standards for self-management education. Diabetes
Mel and Enid Zuckerman College of Public Health.
Care 27:S143.
(2004). Carondelet Foundation Community Dia-
Arizona Department of Health Services. (2003). Diabetes
betes Program. Final Summary Report. Tucson,
and Associated Complications in Arizona. 2001
AZ.
Status Report. Phoenix, AZ.
Index
Acculturation: see Culture change Anxiety, 145; see also Fear

Achievable benchmarks of care (ABC), 13 Arizona, 239–241
Acidosis, 208 Arizona Community Health Outreach Worker
Action, 167, 168 (AzCHOW), 248
cues to, 166 Arizona Department of Health Services pilot project,
likelihood to take, 166–167 368
Adiponectin, 65–66 Arizona Diabetes Initiative (AzDIn), 29
Adjusted percentage fraction (APF), 13 Arizona State Diabetes Collaborative (ASDC)
Aerobic endurance, 128 core measure set, 28
Airport security, 154–155 framework, 26
Alcohol consumption, 88–89, 114 study of, 29–31
Alpha-glucosidase inhibitors, 74–75 Arthropathy, 177
Alpha lipoic acid (ALA), 261 ASP (Application Service Provide), 56
American Accreditation Health Care Atkins Diet, 91–92
Commission/Utilization Review and
Accreditation Committee (AAHC/URAC), 308 Behavior change
American Association of Diabetes Educators (AADE), communication guidelines to promote, 169–172
162, 308, 309 motivating, 167
American Board of Quality Assurance and Utilization stages of, 167–168
Review Physicians (ABQ-AURP), 308–309 theoretical perspectives on, 165
American Diabetes Association (ADA) health belief model, 165–167
certification by, 308, 309 putting theory into practice, 168–169
nutritional recommendations, 82–88 self-efficacy, 168
standards of care, 66–67 transtheoretical theory, 167–168
American Indians and Alaska Natives (AI/AN), 45–47 Behavioral management, 143–144, 149; see also
Amputation, 175–177, 314 Emotional continuum; specific topics
risk factors for, 180 Benefits Improvement and Protection Act (BIPA), 303,
Anger, 145 305–306
Angiotensin converting enzyme (ACE) inhibitors, Beta-blockers, 207–208
207 Beta cells, 63–65
ACE-I, 206–207 Biguanides, 73–74
Angiotensin receptor blockers (ARBs), 206 Bilberry, 263
Annual physical exam, 67 Biotin, 258
Antibodies to islet cells, 62 Bitter melon, 262–263
Antidiabetic agents, oral; see also Medications Blindness, 312; see also Retinopathy
in treatment of diabetes in pregnancy, 195 Blood glucose control: see Glucose control
Antiemetics, 152 Blood pressure, 67, 126
Antihypertensive drugs, 206–208 Body mass index (BMI), 79–80
Antirejection methods, 63 Border communities: see Mexico-U.S. border
395
396 INDEX
Botanicals: see Herbs execution phase, 24–25

Business Associate Agreements and HIPAA, 306 planning phase, 24
self-management component, 168–169
C-reactive protein (CRP), 257 Chronic disease, 19
Calcium channel blockers, 207 Chronic Disease Management (CDM): see Scott and
Caloric needs for weight maintenance, estimating, 90, White Health Plan
98 Chronic Disease Self-Management Program (CDSMP),
Calorie count, choosing foods that add up to right, 169, 172–173
106–107, 109–111 Chronic-illness care, state and regional collaboratives
Carbohydrate Addicts Diet, 90, 98 that improve, 26, 27
Carbohydrates, 82, 114 Chronic kidney disease (CKD), 199, 312; see also Renal
counting, 99, 118–121 disease
reasons for, 118 defined, 201–202
net, 83 diagnostic evaluation, 204–205
Cardiovascular disease, 314 National Kidney Foundation K/DOQI guidelines,
Cardiovascular dysmetabolic syndrome: see Prediabetes 201–202
Cardiovascular fitness, 128 stages and prevalence, 202, 209
Care coordination, 284 treatment considerations, 205–209
Carle organizations in type 1 diabetes, 202–204
diabetes management program, 352–355 in type 2 diabetes, 204
program outcomes, 355 Chronically ill, closing the quality chasm for the, 20
health care system, 351–352 Clinica Adelante, 369–370, 381
Carondelet Foundation grant, 387 Clinical information systems, 22–23
Carondelet Health Network (CHN), 383–384, 387–388 Coenzyme Q10 (CoQ10 ), 261–262
budget issues, 386 Collaboratives, 23, 29–32; see also Arizona state
inpatient case management, 385 diabetes collaborative; Chronic Care Model
outpatient and inpatient issues, 384–385 regional and statewise IHI BTS-style diabetes, 26, 27
profile of clients served, 388 synchronous, 29, 30
recognized program, 386–387 Community health advisors (CHAs), 245–246
staffing, 385 case study, 249–250
structure and content, 385–386 development of, 249
Case management, 284–285 development of advocacy for, 248–249
hospital-based, 287–288, 385 education and training, 247–248
Case review, 28 objectives, 248
Centers for Medicare and Medicaid Services (CMS), 5 training curriculum, 247–248, 250–253
Certified diabetes educators (CDEs), 173–174, 239, effectiveness, 246–247
384–386 Community health nursing, 285
Change, behavioral: see Behavior change Community Health Workers (CHWs), 387
Change package, 24 Community oriented primary care (COPC), 285
Charcot foot, 177 Community resources, 21–22
Charts, manual, 273 Comorbidities, 292–293
Cholesterol, 114 Complementary and alternative medicine (CAM), 255,
Chromium, 258–259 266; see also Herbs; Nutritional supplements
Chronic Care Improvement program (CCIP), 301–302 Compliance: see Patient compliance
Chronic Care Model (CCM), 19–21, 31–32 Congenital anomalies, 192
background, 20 Consolidated Health Informatics Initiative, 303, 307
case study, 29–31 Continuing Care Clinic (CCC), 367–368
components of collaborative framework pilot programs, 368–382
change package, 24 Continuous quality improvement (CQI), 3
charter, 23 Continuous subcutaneous insulin infusion (CSII),
measurement strategy, 24 71–72; see also Insulin pumps
defined, 21–23 Contraception, 197
detailed version, 24 Control, cultivating a sense of, 148
fundamental care unit, 20–21 Coronary artery bypass graft (CABG), 13
improvement collaboratives accelerating adoption of, Coronary artery disease (CAD), 86
23 Cortisol, 256
development phase, 23–24 Cost-effective care, 215–217
INDEX 397
Cost(s); see also Funding Dietary reference intake (DRI), estimates of, 86
of diabetes, 311 Dietitians, registered, 81–82
direct costs, 313 Diets, comparison of popular, 89–97
indirect costs, 313–314 Dihydropyridines, 207
literature review, 312–313 Discrimination laws, 303, 307
social costs, 314 Disease management (DM), 6, 14, 221, 283, 301; see
of medical care, 4 also under Rural and underserved populations
how to compute direct and indirect, 315–316 as benefit or administrative service, 294
reducing the cost of medications, 216–217 definitions, 283
of preventing diabetes, 312–313 historical precursors to, 284–285
Creativity, 148 regulations in
Cues to action, 166 federal laws and, 302–307
Cultural competence, 35–39 proliferation of guidelines and, 301–309
Native Americans and, 45–47 Disease management (DM) program support, research
promoted through community partnerships, 38 and policy issues associated with, 283–284
Cultural sensitivity, 35 Disease management (DM) programs, 286; see also
Culture, factors that influence, 36 Incentive programs; specific programs
Culture change, 38 accreditation and certification, 307–309
models of, 36–38 buying vs. building, 229–231, 293–294
two-culture matrix model, 37–38 dependence upon information systems, 294–295
health care market and government, 286–294
Decision support, 23 return on investment, 291–292
Delivery system design, 22 state mandated, 304, 305
Demographics, 166 Disease management (DM) research, cost-quality
Depression, 126–127, 145–146 nexus, and policy, 283–284, 291–294, 296
Dermatologic examination, 178–179 Diuretics, 207
Diabetes care centers (DCCs), 384–386 Docosahexaenoic acid (DHA), 260–261
Diabetes case managers (DCMs), 385 Dyslipidemia, 127
Diabetes Control and Complications Study (DCCT), 3
Diabetes Day Group Visit (DDGV), 368, 372, 374, 376 Eating Well for Optimum Health, 92
Diabetes educators, 173–174 Education, patient, 8, 185, 284; see also under
Diabetes management (DM), 143; see also specific Mexico-U.S. border
topics Educators: see Certified diabetes educators; Promotoras
three-pronged approach to comprehensive, 143–144 Eicosapentaenoic acid (EPA), 260–261
Diabetes management (DM) programs: see Disease Electronic medical records (EMR), 15–16
management (DM) programs Emotional continuum, 145–146
Diabetes mellitus (DM); see also specific topics awareness, acceptance, and action, 146–147
etiology theories, 183–184 building a foundation, 146
prevention, 314–315; see also Diabetes Prevention building a framework, 147–149
Program; Prediabetes depression, 145–146
prodromal phase: see Prediabetes Emotional management, 144, 257; see also Stress
risks associated with concurrent illness, 151 Emotional reactions, common, 144–145
standard forms of care, 66–67 Empowerment, patient, 239
type 1: see Insulin-dependent diabetes mellitus End stage renal disease (ESRD), 204, 209–210
type 2: see Noninsulin-dependent diabetes mellitus Environmental causes of type 1 diabetes, 62–63
Diabetes Prevention Program (DPP), 66, 131–132, 314 Essential fatty acids (EFAs), 260–261; see also Fats,
Diabetes Self-Management Education Core Outcome types of
Measurements, 162 Ethanol/ethyl alcohol, 88–89
Diabetes Self-Management Education (DSME), 309 Evidence-based medicine (EBM), 12
Diabetic ketoacidosis (DKA), 151, 152, 190 Exchange method (meal planning), 99
Diagnostic criteria, 197 Exercise, 66, 90
Diet, in treatment of diabetes in pregnancy, 195 benefits of
Diet planning; see also Meal planning blood glucose control, 125–126
essentials of, 90, 98–100 blood pressure, 126
Dietary causes of type 1 diabetes, 63 depression, 126–127
Dietary recommendations, 256; see also Nutritional diabetes prevention, 125
recommendations insulin sensitivity, 126
398 INDEX
Exercise (cont.) Fish oils, 260–261

benefits of (cont.) Flu-related deaths, 315
lipids, 127 Folic acid (folate), 258
weight control, 126 Follow-up, 8
goals of, 127 Food label reading, 99–100, 121–123
aerobic endurance, 128 Food servings
flexibility, 129 examples from each macronutrient group, 98, 99
muscle strength, 128 portion/serving size, 98, 112–113
public health recommendations, 127–128 Foot, diabetic, 175–176, 180
weight control, 128 risk categorization system, 179
motivating people to, 134 Foot care, 154, 177, 347
creating readiness and stages of change, 134–135 Foot examination, 67, 176–177
strategies for enhancing maintenance, 135 clinical examination, 177–180
perceived barriers to, 136 diagnosis and evaluation, 177
planned, 128 patient history, 177, 178
resources, 141–142 Foot system, diabetic, 179
risks of, 129 Footware examination, 179
hypoglycemia, 129–130 Foundations, funding from, 319
steps for promoting and prescribing, 137 Fructose, 83
in treatment of diabetes in pregnancy, 63 Fruits, 99
Exercise assessments, 129, 135 Fundamental care unit, 20–21
medical screening, 135 Funding, 315
recommended screening procedures, 136 Funding Grid, 318
PAR-Q, 135 Funding sources, 319–320
physical activity history, 136 identifying, 317–319
readiness for change, 136 Funding strategies, 315, 317–319
Exercise classes, group, 133–134 defining the disease management system and process,
Exercise Intrinsic Motivation questionnaire, 136–137 317
Exercise recommendations, 130 identifying target population and care needs,
duration, 131 316–317
energy expenditure, 131–132 Fundraising activities, 320
example of exercise prescription, 131
flexibility, 132 Gamma linoleic acid (GLA), 260
frequency, 130 Garlic, 264
intensity, 130–131 Genetic factors, 61–62, 64–65
progression, 132–133 Gestational diabetes mellitus (GDM), 183, 189, 313
type, 131 classification, 190
walking vs. other activities, 132 contraception and prepregnancy counseling, 197
Exercise self-efficacy, 136–137 definitions, 189
Eye disease, 314; see also Retinopathy delivery and, 196
Eye exams, 217 metabolic management during labor, 196–197
fetal assessment, 195–196
Faith-based grants, 319 laboratory and ancillary testing, 196
FAST approach to disease management, 343–344 management, 195
Fasting glucose, impaired: see Prediabetes monitoring blood glucose, 194
Fat intake, 85–86, 120; see also Fats treatment goals, 195
Fat mass; see also Body mass index maternal and fetal complications, 190–191, 193
and insulin resistance, 66 congenital anomalies, 191–192
Fats; see also Lipids fetal hypoglycemia, 192–193
types of; see also Essential fatty acids (EFAs) growth and development, 193
and lipid profile, 86 neonatal respiratory problems, 193
that predominate in different foods, 87 perinatal mortality, 191–192
Fear, 144; see also Anxiety placental problems, 191
Fenugreek, 263–264 prevalence, 189–190
Fetal complications: see Gestational diabetes mellitus screening and diagnosis, 193–194
Fiber, 115 diagnostic criteria, 194
Fiber rule, 122–123 postpartum screening, 197
INDEX 399
Ginseng, 264–265 Hydramnios, 191

Glomerular filtration rate (GFR), 199–200; see also Hyperglycemic hyperosmolar nonketotic syndrome
Chronic kidney disease (HHNK), 151
Glucometers, 271–272 Hyperimmunity, 62
areas of improvement for, 272 Hyperparathyroidism, 208–209
Glucose control, blood Hypertension, 191
exercise and, 125–126 Hypoglycemia, 278
Glucose monitoring, 194 exercise and, 129–130
Glucose monitoring systems, continuous, 278 fetal, 192–193
Glucose production, liver, 64 Hypoglycemics, oral
Glucose Revolution, 93 and nutrient depletion, 262
Glucose tolerance, impaired: see Prediabetes
Glucose tolerance test (GTT), 194 Immunologic medications, 63
Glycemic index (GI), 84–85 Improvement, model for, 25
Glycemic load, 84 Incentive programs, 173
Government funding, 319 state, 292
Grains, 99 Infection, 177
Group visits for the uninsured: see Diabetes Day Group Institute for Healthcare Improvement (IHI), 20, 23, 26,
Visit 27
Groups, diabetes, 148 Insulin adjustment in type 1 diabetes, 153
Gymnema, 265 Insulin delivery, 71–72
Insulin-dependent diabetes mellitus (IDDM), 61, 79,
HbA1 c, 67, 81, 82, 246–247, 256, 313 153, 176; see also Diabetes mellitus; specific
Health belief model, 165–167 topics
Health care, organization of, 22 kidney disease and natural history of,
Health care costs, 4 202–204
Health care market nutritional recommendations, 152; see also
competing in, 49–50, 53–57; see also Technology Nutritional recommendations
revolution in health care origin, 61–63; see also Milk
and government health care programs, 286–291 Insulin injections
Health care quality, need for improvement in, 3; see also in prediabetics, 63
Quality improvement in treatment of diabetes in pregnancy, 63
Health Care Quality Improvement Act (HCQIA), Insulin innovations, 72
302–304 Insulin levels, blood
Health insurance: see Disease management (DM) medications that increase, 130
programs; Health plans; Uninsured Insulin products, premixed, 71
Health Insurance Portability and Accountability Act Insulin pumps, 71–72, 277–278
(HIPAA), 299, 306–307 Insulin regimens, 70–71
Business Associate Agreements and, 306 Insulin release, pancreatic
media contacts and, 306 medications that increase, 130
Health plan diabetes management (DM), 288 Insulin resistance, 184; see also Prediabetes
Health plans, 288; see also Disease management (DM) fat mass and, 66
programs; Uninsured Insulin secretagogues, 72–73
rural, 222, 223 dosing information, 74
Health-risk appraisals, 346 Insulin sensitivity, exercise and, 126
Health Services Advisory Group (HSAG), 29–31 Insulin types, 70
Heart rate monitors, 277 Insurance: see Disease management (DM) programs;
Herb-drug interactions, 266 Health Insurance Portability and Accountability
Herbal preparations, 88 Act (HIPAA); Health plans; Uninsured
Herbs, 262–267 Intercultural sensitivity; see also Cultural competence
contraindications of selected, 266 continuum of, 38
Hispanic American culture, 41–42 developmental model and stages of,
Homeostasis Model Assessment for Insulin Resistance 38–39
(HOMA) index, 184 Interventions, 9–10; see also specific topics
Hospital-based case management, 287–288 Intrinsic minus foot, 177
Hospital case study in diabetes management, Ischemia, 177
383–388 Islet cell destruction, causes of, 61–63
400 INDEX
Jenny Craig, 93 Mediterranean heart diet, 93

Joint Commission for Accreditation for Hospital Medium chain triglycerides (MCTs), 261
Organizations (JCAHO), 308 Metabolic syndrome, 204; see also Prediabetes
Metformin, 73–74
Kidney disease: see Chronic kidney disease; Renal Mexico-U.S. border
disease diabetes on, 236–237
Kidney transplant, 209–210 diabetes outreach and education programs on,
posttransplant considerations, 210–211 237–239
Kushner’s personality type diet, 93 creating environmental change, 241–242
program case studies, 239–241
Latinos: see Hispanic American culture program outcomes, 241
Levels of Patient Education Outcome Attainment Mexico-U.S. border environment, 235–236
model, 163, 165 Microalbumin, 67
Lifeskills teaching guide, 112–117 Milk, cow’s, 63, 99, 256
Lifestyle, 66, 255–257 Minerals, 87–88, 116–117, 258–260
Lipids, 67, 86, 127; see also Fats Motivating; see also Exercise, motivating people to
Lipoic acid: see Alpha lipoic acid behavior change, 167
Literacy, 163–165 Mountain Park Health Center (MPHC), 369–370,
Liver glucose production, 64 376–377, 379
LOPS (loss of protective sensation), 177 Muscle metabolism, 64
Muscle strength, 128
Magnesium, 259 Musculoskeletal examination, 178
Managed care, 288
McGraw, Phil, 96 National Committee for Quality Assurance (NCQA),
Meal planning, 98–99, 104–105, 108–109 307–308
exchange lists for, 98 Native Americans, 45–47
Meal plans Nephron, schematic representation of, 201
adding variety to, 106–107 Nephropathy, 190–191; see also Renal disease
sample, 105, 108–109 ”Net carbs,” 83
Measurement strategy, 24 Neuroarthropathy, 177
Meat, 85 Neurologic examination, 178
Medicaid, 304 Neuropathy, 176–177, 191
Medicaid programs, 288–289 diabetic peripheral, 177
Medical nutritional therapy (MNT), 80–82, 363 natural history, 202–203
Medical procedures, 153; see also Surgery Niacin, niacinamide, and nicotinamide, 257–258
Medicare, 289–290 Nogales, Arizona, 239–240
Medicare Prescription Drug, Improvement, and Noninsulin-dependent diabetes mellitus (NIDDM), 79,
Modernization Act of 2003 (MMA), 29, 176; see also Diabetes mellitus; specific topics
303–304 kidney disease and natural history of, 204
Medicare quality improvement organizations (QIOs), nutritional recommendations, 153; see also
27–29 Nutritional recommendations
Medication adjustment in type 2 diabetes, origin, 63–66
152–153 Nurse call centers, 285
Medication management, 69 Nursing, public health, 285
for type 1 diabetes, 69–70 Nutrition, 79–82, 101
for type 2 diabetes, 72, 73 case study, 100
Medications, 152; see also Antidiabetic agents intake analysis, 100–101
accessing, 76–77 teaching materials, 102–104
combination therapy, 76 Nutrition needs, 114–117
and nutrient depletion, 262 Nutrition survival skills for diabetes, 363–365
reducing the cost of, 216–217; see also Cost(s), of Nutritional recommendations; see also Dietary
medical care recommendations
that increase blood insulin levels, 130 historical perspective, 81
that increase pancreatic insulin release, 130 for macronutrients, 82–87
type 2 diabetes oral for micronutrients, 87–88
characteristics of, 73 for type 1 diabetes, 152
dosing information, 75 for type 2 diabetes, 153
INDEX 401
Nutritional supplements, 257, 260–266; see also Predictive modeling technologies, 295–296
Minerals; Vitamins Pregnancy complications, 313; see also Gestational
diabetes mellitus
Obesity: see Body mass index; Weight loss Prevention, 125, 184–185, 314–315; see also Diabetes
Okinawa program, 94–95 Prevention Program
Omega Diet, 95 Private health information (PHI), 306
Onion, 264 Process measures, 6–8
Organizational culture and system change, 10 Promotoras, 238–241
Osteoarthropathy, 177 role in continuing health care model, 249–250
Outcome measures, 6–7 Protein, 85, 114
Outreach programs, 185; see also under Mexico-U.S. preferred and not preferred sources of, 85
border Public reporting, 15
Pancreatic insulin release, medications that increase, Quality, clinical

130 diabetes management and, 295
Paraprofessionals, disease management Quality improvement organizations (QIOs), 5,
training needs, 295 27
Patient assistance program resources, 77 Medicare, 27–29
Patient compliance Quality improvement projects (QIPs), 5, 10
among Hispanic Americans, 41, 42 Quality improvement (QI), 16–17, 49–51,
among Native Americans, 46 53–55
factors and impediments to, 224–225 business case for, 26–27
Patient diabetes MAP, 163, 164 case- and systems-based, 28
Pay-for-performance, 15 components, 6
Pedometers, 275–277 flexibility in, 13
Peer review organizations (PROs), 28 health services research and, 7–8
Perceptions, individual, 166 important considerations in, 10–14
Personal digital assistants (PDAs), 272–273 absolute vs. relative standards, 11–12
Pharmaceutical companies, funding from, 320 challenge of small case numbers, 12–13
Physical activity log, 140 composite vs. individual indicators, 12
Physical activity planner, 139 evidence-based medicine, 12
Physical activity readiness questionnaire (PAR-Q), 135 face validity, 12
Physical exam, annual, 67 reliability of data, 12
Physicians, chronic disease management and, 286 scoring improvement vs. performance,
Phytoestrogens, 265 10–11
Placental problems, 191 weighted measures, 10
Plan-Do-Study-Act (PSDA) improvement cycle, 25, limitations of indicator-specific, 13–14
368, 376, 377, 381–382 on national, state, and regional levels, 14
Pneumonia-related deaths, 315 origins of, 3
Podiatry: see Foot care and patient satisfaction, 9
Polyols, 83 reasons for doing, 4
Poor persons, diabetes management for, relative, 11
290–291 Quality indicators, clinical, 345
Potassium, 259 Quality measurement, 5–7
PPAR-gamma, 65–66 structural component, 6
Prediabetes, 183, 185, 187; see also Metabolic Quality measures, 28, 54
syndrome
defined, 183 Readiness for change, 134–136, 167–168
diagnosing and treating, 185, 186 Registered dietitians (RDs), 81–82
controversies in, 184 Relationships, 148
etiology theories, 183–184 Relative improvement, 11
high risk/prediabetes quality indicators, Relaxation, 147–148
186 Renal disease, 91; see also Chronic kidney disease;
prevention of, 184–185; see also under Diabetes Nephropathy
mellitus end stage, 204, 209–210
applications of, 185 Renal physiology, 199–201
terms for, 183 Retinopathy, 67, 191
402 INDEX
Rural and underserved populations; see also Sociodemographics, 166

Mexico-U.S. border Sodium intake, 115
chronic diseases most responsible for patient visits in, Somers, Suzanne, 94
222 South Beach Diet, 96
disease management (DM) in, 221, 231–232 Soy, 265
background, 221–222 Spirituality, 148, 257
challenges of providing, 224–227 St. Elizabeth of Hungary Clinic (SEHC)
factors favoring urban patients, 225, 226 acute episodic care, 348–349
use of established clinical guidelines and protocol barrier reduction strategies, 349
in, 228 CCC pilot program, 368–376, 378
disease management (DM) programs disease management, 347–348
buying vs. building, 229–231 health care delivery model, 343–346
planning/implementation/sustainability, 229–231 health promotion, 346–347
Rural areas, information systems and data limitations in, proactive disease management program, 343–346
228–229 Starches, 99
Rural Chronic Disease Management Research Study, Stress, 256
222–224, 231 managing, 146, 149; see also Relaxation
Rural disadvantages associated with disease Stretching, static, 129, 132–133
management programs, 225 Sucrose, 82
Rural health care, future potential and promise of Sugar alcohols, 83
disease management in, 227–228 Sugar Busters, 94
Rural health plans, chronic diseases managed by, 222, Sugar in diet, 82–83
223 Sulfonylureas (SFU), 72–73, 76
Rural-urban advantages in disease management, Support networks: see Social support
225–226 Surgery, 153
recommendations for preoperative period, 153
Safety, patient, 5–6 in type 1 diabetes, 153
Safety net providers, diabetes management for, in type 2 diabetes, 154
290–291 Sweeteners
Scott and White Health Plan (SWHP) nonnutritive, 83
beginnings, 357 nutritive, 82–85
next steps, 360–361 Syndrome X: see Prediabetes
problems, progress, and lessons learned, 357–358
progress and success, 358–360 Technologies, 279; see also Self-management
Self-efficacy, 168 information systems
Self-management, 161–162, 173–174 emerging, 277–278
adult learning principles, 162–163 Technology revolution in health care, preparing for the,
challenges in talking with patients about, 172 50–52, 54–57
learning styles and, 163 Telehealth, 278–279
literacy and, 163–165 Telenurse, 285
strategies while talking with patients about, Thiazolidinediones (TZDs), 66, 75–76
169–172 Transplant recipients, posttransplant considerations in,
Self-management education goals, 162 210–211
Self-management information systems, 273–278 Travel, 154–155
Self-management support, 22 adjusting insulin for, 155
Self-management support tools, 172, 374, 375 dealing with time zone changes, 155
Service delivery paradigm, 52–53 packing, 154
Service delivery triad, 52, 55–57 Treatment compliance: see Patient compliance
Sick days, 156, 158 Troglitazone, 66
defined, 151 Tucson southside, 240–241
importance, 156, 158
for type 1 diabetics, 156–157 Ulceration (ulcer), 177, 178
for type 2 diabetics, 158–159 cycle of pathways leading to, 175, 176
what to do during, 156–159 Uncertainty, 144
what to eat during, 156, 158 Uninsured, 213–214, 236; see also Diabetes Day Group
Smoking, 256 Visit
Social support, 148, 237, 256–257 diabetes management for the, 290–291
INDEX 403
health practitioners working with the, Walking planner, 138

215–216 Walking schedule, 141
myths and facts regarding the, 214–217 Water intake, 86–87, 115
University partnerships and funding, 319 Weight control, exercise and, 126, 128
Urinary tract infections (UTIs), 191 Weight loss; see also Body mass index
Utilization Review and Accreditation Committee importance, 89–90
(URAC), 308–309 Weight maintenance, estimating caloric needs for, 90, 98
Weight Watcher’s, 96
Vanadium, 259–260 Wounds: see Ulceration
Vascular examination, 178
Vitamins, 87–88, 116 Yuma County, Arizona, 240–241
B vitamins, 257–258
vitamin C, 258 Zinc, 260
vitamin E, 258 Zone Diet, 92

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Handbook of Diabetes Management

Handbook of Diabetes Management

Jane Nelson Bolin

Springer Science+Business Media, Inc.

Printed in the United States of America. (HPC/TB)

About the Editors

Kathleen Lambert, BSN, RN, JD

I. THE DIABETES FRAMEWORK

1 Essentials of Quality Improvement with Special Reference to Diabetes 3

3 Promoting Cultural Competence through Community Partnerships 35

3A Hispanic American Culture and Diabetes 41

3B Cultural Competency: Native Americans 45

4 Preparing for the Technology Revolution in Health Care 49

II. CARING FOR PEOPLE WITH DIABETES

5 Concepts on the Origin of Diabetes 61

7 Nutrition for Individuals with Diabetes 79

8 Diabetes and Exercise 125

9 Living Well with Diabetes: An Approach to Behavioral Health Issues 143

10 Planning for Sick Days, Surgery, and Travel 151

12 The Diabetic Foot 175

III. SPECIAL CARE ISSUES

13 Prediabetes: A Risky Prodrome to Diabetes 183

14 Gestational Diabetes 189

15 Chronic Kidney Disease 199

16 Caring for the Uninsured and Diabetes 215

17 Disease Management in Rural Populations: Can It Be Done? 223

18 Caring for the Border Communities 237

19 Utilizing Community Health Advisors in Diabetes Care Management 247

20 Complementary and Alternative Medicine in Diabetes 257

21 Leading Edge Technologies Related to Diabetes Care 273

IV. BUSINESS ISSUES

22 Disease Management Research and Policy Initiatives 283

23 Legal and Regulatory Considerations of Diabetes Disease Management 301

26 Tools for Getting Your Message Out About Diabetes: Marketing/Public

Case Study 1: Diabetes Disease Management Program 347

Case Study 2: Carle’s Diabetes Management Program 355

Case Study 6: A Hospital Case Study in Diabetes Management: Carondelet

The Diabetes Framework

Essentials of Quality Improvement with

ORIGINS OF QUALITY virtually inevitable downhill course resulting

WHY DO QUALITY patient managed by diet and exercise alone

THE CENTERS FOR MEDICARE development of performance measures has

TABLE 1.1. The Structural Component of Quality Measurement

TABLE 1.2. Commonly Used Performance Measures (Indicators) in Diabetes

QUALITY IMPROVEMENT AND other outcome measures, patient satisfaction

TABLE 1.3. Relative Quality Improvement

PUBLIC REPORTING AND agreed to tie their Medicare reimbursement

The Chronic Care Model

Anita C. Murcko1, Jean Donie2, Scott Endsley3 , and Larry Cooper4

Services Advisory Group, Phoenix, Arizona

Problems cannot be solved at the same level of

INTRODUCTION blindness, kidney disease, amputations, ner-

The Chronic Care Model is not a quick ﬁx or

r Improve patient safety by reducing med- IMPROVEMENT

r Embed evidence-based guidelines into Development Phase

A change package is the second major Planning Phase

“best strategies” for improving care. Reﬁning

FIGURE 2.4. PDSA Improvement Cycle (Langley et al., 1996, p. 7).

STATE AND REGIONAL as ﬁnancial success (IHI, n.d.-a; IHI, n.d.-b;