Tackling the Diabetes Epidemic in North Carolina

The devastating effects of diabetes are well-known to healthcare professionals. Complications such as neuropathy, amputations, kidney disease, blindness and a higher risk for heart disease can overwhelm not only the person suffering from the disease, but their family as well. Managing diabetes is a lifelong commitment that is often neglected, leading to significant healthcare costs. A 2006 study showed that rehospitalizations within 30 days of discharge occurred in 20% of patients with diabetes, which is more than the 5%–14% estimated for all hospital discharges.¹ A 2008 study found that hospital stays for patients with diabetes accounted for 20% of hospitalizations and $83 billion (23% of total hospital costs) in the U.S.²

Once a patient is diagnosed with diabetes, formal education efforts can reduce the risk of hospital readmissions, according to a study presented at the American Diabetes Association 2013 Scientific Sessions.³ While diabetes is not currently on the list of diseases for which Medicare refuses reimbursement if the patient is readmitted within 30 days of discharge, most in the medical community expect it will soon make the list. The challenge is that diabetic patients, particularly those who are older and have multiple comorbidities, are more likely to be readmitted.⁴

Reducing Hospitalizations

The best method of treating a complex disease such as diabetes is to avoid it in the first place. The more critical components are eating well and exercising regularly, but that can be a struggle.

The good news is that innovative programs are succeeding in helping people reduce their risk of diabetes hospitalizations and rehospitalizations. A recent report from the Center for Health Law and Policy Innovation at Harvard Law School delved into the diabetes epidemic in North Carolina to determine if there are ways to implement some of these programs on a statewide level.

The 2014 North Carolina State Report: Providing Access to Health Solutions (PATHS)⁶ was established with three main goals: to describe the impact of type 2 diabetes in the state; to promote the discussion of policies and programs that affect type 2 diabetes; and to advance recommendations for how the state can reduce the prevalence and consequences of type 2 diabetes.

Sarah Downer, JD, clinical Instructor at the Harvard Law School’s Center for Health Law & Policy Innovation and one of the report’s authors, says the project was a perfect fit. The CHLPI is an experiential learning program that offers law students an opportunity for hands-on experience in health policy and food policy. “Diabetes reform is a perfect blend of the two,” she says. “Among an estimated 86 million [people suffering from prediabetes] in this county, one quarter will develop diabetes within 3–5 years. This is an important population to reach.”

The Center was already involved in “Together on Diabetes,” an initiative with the Bristol-Myers Squibb Foundation funding food-based research projects across the country.7 Downer explains the Center provided the policy overlay and was responsible for legal and legislative policy reform.

Originally established to focus on an HIV initiative that provided direct service and legal representation for people struggling with the disease, the Center evolved to focus on policy for any person living with chronic illness. Downer says the Center saw the need for complex, community-based care and education to help reduce the risk and effect of these diseases. That approach is particularly successful for diseases like diabetes. “Knowledge is power with regards to type 2 diabetes,” she says.

Located squarely within the “diabetes belt,” North Carolina was chosen because of its unique set of challenges. Its rate of diabetes has reached epidemic proportions, almost doubling over the last 20 years to become the seventh-leading cause of death in the state. A disproportionate number of African- and Native Americans are impacted. For them, respectively, the disease is the fourth- and third-leading cause of death.8 People who develop type 2 diabetes can lose as many as 15 years of life expectancy.9 And the average healthcare cost for the typical North Carolinian is $2,600 per year, Downer says. For a diabetic, that figure jumps to a whopping $12,000.

PATHS

North Carolina state legislators and healthcare providers have been focusing on ways to provide access to nutritious food through a committee tasked with identifying “food desert zones”—geographic areas where healthy food options do not exist. While some programs are already in place in pockets around the state, the large, diverse population posed special challenges that were creating roadblocks to statewide policy reform.

After conducting a statewide analysis to identify some of the critical issues, Downer and her colleagues began meeting with people throughout the state to understand what’s currently being done to address this complicated disease. 

“Our role is to provide backbone support to the actors who will really make change in the state,” Downer says. “We were hoping to bring everyone together to align advocacy and efforts in a targeted way. We realized that it was incredibly important to have all of those skills and people working together.”

As difficult as it is to get everyone in the same room, Downer believes it’s a critical first step for any project. The key is to build on current resources and identify what is missing so there is no duplication of effort or stepping on toes. Ongoing communication can be maintained through forums. The Center plans to stay in the state through 2016 to continue developing working groups in topic areas and targeting efforts.

One of the challenges is that diabetes is such an all-encompassing disease, and its lifestyle implications are enormous. “To improve the health of these patients, large-scale cultural shifts must occur,” Downer says. Change requires a holistic approach implemented through public and private partners in a way that can be customized to every region. To prevent or reverse the effects of diabetes and other food-related illnesses, policy changes are needed to promote programs to help individuals make modifications in food choices and activity levels.

Key roadblocks were identified in these discussions and helped guide the next step. One was a lack of education among diabetes patients, especially when they’re first diagnosed. “No one had ever talked with them about diet and activity levels. They didn’t realize how their eating habits contributed to their disease,” Downer says.

Communicating that message requires a cultural shift. Eating fried foods and drinking sweet tea is as deeply identified with Southern culture as its storied reputation for hospitality. And diabetes has become so prevalent in the South that it’s virtually considered a fact of life rather than a preventable condition. Any program would need to demonstrate healthier versions of traditional meals without being disparaging about the comfort food families have enjoyed for generations.

The result is the Diabetes Prevention Program. It was developed to work directly with patients identified as at risk for diabetes. Part class and part support group, the year-long program begins with a 16-week intensive to reduce body weight by 7%. Participants learn about healthy foods and participate in 150 minutes of physical activity a week. A health coach assists.

At a cost of $400–$500 per participant to administer, the savings for those who participate in the Diabetes Prevention Program are significant. 

Recommendations & Challenges

The report includes recommendations for establishing a diabetes prevention program. These include:

• Building a whole-person model of care—An effective approach coordinates primary care, lifestyle modification and management, specialty care and access to community resources.

• Increasing access to needed services for people with diabetes—Diabetes management is complex and can be difficult for patients who lack regular and dependable access to healthcare.

• Increasing access to providers who treat diabetes—For people with or at risk for diabetes, a strong care team helps increase knowledge and skills as well as healthy behaviors.

The biggest obstacle facing many people in North Carolina is access to healthy food. This year a state-sponsored committee explored ways to improve access to health foods in food desert zones where healthy food is difficult to find. However, funding has been complicated by politics.

One option is to provide tax credits for grocery stores willing to build in food desert zones. Another is mobile grocery stores. Not only can these bring healthy food for purchase, they can ensure that everyone who is eligible for food and nutrition assistance programs is signed up.

Putting It Into Practice

Over the past 2–3 years, the Diabetes Prevention Program has been implemented through six YMCAs in North Carolina. Six more are slated to start in 2015–16. Sheree Vodicka, executive director of YMCAs in North Carolina, is coordinating efforts to find third-party entities that will help fund programs such as the Diabetes Prevention Program.

“The Y isn’t just bringing people into our buildings, teaching them classes and giving them a place to get physical activity,” Vodicka says. “We are making sure they can go into their neighborhood to get fresh fruits and vegetables, like they are being told in their class.”

The North Carolina Ys are focusing on two key aspects of the report: geographic access to healthy food and the “built environment,” a term used to describe the buildings, sidewalks and highways in communities. “Most communities are now built for cars, not people. We have engineered walking—one of the most approachable forms of daily physical activity—out of our lives,” Vodicka says.

The PATHS program launched last January with a two-day forum that involved local stakeholders. Since then, they began offering the Diabetes Prevention Program through the Ys. Vodicka says they have seen tremendous results. “We are seeing a weight loss of 5.77% after the first 16 weeks,” she says. That is compared to an average of 4.9% within the national YMCA system. Unlike other weight loss programs, Diabetes Prevention Program participants continue to lose weight, averaging a total of 6.4% weight loss by the end of the year. “I’ve been a dietitian for 25 years, and generally most people fall off the wagon and not only gain it back, but then some,” Vodicka says. “This truly is a remarkable program.”

Some North Carolina Ys are also working to meet the food and activity needs of their communities. In Western North Carolina, for example, a YMCA used grants to convert a school bus into a mobile kitchen that travels to rural communities, teaching residents how to prepare local produce in a healthier way. Other YMCAs have planted community gardens. Volunteers cultivate and donate produce to local food banks and pantries. Local farmers are asked to donate excess produce at special drop-off points.

The most unique—and according to Vodicka, critical—component to a successful program is the health coach. “Our motivation [for making dietary changes] might be very different, but we still all must learn the same tools and tricks to succeed,” she says. Interpersonal issues that impede a person’s success must be addressed. Sabotage within the family is not uncommon. “That’s where referral to a qualified counselor is important: to make sure the family is given guidance. That can be a significant issue,” she says.

Although weight loss can be observed quickly, Vodicka says making that cultural shift toward healthier choices will take at least a generation. “It’s a formidable obstacle,” she says, “and like a lot of health issues, it’s going to take some work.”

Downer says the PATHS team will continue to be involved, conducting a federal-level policy analysis based on the state-level findings and to identify common best practices. 

References

1. Robbins JM, Webb DA. Diagnosing diabetes and preventing rehospitalizations: the urban diabetes study. Med Care, 2006; 44: 292–6.

2. Fraze T, Jiang J, Burgess J. Hospital stays for patients with diabetes, 2008. HCUP Statistical Brief 93, www.hcupus. ahrq.gov/reports/statbriefs/sb93.pdf.

3. Healy SJ, Black D, Harris C, et al. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care, 2013 Oct; 36(10): 2,960–7.

4. Tucker ME. Inpatient Diabetes Education Seems to Reduce Readmissions. Medscape, www.medscape.com/viewarticle/807384.

5. Koro ME, Anandan S, Quinlan JJ. Microbial quality of food available to populations of differing socioeconomic status. Am J Prev Med, 2010 May; 38(5): 478–81.

6. Morgan M, Downer S, lopinsky T. PATHS: Providing Access to Healthy Solutions—The Diabetes Epidemic in North Carolina: Policies for Moving Forward. Center for Health Law & Policy Innovation, Harvard Law School, https://www.chlpi.org/wp-content/uploads/2013/12/PATHS_NC_North_Carolina_PATHS_Executive_Summary_FINAL_5-13-14.pdf.

7. Bristol-Myers Squibb Foundation. Together on Diabetes, www.bms.com/togetherondiabetes/pages/home.aspx.

8. North Carolina State Center for Health Statistics. Leading Causes of Death by Age Group: North Carolina Residents, 2012, www.schs.state.nc.us/schs/deaths/lcd/2012/pdf/TblsA-F.pdf.

9. Konen J, Page J. The state of diabetes in North Carolina. NC Med J, 2011 Sep–Oct; 72(5): 373–8.