Public Policy

Public Policy in the Ecological Model deals with laws, rules, regulations and mandates. This is important because the laws can change to help people with Type 2 Diabetes. Below is information about policy recomendations that are being made for women with Diabetes. It is from the National Center for Chronic Disease Prevention and Health Promotion. Interim Report: Proposed Recommendations for Action A National Public Health Initiative on Diabetes and Women's Health Strategy and Policy Recommendations Many state and local agencies and organizations, including the diabetes control programs supported in large part by CDC, are engaged in the prevention and control of diabetes. However, significantly large gaps exist in the tools, capacities, and resources of these organizations. To fill these gaps, this section presents recommended strategies and policies of highest priority for action in the next 3-5 years. Recommendations encompass two major areas: Communication and Education and Services and Programs. Included in the area of communication and education are recommendations for increasing awareness of diabetes among women, the disease’s impact on women’s health, effective prevention strategies, and the importance of early diagnosis and management. Strategies and policies target women in each of the life stages, as well as their families, health care providers, and other professionals who may serve them. Recommendations in the area of services and programs aim to improve the effectiveness of services at the local, state, and national levels to prevent and manage diabetes among women. They encompass strategies and policies for schools, work sites, health care systems, and other community organizations and settings. Top of Page All Women Several key strategy and policy recommendations pertain to women of all ages, regardless of their life stage. Some of these recommendations also appear later in this report, in the context of a specific life stage. Strengthen advocacy on behalf of women with or at risk for diabetes, either by constituting a new organization focused exclusively on the issues related to diabetes and women’s health, or by forming a consortium of existing organizations with missions that encompass diabetes, chronic disease, and quality of life for women. Increase awareness among the general public of the seriousness and preventability of diabetes in women. Using social marketing approaches, educational programs should be designed to appropriately consider age, language, literacy level, culture, race, ethnicity, motivation, and other relevant factors including access to personal, family, and community resources. Expand community-based health promotion education, activities, and incentives for all ages in a wide variety of settings such as: schools, workplaces, senior centers, churches, civic organizations, and the like. Of particular importance are messages promoting physical activity, healthy eating, and smoking cessation. Materials and activities should be available at all times of the year, but especially materials on diabetes during National Diabetes Awareness Month in November. Representatives of community organizations should be involved in all aspects of the program, from early planning through implementation and evaluation. Integrate diabetes messages and prevention activities within the larger context of chronic disease prevention and health promotion. Health organizations should strive to cooperate, strategize, and plan public health initiatives with organizations in other sectors, such as education, parks and recreation, city planning, and businesses. Enhance community development policies and practices including “smart growth” initiatives and empowerment zones) that promote safe environments for physical activity such as: recreational facilities and activities, parks, sidewalks, mass transit, well-lit neighborhoods. Increase availability of and access to healthy food choices for all sectors of the population. This recommendation is particularly important for urban and economically disadvantaged populations. Support policies and programs in schools and workplaces that respect the health-related needs of their female students and employees, particularly women with or at risk for diabetes, and facilitate prevention and self-management of the disease. Fortifying community programs with guidelines on education strategies at different levels of funding, including tips for developing multisectoral coalitions, implementing strategies, ways to use available resources most efficiently, discussion of resource allocation issues to aid decision making, and suggestions for accessing extant resources, measures for evaluating diabetes activities, dissemination of “best practices” and lessons learned from community programs and in workplace and school settings (for example, physical activity programs, health coverage, healthy cafeteria foods, and support groups), enhanced funding opportunities, simplified processes for securing financial support from federal, state, and local agencies, and technical assistance (such as workshops and mentoring) to help state and local policy makers prepare and submit successful proposals to potential government and private funding sources. Assure access to trained health care providers who offer quality services to prevent and manage diabetes among women of all ages. Care should be tailored to the woman’s specific life stage, race, ethnicity, culture, religion, family and financial situation, motivation, and needs. Expand public and private health insurance packages to provide adequate coverage for preventive care, including health promotion, health and nutritional education, physical activity, self-management, and screening for complications among women diagnosed with diabetes. Top of Page The Adolescent Years (ages 10-17 years) The primary emphasis of public health action in the adolescent years is to improve the health and preventive practices among all youth, and more particularly among girls already diagnosed with diabetes. To accomplish this goal, several major challenges must be overcome. These challenges include: lack of diabetes education and prevention materials appropriate for adolescent females; inadequate numbers of trained physicians who specialize in caring for this age group; lack of physical education programs in schools; lack of awareness of the need for weight control, healthy diets, and physical activity among adolescents; and a plethora of fast food and other unhealthy eating options. Opportunities for prevention and hope for the future are influenced by recent school policy changes and better models for physical education and health education curriculum. Successes for other diseases and health problems that might benefit diabetes prevention efforts (such as no smoking and Drug Abuse Resistance Education [DARE] campaigns) include: more effective media messages to raise awareness and promote healthy lifestyles; advances in electronic and computer technology as a teaching tool; and the receptivity of adolescents to computer technology. Communication and Education For Professionals Examine and improve the health professional school curriculum as it relates to preventing diabetes complications among adolescents. Strengthen continuing education and training for physicians, nurses, and other health care providers on adolescent weight control, glucose management, eating disorders, and other diabetes prevention and management issues relevant to female adolescents with or at high risk of diabetes. Explore establishing a subspecialty of physicians on diabetes care for female adolescents. Target dentists to help prevent periodontal disease in adolescents, particularly girls, with type 1 diabetes. For Adolescent Females and Their Families family-oriented education materials covering such topics as nutrition, physical activity, and a family’s risk of diabetes and other chronic diseases. Begin to introduce concepts of reproductive health to adolescents and their families, particularly the relationship between poor contraception and congenital anomalies. Structure educational messages to encourage female adolescents with diabetes to engage in regular physical activity and make healthy food choices in the face of the vast fast food market. Use teen media outlets, entertainers, and community “champions” (including teen performers with diabetes) to deliver key messages to adolescent females. Search for positive images and role models for girls that, for example, emphasize being “strong” rather than “thin.” Target gestational diabetes and broader family health messages to pregnant adolescents, urging the teens to, for example, get their glucose level checked. Educate recipients of public assistance (such as food stamps and Women, Infants and Children [WIC] program services) on preparing healthy and appetizing meals within a limited budget for families with an adolescent with diabetes. Services and Programs In Communities Create positive, rewarding forums that promote healthy eating and physical activity among adolescent females. Partner with established groups such as Girl Scouts and Girl Power, and use locations where adolescents typically congregate. Consider such programs as “teen summits” (similar to the Black Entertainment Television’s Teen Summit program), visits to local cable channel stations, and televised “town hall meetings” on health issues. Involve young girls in the planning and delivery of these programs whenever possible. Establish appealing and acceptable alternatives to competitive sports for those adolescent females who would otherwise not engage in any physical activity. Expand support groups (at YWCAs, churches, and other grassroots organizations’ sites) for adolescent girls with diabetes and their families. In Schools Integrate health into the school science curriculum and supplement with activities that directly influence adolescents, such as videos and guest speakers with thought-provoking messages that have been shown to change behavior. Conduct awareness campaigns to influence parental behavior to prevent and manage diabetes among children. Heighten sensitivity to the challenges of disease management specific to adolescents. Urge community and state boards of health and education to allocate more funding for physical activity programs in public schools offered before, during, and after school. Develop school policies that limit soda and candy vending machine availability in schools (or support vending machines for healthy snacks and drinks), and promote healthy food choices in cafeterias. Advocate for national support of on-site school nurses to aid youth diagnosed with diabetes and other health problems. Educate school system administrators and teachers about diabetes and its management so that a “diabetes friendly” environment can be established and medical emergencies avoided or handled appropriately. In Work Sites Educate employers of adolescents, such as retailers, grocery stores, fast food restaurants, and other restaurants, about the risks for diabetes among adolescents and the need for adequate breaks, healthy food choices, and health insurance. In Health Care Systems Promote early diagnosis and self-management of diabetes, particularly type 2 diabetes, among health care providers. Encourage guidelines that trigger interventions for adolescents at risk of developing type 2 diabetes. Risk factors include low waist-to-hip ratio and an apple-shaped body type. Define a healthy weight loss regimen for overweight adolescents, focusing on the influences of family and school. Encourage health insurance companies to cover health and nutrition education for adolescents (for example, management of obesity and eating disorders). Develop population-specific messages, materials, and programs for health insurance or pharmaceutical companies to use for diabetes education and self-management among adolescents. Collaborate with diabetes prevention and control programs in state health departments to develop prevention efforts among adolescents. Top of Page The Reproductive Years (ages 18-44 years) One of the major barriers to self-care facing women in their reproductive years is balancing the demands of marriage and other relationships, work, child care, household chores and hobbies. The result is limited time for physical activity, healthy eating patterns, and attending to the woman’s own health care needs. In addition, physical activity is further restricted during pregnancy and early postpartum. Mothers may not lose the weight gained during pregnancy and thus put themselves at greater risk of obesity and of developing diabetes in later pregnancies or later in life. Cultural differences influencing these behaviors are also important to understand. Conflicting health messages from a multitude of sources addressing chronic disease prevention is another barrier to self-care. Strategies for countering these barriers include tailoring messages to reproductive-aged women, capitalizing on the intergenerational aspects of gestational diabetes, and including men and families as supportive partners. Prenatal and other reproductive health services represent important vehicles for identifying and instituting preventive care for women at high risk for diabetes. Communication and Education For Professionals Establish a clearinghouse of programs and materials for women of reproductive age, and disseminate best practices and lessons learned from community programs (such as the National Kidney Foundation’s Healthy Hair Beauty Salon Project in Michigan) and workplace, clinic, and other settings (for example, exercise programs, health coverage, healthy cafeteria foods, and support groups). For health care providers, expand education in diabetes prevention and management, emphasizing such specialties as family planning, obstetrics, gynecology, general practice, family practice, midwifery, and social services (for example, providers in WIC or the Expanded Food and Nutrition Education Program [EFNEP]). Encourage makers of drugs and instruments for diabetes management (such as insulin, oral agents, acarbose, and glucose meters) to include a public message in the package encouraging good diabetes control. Urge pharmacies to provide information for patients. For Women and Their Families Include lifestyle counseling and education strategies for women with and without diabetes in preconception, prenatal, and postpartum care (including women with or at risk of gestational diabetes). Address contraception and pregnancy planning. Emphasize to women, health care providers, and health insurers the importance of appropriate follow-up diagnostic and preventive care after delivery for women with gestational diabetes and other risk factors for type 2 diabetes. Increase diabetes awareness programs and materials in workplaces and other settings, such as drug stores, health clinics, the media, community recreational centers, school newsletters, and church bulletins. Review educational materials produced by organizations serving women of reproductive age (such as March of Dimes; Healthy Mothers, Healthy Babies Coalition; and Maternal and Child Health Bureau) to ensure inclusion of appropriate, current, and consistent information regarding diabetes and related risks (for example, obesity, poor diet, and physical inactivity). Materials should also be culturally and linguistically appropriate. Educate women with diabetes and prior gestational diabetes about the risk to their offspring for developing diabetes. Establish a follow-up program to test these children. Services and Programs In Communities Provide opportunities to support and sustain lifestyle changes among women of reproductive age, including assessment and counseling within the framework of existing programs and services, and linking to other available resources, peer and other social support programs geared toward women for exercise, healthy eating, and diabetes self-management, and assessment of family and community barriers specific to this age group, such as lack of access to affordable child care. Evaluate existing community programs to maximize opportunities for prevention activities, improved quality, and increased access to health care among women in their reproductive years. Adapt existing resources to the needs of reproductive-aged women, and ensure appropriate support services such as child care to enable time for physical activity. In Schools Use school sites as a way to reach women in their reproductive years, such as students, mothers of students, and female teachers, with prevention and management messages. Influence policies of colleges and universities to require a minimum number of hours of physical education and to include healthy food options in cafeteria food plans. Encourage colleges and universities to promote exercise, dance, and other physical activities for females. In Work Sites Promote partnerships between health care providers and workplaces, and encourage employers and employees to discuss needed diabetes benefits in the health package offered. Promote workplace policies that positively affect the health of women of reproductive age, such as flextime for exercise on lunch hours, shower facilities, health club memberships, and support for insulin breaks. Promote purchasing cooperatives among small businesses to enable progressive health insurance packages. In Health Care Systems Develop a chronic disease prevention policy for reproductive-aged women, and enhance cooperation among state and community chronic disease programs to support common prevention strategies (for example, exercise, nutrition, and smoking cessation). Ensure that all women who have had or are at risk for gestational diabetes are identified, treated, and followed up regularly over time in traditional and nontraditional settings (for example, WIC, mobile outreach services, family planning clinics, Indian Health Service clinics, and community health centers). Assure postpartum follow-up to assess risk factors, conduct diagnostic testing for diabetes with other routine tests, and recommend preventive strategies. Use existing programs such as WIC and the State Children’s Health Insurance Program to reach at-risk women to promote preventive activities, and provide tools that health care providers can incorporate into routine care. Expand activities like “Project Fresh” in WIC programs to encourage fresh fruit and vegetable consumption. Promote expansion of routine physical examinations of reproductive-aged women to include assessments of physical activity, diet, hip and waist measurements, and body mass index in addition to standard weight and blood pressure measurements. Glucose screening should also be performed if the woman is significantly overweight and has one or more risk factors for diabetes. Review existing standards of care for women of childbearing age to determine if the guidelines are comprehensive and whether they have been implemented (for example, those sponsored by the American College of Obstetrics and Gynecology, the American Diabetes Association, the U.S. Preventive Health Services Task Force, and WIC). In addition, the standards and guidelines should be updated as appropriate. Modify current policies regarding weight gain during pregnancy to promote appropriate, rather than excessive, weight gain regardless of age or ethnicity. Promote comprehensive health care coverage that includes diabetes prevention and management for women of reproductive age. Top of Page The Middle Years (ages 45-64 years) During this life stage, some of the major barriers to preventing diabetes and its complications are similar to those in the reproductive years. Prevention takes a backseat to treatment, particularly for acute health issues. A transition in health care providers occurs, from gynecologists to family practitioners, internists, or specialists. Women may have even less time to focus on their own needs as they begin to care for their children and also for their own parents. However, this role as the primary decision maker, sandwiched between two generations, affords a rare opportunity. The woman’s sphere of influence is broader and deeper than at any other time in her life; she has the chance to be a role model for female relatives and friends. Middle age is also the time when women are most active in civic and religious organizations, offering an ideal site for delivery of prevention messages, interventions, and support. Communication and Education For Professionals Increase training opportunities for health care professionals to learn how to effectively prevent and manage diabetes in middle-aged women. Consider such mechanisms as continuing education units, web-based training, CD-ROMs, and partnerships with pharmaceutical companies. Develop and disseminate a list of successful programs (“best practices”) that promote the incorporation of physical activity and healthy eating into the daily routines of women who are employed, raising children, or both. Encourage providers to explore the use of both traditional and alternative medicine for preventing and treating diabetes among women in their middle years. For Women and Their Families Emphasize physical activities and healthy eating habits appropriate for the middle years, and focus on incorporating them into the daily routines of work and family. Stress that prevention of weight gain, not just weight loss, can prevent diabetes onset. Promote self-management among middle-aged women with diabetes, and provide support and education for self-care. Develop champions for diabetes among middle-aged women, and use them to deliver messages about the positive benefits of physical activity and healthy eating. Services and Programs In Communities Encourage policy makers to focus on priorities for women in their middle years: chronic disease in general, and diabetes in particular, modifiable risk factors, such as age-appropriate physical activity within daily life, diet, and smoking, support needs, focus on family and quality of life, and preparation for menopause and retirement. Establish community support groups similar to Alcoholics Anonymous (AA) and Weight Watchers designed primarily for middle-aged women with diabetes. Use pharmacies and other nontraditional sites (such as beauty salons) to reach middle-aged women diagnosed with or at risk of diabetes. In Work Sites Promote work site policies that encourage and support physical activity and healthy eating. Highlight diabetes prevention and education. Consider using work sites for training and support groups on caregiving. Establish “health days” or release days for employees on which they can schedule diagnostic testing for diabetes and other routine medical tests on-site or off-site. In Health Care Systems Develop “best practices” for prevention and treatment of diabetes among women in their middle years. Work with health insurers and policy makers to expand reimbursement policies to include prevention services for women throughout their life span. Integrate diagnostic testing for diabetes with routine tests for other chronic diseases, such as mammograms, Pap smears, and colonoscopies). Top of Page The Older Years (ages 65 and older) Health insurance barriers are compounded in the older years, with the transition from employer-based coverage to Medicare and other private or public health insurance carriers. The elderly also frequently experience isolation, depression, and lack of social support from their families and communities. Prescription drug coverage is an issue, as is the fragmentation of health care services. Financial resources may be limited, particularly for those relying on Social Security and fixed incomes. In addition, the number of elderly persons from racial and ethnic minority populations who have limited English proficiency is increasing dramatically, with no comparable increase in the availability of culturally and linguistically appropriate health care services. Opportunities for prevention lie in the frequency of health care visits among the elderly for diabetes and comorbidities. Although the actual face-to-face time with health care providers is limited, that time can be optimally used for meaningful education and motivational messages. Community, civic, and religious organizations can also play key roles in promoting behaviors that improve health and quality of life. Communication and Education For Professionals Encourage health care providers to become aware of and inform their elderly patients about relevant community services. Train nurses, other clinic staff, and lay educators on key messages for older women with or at risk of diabetes (for example, about the need for foot screening). Incorporate training on cultural competence into the curriculum of all health care professions, particularly for providers who interact with older women. Train housing managers, community health workers, and senior center workers on how to recognize signs of depression and how to respond appropriately to those signs. For Women and Their Families Promote self-management and education through advocacy and training for the elderly and their health care providers and through expanded availability of quality programs. Design a media campaign targeted to elderly women, with a diabetes champion (a celebrity or community leader) as spokesperson. Use mainstream media that will reach older women, such as the popular magazines Good Housekeeping, Ladies’ Home Journal, and Readers Digest and the American Association of Retired Persons (AARP) newsletters. Educate seniors on lifestyle changes that prevent and treat diabetes, including physical activity, healthy eating, and relieving depression. Emphasize all the diseases that typically have onset in later life and their relationships (for example, between heart disease and diabetes). Services and Programs In Communities Build community coalitions that involve the elderly and address their unique needs. Identify key places and organizations to reach the elderly (such as libraries, grocery stores, senior centers, Lions Clubs, churches, Area Agencies on Aging and other non-traditional, non-health care organizations) and involve them in program planning and implementation. Expand intergenerational programs and activities. Partner with local and state commissions on aging to provide transportation for the elderly (such as “Call a Bus”), while also expanding programs that serve the elderly in their homes and congregate living sites to avoid transportation and other motivational issues. In Health Care Systems Ensure affordable, accessible, and appropriate care for older women by expanding preventive services, increasing public awareness of diabetes and its burden, and facilitating greater community involvement. Increase the priority of federal, state, and local funding for diabetes training for elderly patients and their health care providers, prescription drugs and health insurance coverage, and grassroots and community programs. Top of page Content source: National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation

Community

  The Community level of the Ecological Model includes demographics, economics, geography, culture, transportation, water, financial services, medical system, and environment. These are also things that people with Diabetes encounter every day. Below is a medical service that is doing research to fight Diabetes.

 
 

 

 

On This Page

• What is TRIAD?
• Health system factors
• Patient factors
• Patient-physician interaction
• TRIAD key findings, 1998–2008
• Acknowledgements
• For public inquiries and TRIAD publications
• For other information
• Veterans Administration study
• CDC commentary on TRIAD

Translating Research Into Action for Diabetes (TRIAD) Fact Sheet, 2009

The Translating Research Into Action for Diabetes (TRIAD) Fact Sheet, 2009  [345–KB] is provided in Portable Document Format. 

What is TRIAD?

TRIAD is a national, multicenter prospective study that provides useful information about effective treatments and better care for people with diabetes in managed care settings. TRIAD was launched in 1998 to evaluate whether managed care organizations’ structures and strategies affect the processes and outcomes of diabetes care among adults, and to identify the barriers to and facilitators of high-quality care and optimal health outcomes. At that time, there was interest in whether disease management programs would improve diabetes care and outcomes. Numerous TRIAD study publications contribute to an evidence-based body of knowledge that allows managed care organizations and health care policy makers to make informed decisions on ways to improve care for people with diabetes.
The TRIAD study group comprises 6 translational research centers (Figure 1) and their 10 health plan partners. When TRIAD began, these health plans contracted with 68 provider groups to deliver primary and specialty care to more than 180,000 adult enrollees aged 18 years and older with diabetes. TRIAD is funded by a cooperative agreement from the Centers for Disease Control and Prevention (CDC) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). A list of the investigators at each of the six research centers is available at the TRIAD Web site (www.triadstudy.org).

Figure 1 Text

TRIAD has assembled one of the largest cohorts of patients with diabetes ever studied. TRIAD collected and linked data from patients, providers, provider groups, and health plans. The diversity of patient data – obtained through surveys, medical record reviews, and administrative records – makes TRIAD unique.
This fact sheet synthesizes 10 years of TRIAD research and analyses and focuses on the following areas:

• How health system factors are associated with processes of care.
• How patient factors determine clinical outcomes, for better or worse, and the effectiveness of diabetes disease management strategies.

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Health system factors

By using Donabedian’s paradigm (Figure 2), TRIAD characterized and examined both managed care structural characteristics and disease management strategies. In Donabedian’s paradigm, system factors are hypothesized to influence patient care processes, which, in turn, influence patient outcomes.

Figure 2 Text

Processes of care

• Improvements in processes of care are not necessarily associated with improvements in intermediate outcomes (e.g., hemoglobin A1c [HbA1c] value, LDL-cholesterol level, systolic blood pressure.
• Greater use of performance feedback measures, physician reminders, and structured care management were strongly associated with better process of care performance. Structured care management included the use and dissemination of clinical guidelines, patient reminders, formal care management and case management by nonphysician providers, and provision of health education resources.
• Accurate clinical data are essential for high-quality chronic disease care. They are needed at both the point of care and in disease registries. However, some health care systems participating in the TRIAD study failed to accurately record simple process measures. One study showed poor concordance between patients’ self-report of recent retinal examinations and medical records of such examinations. The discordance was primarily due to medical records failing to capture patient reported eye examinations.    

The effects of cost-shifting

TRIAD found consistent negative effects of cost-shifting to patients. Cost-shifting, whether as copayments or coverage gaps, was associated with reduced recommended medication use and reduced preventive care. Lower income patients appeared to be more sensitive to the effects of cost; however, the effects were present across all income levels.

• Among the 2005 cohort survey respondents, 14% reported using less than the recommended dose of medicine because of cost, and patients with greater out-of-pocket costs were less likely to take the full dose of provider-recommended medicine.
• Compared with those without coverage for selected diabetes services and supplies, participants with full coverage (no out-of-pocket copayments) were more likely to have—
  • A retinal exam (78.4% vs. 69.8%).
  • Attended a diabetes education session within the prior 12 months (28.8% vs. 18.8%).
  • Practiced daily self-monitoring of blood glucose (74.8% vs. 58.6% among insulin users).
• Compared with patients in good control for three vascular disease risk factors, those patients not in control for at least two factors were more likely to report that out-of-pocket costs were a barrier to self-management.

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Patient factors

TRIAD findings (Figure 3) indicated that health system interventions only modestly affected patient outcomes. Accordingly, the study’s focus shifted to examine the links between (1) patients’ sociodemographic and clinical characteristics and outcomes and (2) outcomes and system factors.

Figure 3 Text

TRIAD study findings showed differences by patient subgroups, which could be used to tailor information and interventions and influence positive health outcomes.

Age

Expressing health risks in terms of more immediate adverse outcomes (e.g., work fatigue and absences, bodily pain, diminished concentration, depressed mood, poor sleep) was more effective in motivating younger than older patients to engage in diabetes self-care than providing information about potential, but not immediate, complications of the disease.

• Younger adult patients with diabetes generally received fewer recommended processes of care and were more likely to have persistent lapses in processes of care compared with older adults. Persistent lapses were defined as missing any of five recommended exams over a 3-year period, including HbA1c, cholesterol, microalbuminuria, retinal, and foot.
• Younger patients with diabetes were more likely to have worse intermediate outcomes and less likely to have good risk factor control. Intermediate outcomes were defined as a combined measure of HbA1c, LDL cholesterol, and systolic blood pressure control.
• Younger adult patients were more likely to have had a recent microalbuminuria screening test, even though older patients were at higher risk for chronic kidney disease.
• Among patients 25-44 years of age with less than a high school education, 50% were current smokers compared with only 7% of college-educated persons aged 65 years and older.
• Walking for at least 20 minutes each day was slightly less likely in patients older than 65 than for younger patients (64% vs. 70%), and older patients were less likely to report sustained walking between the second and third TRIAD surveys (63% vs. 71%).

Gender

Although modest, differences were found between men and women in processes and outcomes for cardiovascular disease risk factors (Tables 1 and 2). Compared with men, women in the TRIAD study—

• Used less medicine, regardless of their cardiovascular disease (CVD) status.
• Were less likely (among patients without CVD) to be advised to take aspirin or have lipid profile testing.
• Were less likely to control their blood pressure and LDL-cholesterol (among patients in a TRIAD plan with known CVD). However, these women had slightly lower HbA1c levels.
• Had a slightly better HbA1c and LDL-cholesterol control if they had a female physician.

Table 1.

Processes of care	With CVD		Without CVD
	Women (%)	Men (%)	Women (%)	Men (%)
Aspirin used	33.2	39	14	16.4
Lipid medications used	51.5	57.6	34.8	35.9
Aspirin advised in those not taking aspirin	55.2	58.1	27	32.5
Lipid profile tested in those not using lipid medications	53.2	54.8	54.4	58.3

Table 2.

Outcomes	Female patients		Male patients
	Female MD  (%)	Male MD  (%)	Female MD  (%)	Male MD  (%)
A1c < 8	70	68	66	66
LDL-c < 100	47	46	54	55
SBP < 130	53	52	60	60

Race and ethnicity

Whites, African Americans, Latinos, and Asians or Pacific Islanders were well represented in the TRIAD cohort. Although all patients in TRIAD had comparable health coverage, striking disparities in health behaviors and outcomes were found among whites and African Americans. African American patients consistently had poorer control of blood pressure, LDL-cholesterol, and HbA1c.
Surprisingly, processes of diabetes care did not differ greatly among the four principal racial or ethnic groups. Compared to whites, African Americans had lower LDL-cholesterol testing (61% vs. 68%) and influenza vaccination rates (59% vs. 68%), but significantly higher foot exam rates (89% vs. 83%). Latino patients had higher dilated eye exam rates (83% vs. 76%) than whites.
However, there were notable racial and ethnic differences in control of all three intermediate outcomes. In 2000, African American patients had the poorest blood pressure control — 45% had blood pressure less than 140/90 mmHg vs. 56% of white patients. For LDL-cholesterol, mean levels were significantly higher for African Americans than white patients (118 vs. 111 mg/dL), but neither Asian/Pacific Islanders nor Latinos differed significantly from whites. All three minority populations had slightly, but significantly higher HbA1c levels than whites.
The TRIAD study findings suggest several possible explanations of the disparities in health behaviors. Compared with white patients with diabetes, African American patients had—

• More sensitivity to out-of-pocket costs.
• Poorer quality of patient-provider relationships.
• Higher prevalence of undiagnosed or untreated depression.
• Fewer resources and greater stress as a result of living in socioeconomically deprived neighborhoods.

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Patient-physician interaction

The quality of physician communication and patients’ trust in their physicians were generally associated with better clinical management and outcomes.

• Among patients with persistent poor glycemic control on oral agents, those reporting better physician communication and those with fewer misconceptions about insulin were more likely to begin insulin therapy.
• Better patient-reported provider communication (i.e., physicians who listen, explain, show respect, spend time) did not appear to attenuate observed educational disparities in health behaviors (i.e., smoking cessation, increased physical activity, diabetes-related health-seeking activity).

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TRIAD key findings, 1998–2008

Implications for health system policies and best practices

Managed care systems should emphasize the development and reporting of care processes known to be closely linked to improved outcomes. Increased system-level attention to monitoring and improving treatment intensification rates may help improve intermediate outcomes. Specific areas for research and possible interventions that may improve the health of people with diabetes include the following:

• Redesigning benefits to lessen the cost burden of medicine on patients will ensure more people with diabetes take the prescribed medications.
• Increase cardio-metabolic control and behavioral and medical interventions to treat depression.
• Improve efforts to encourage provider communication and increase patient trust.

Tailoring programs to the needs of people with diabetes will improve outcomes. Programs need to—

• Consider the special needs created by family and work obligations.
• Avoid one size fits all and design programs to eliminate disparate outcomes among populations. For example, greater promotion of mail-order pharmacies could be very useful for patients with problems accessing pharmacies.
• Redesign programs to include sociodemographic and clinical subgroup patient differences in health-related behaviors and control of major cardio-metabolic risk factors.

For other information

For public inquiries and more information about diabetes, please visit the Centers for Disease Control and Prevention Web site www.cdc.gov/diabetes/ or call 1-800-CDC-INFO (232-4636).

Institutional

The Institutional level of the Ecological Model consists of work, education, recreation, clubs, volunteer groups and faith. These aspects of life are important when dealing with Diabetes because they are the thinks that we take part in every day of our lives. Some benefits that these institutions can have for people are further education about Diabetes, the risk and treatment. Work, recreation and clubs can offer a great opportunity for physical education which can prevent Type 2 Diabetes from occurring and help to manage it better. Below I have posted links to many popular fitness facilities that would help with Type 2 Diabetes. Below it there is also an article from Medline Plus about Diabetes risk and how exercise can help to prevent it.



Exercise can delay or prevent the onset of Type 2 Diabetes!

Join a fitness club near you!

Gold's Gym

Bally Total Fitness

Lifetime Fitness

LA Fitness

Cardinal Fitness

Curves 

 

http://www.carolinemiller.com/tips/nov24-2009.html

"Small Steps, Big Rewards": You Can Prevent Type 2 Diabetes

The good news is, type 2 diabetes can be prevented or treated. By losing a modest amount of weight, getting 30 minutes of exercise five days a week, and making healthy food choices, people at risk for type 2 diabetes can delay or prevent its onset. Those are the basic facts of "Small Steps. Big Rewards: Prevent type 2 Diabetes," created by the National Diabetes Education Program (NDEP). This first-ever, national diabetes prevention campaign spreads this message of hope to the millions of Americans with pre-diabetes (higher than normal blood glucose levels but not yet diabetes).

"Fifty four million Americans are at risk for type 2 diabetes."

"Fifty four million Americans are at risk for type 2 diabetes," says Joanne Gallivan, M.S, R.D., NDEP director at the National Institute for Diabetes and Digestive and Kidney Disease (NIDDK). "There are steps you can take to prevent it. It boils down to following a healthy lifestyle— not making huge steps, but small steps that can lead to a big reward, such as eating smaller portions and taking the steps instead of the elevator."

The science behind NDEP's campaign is based on the Diabetes Prevention Program (DPP), a landmark study sponsored by the NIH. The study found that people at increased risk for type 2 diabetes can prevent or delay the onset of the disease by losing five to seven percent of their body weight through increased physical activity and a reduced fat, lower calorie diet. That's about a 10 pound weight loss if you weigh 200 pounds.

In the DPP, modest weight loss proved effective in preventing or delaying type 2 diabetes in all high-risk groups. "If you have diabetes in your family, you will want to bring this information to their attention," says Gallivan. "Healthy lifestyles are good for everyone."

 For more information: Click here to go to Medline Plus

Interpersonal/ Groups

 The Interpersonal level of the Ecological Analysis includes family, friends, co-workers, social groups, relationships and social support. These people in your life can have a great impact on your life with Diabetes or your risk of having Diabetes. For people who have Type 2 Diabetes, the people around you can be there to support you and motivate you to get proper exercise and eat healthy. They can also be there to help with things like testing blood glucose levels and taking insulin shots. I feel that another large role of family in regards to Diabetes is letting everyone know about their disease so that they are prepared. Diabetes is hereditary so family members need to be aware of their higher risk for this disease if other family members currently have it. Below I have attached information from the Centers for Disease Control and Prevention on how to talk to family members about diseases and risks.

Gather and Share Your Family Health History

 
If you are concerned about a disease running in your family, talk to your doctor at your next visit. A doctor can evaluate all of the risk factors that may affect your risk of some diseases, including family history, and can recommend you a course of action to reduce that risk.

Thanksgiving is National Family History Day

The US Surgeon General has declared Thanksgiving to be National Family History Day, encouraging Americans to share a meal and their family health history.  Family health history information can help health care providers determine which tests and screenings are recommended to help family members know their health risk. This year the Surgeon General updated and improved the My Family Health Portrait tool, which can help individuals collect and organize family history information.  Learn more about family health history.

Family members share genes, behaviors, lifestyles, and environments, which together may influence their risk for developing chronic diseases. Most people have a family health history of common chronic diseases (e.g., cancer, heart disease, or diabetes) and other health conditions (e.g., high blood pressure and high cholesterol). A person with a close relative affected by a chronic disease may have a higher risk of developing that disease than a person who doesn't.

Americans know that family history is important to their health. One survey found that 96 percent of Americans believe that knowing their family history is important.  Yet, the same survey found that only one-third of Americans have ever tried to gather and write down their family's health history. Are you ready to collect your family health history but don't know where to start?

Make a list of relatives.

Write down the names of blood relatives you need to include in your history.

•  
• The most important relatives to talk to for your family history are your parents, your brothers and sisters, and your children.
• Next should be grandparents, uncles and aunts, nieces and nephews, and any half-brothers or half-sisters.
• It is also helpful to talk to great uncles and great aunts, as well as cousins.

Prepare your questions.

Among the questions to ask are:

• Do you have any chronic illnesses, such as heart disease, high blood pressure, cholesterol or diabetes?
• Have you had any other serious illnesses, such as cancer or stroke?
• How old were you when you developed these illnesses?

Also ask questions about other relatives, both living and deceased, such as:

• What is our family's ancestry - what country did we come from?
• What illnesses did your late relatives have?
• How old were they when they died?
• What caused their deaths?

To organize the information in your family history you could use a free web-based tool such as My Family Health Portrait.

Family history can give you an idea of your risk for common diseases like cancer, heart disease and diabetes, but it is not the only risk factor. If you are concerned about a disease running in your family, talk to your doctor at your next visit. A doctor can evaluate all of the risk factors that may affect your risk of some diseases, including family history, and can recommend you a course of action to reduce that risk.

For more information: Click here to visit the CDC website 

Intrapersonal

 The Intrapersonal level of the Ecological model consists of the personality, knowledge, attitudes, beliefs, and skills within the individual. These characteristics will determine whether a person deals with the problem of Diabetes. If a person has no previous knowledge of this disease then they may not know what to expect. Therefore, if that person has no previous knowledge then their attitudes and beliefs about this disease will be very vague. I believe that knowledge is the most important part of the intrapersonal level so below is information from the American Heart Association about Diabetes.


About Diabetes

"Diabetes mellitus," more commonly referred to as "diabetes," is a condition that causes blood sugar to rise to dangerous levels: a fasting blood glucose of 126 milligrams per deciliter (mg/dL) or more.

How Diabetes Develops

Most of the food you eat is turned into glucose, or sugar, for your body to use for energy. The pancreas, an organ near the stomach, produces a hormone called insulin. This hormone is necessary for the body to be able to use sugar or glucose, the basic fuel for cells in the body. Insulin's role is to take sugar from the blood into the cells. When your body does not produce enough insulin and/or does not efficiently use the insulin it produces, sugar levels rise and build up in the bloodstream. When this happens, it can cause two problems:

1. Right away, the body's cells may be starved for energy.

2. Over time, high blood glucose levels may damage the eyes, kidneys, nerves or heart.

Types of Diabetes

There are two main types of diabetes: type 1 diabetes and type 2 diabetes. Both types may be inherited in genes, so a family history of diabetes can significantly increase a person's risk of developing the condition. 

Type 2 diabetes is the most common form of diabetes. Historically, type 2 diabetes has been diagnosed primarily in middle-aged adults. Today, however, adolescents and young adults are developing type 2 diabetes at an alarming rate. This correlates with the increasing incidence of obesity and physical inactivity in this population, both of which are risk factors for type 2 diabetes.

This type of diabetes can occur under two different circumstances:

•     The pancreas doesn't make enough insulin, or
•     The body develops "insulin resistance" and can't make efficient use of the insulin it makes

In a mild form, this type of diabetes can go undiagnosed for many years, which is a cause for great concern since untreated diabetes can lead to many serious medical problems, including cardiovascular disease. Type 2 diabetes may be delayed or controlled with diet and exercise.

For more information: Click here to visit the American Heart Association Website