Diabetes

In This Issue:

Reinventing OMH

by Audrey F. Manley, M.D., M.P.H.
Acting Deputy Assistant Secretary for Minority Health

I have been privileged to direct that team and to have Dr. Clay Simpson of the PHS Health Resources and Services Administration act as my deputy. Mr. Willard Evans provided invaluable service as the other member of the team.

We are beginning to reinvent OMH. We are refocusing on those health issues that comprised OMHs original mission: alcohol and other drug use, cancer, cardiovascular disease, stroke, diabetes; infant mortality, homicide, suicide, injury, and HIV/AIDS.

We are refocusing on crosscutting issues essential to progress in improving the health of our people--issues such as access and financing of health services, health data and surveillance, and the availability of health professionals to serve minority communities.

We are devoting much attention to the ongoing Healthy People 2000 Progress Reviews for Special Populations. My staff are cochairing the reviews for several racial and ethnic groups. We are working with our HS colleagues to ensure that revisions to these objectives reflect the latest knowledge about needs in minority health. We are working with our colleagues in each agency to improve the data on which current and future objectives will be based.

We are reexamining our methods of disseminating information to you. Beginning with our new bulletin, which this month focuses on diabetes, OMH and our Resource Center will experiment with ways to get information quickly and directly into your hands--information about what is going on in OMH and in other PHS programs that can affect minority health.

We are looking for ways to better serve the Assistant Secretary for Health, Dr. Philip Lee, who heads the Public Health Service, so that he can be clear and unequivocal in the direction he provides to PHS agencies for minority health initiatives.

Above all, OMH and our partners need to be ever more resourceful, sharing ideas, evaluating programs, and constantly changing our approach, until we find strategies that work in each of our communities.

We at OMH are changing our style of operation and our responsiveness to you. But we are not changing our commitment to closing the minority health gap.

I look to you to help me and my successors make OMH into an increasingly stronger advocate on behalf of African Americans, Hispanics/Latinos, Asian Americans, Pacific Islander Americans, Native Americans, and Alaska Natives.

OMH Helps Communities Attack Diabetes

The Office of Minority Health (OMH) tries to help minority communities deal with diabetes and other health problems through its Minority Community Health Coalition Demonstration Grant Program, begun in 1986.

Over the years, the program has shown that community-planned and community-operated intervention programs can improve the health status and well-being of community members. Here are the stories of three OMH-funded diabetes projects and the progress their communities are making.

In the past century, non-insulin-dependent diabetes mellitus (NIDDM) has become a major problem for Native American communities, such as Arizonas White Mountain Apaches. Formerly, these Apaches did not eat the refined, high-sugar, high-fat products that now make up the modern American diet, and they no longer spend long hours running, riding, hunting, and gardening. These changes in diet and exercise, the resulting risk factor of obesity, and the possible influence of genetics cause a high rate of NIDDM in this population.

The White Mountain Tribal Authority has initiated diabetes interventions through its Ndee Bii Fitness Project ("of the White Mountain Apache"). The tribal health authority is trying to help modern Apaches recognize the symptoms of diabetes and to know what people can do to prevent or control the disease. One intervention is regular physical activity and loss of excess weight.

The project has had to meet the challenge of communicating with people in isolated rural areas. Regular physical activities are announced through a monthly newsletter, bilingual talk shows, and public service announcements on the local Apache radio station. A fitness center offers classes and activities such as aerobics, country-western dancing, and weight lifting.

Because few, if any, tribal members had experience or education in diabetes and fitness, and the nearest major city with a university is at least 150 miles away, recruitment of qualified technical assistants has been difficult. Community-wide incidence of alcohol abuse, spouse abuse, and lack of telephones or reliable transportation creates problems that compete with or overshadow peoples commitment to prevent or control diabetes.

Culturally appropriate materials, including booklets and videos, get the message across. OMH has helped the project to network with local and nationwide organizations involved with diabetes (including Indian Health Service departments) and has coordinated conference attendance so that staff can receive further training.

Through OMH funding, the project has trained and certified community members as fitness instructors, achieved a large and regular attendance at exercise classes, and offered a variety of fitness classes. The project has also added a full-time male fitness coordinator to the staff, a change that has attracted men to the project for the first time in 2 years. OMH has also assisted in planning a dialysis unit, which is now being constructed.

The project could not have ben as effective without the help of a coalition of the community, IHS, and other tribal departments. The project drew together IHS and tribal staff members, who worked on a 1-day diabetes conference. Diabetic self-help clinics were run by IHS and project staff, and the project created a video showing how tribal entities and IHS can work together.

The Black Health Care Coalition of Kansas City, Missouri, is targeting the areas high concentration of African Americans, who are at much greater risk of diabetes-related health problems than their white counterparts. In five local churches, staff screen people for diabetes and other diseases with similar complications. Staff members counsel people on how to change to a healthy lifestyle, and the project offers classes on cooking and exercise. Dedicated staff do not wait for people to come to the churches. Case managers go out into the community and nearby soup kitchens to screen, educate, and counsel.

Jasper Fullard, M.D., program director, said, "We feel that the church centers seem to be the way to reach minority clients, considering that this is the center of the minority community. In order to reach minorities and have an impact, we must involve churches and get them to take on this kind of program as their own mission to improve health care in the community." When the coalitions grant expires, the churches at which the program functions will continue the program under their own funding.

The program has made 6,000 to 7,000 encounters during the 3-year life of the coalition. People who have been screened have been directed to obtain health care, and staff have followed up by telephone and through letters to encourage them to come back to the center if they are having blood sugar, hypertension, or cholesterol problems. A nurse visited the homes of those who did not return but whose health problems warranted continued participation. Many people said that the program was their only form of health care.

Dr. Fullard, who is also chair of the Cultural Diversity Committee of the American Diabetes Association (ADA), noted that this year ADA is setting up programs in churches all over the State to provide education, train educators in diabetes detection, and help communities to identify and educate people who have the disease. ADA will be involving a number of organizations in an all-out effort to educate African Americans.

Located in a rural area about 30 miles southwest of Honolulu in Oahu, the Waianae Coast Comprehensive Health Center Ohana Health Outreach Diabetes Intervention Project serves a diverse population of Asian and Pacific Islander people--populations that have been extremely susceptible to NIDDM and its complications.

Native Hawaiians suffer disproportionately from diabetes-related complications, and have a shorter life expectancy than the general population of the state. Historically a slim, health, and robust people, as many as two-thirds of Native Hawaiians today may be obese, putting them at risk for diabetes. Studies indicate that contributing factors include a high-fat, high-sugar diet.

Many of these at-risk people also have difficulty using the western health care system, making prevention, early detection, and effective control of diabetes difficult.

Targeted to Native Hawaiian, Samoan, Filipino, and Japanese patients of the Waianae Coast Comprehensive Health Center, the program usually offers services in the patients homes. Highly skilled community health case managers (CHCMs) provide diabetes education and long-term monitoring. Lolani Jameson, project director, said, "The CHCMs function as part of a multidisciplinary diabetes team and serve as the critical link between the patient and the health care team." The health care team works with each patient to develop individualized health plans, which are reviewed periodically.

Services include screening for diabetes complications and providing diabetes support group activities, health fairs, community education for people with diabetes, and a quarterly newsletter.

The Arizona, issouri, and Hawaii projects reflect the spirit of OMH grantees nationwide. Each has found a culturally sensitive avenue to deliver its health care message, and each has been successful because it has allowed communities to "buy into" the program.

For further information on the Minority Community Health Coalition Demonstration Grant Program and additional diabetes programs, contact the Office Of Minority Health Resource Center at 1-800-444-6472.

Eye Health News

Diabetic eye disease is a leading cause of blindness in the United States. When this disease is treated early, vision can be saved, so it is important that people with diabetes have an annual dilated-eye examination.

NEIs National Eye Health Education Program (NEHEP), begun in December 1991, is trying to reach the public with this important prevention message. In addition, NEHEP has a nationwide program urging groups at risk of glaucoma (African Americans over age 40 and all people over age 60) to have a dilated-eye exam at least once every 2 years. NEHEP, a partnership of more than 50 public and private organizations, creates targeted eye health education programs.

NEHEP offers free education kits to health professionals who interact with people who have diabetes: Educating People with Diabetes and Information Kit for Pharmacists. NEHEP also provides public service announcements to newspapers and magazines nationwide.

In November 1994, NEHEP joined with the American Diabetes Association in the initiative "Don't Lose Sight of Diabetic Eye Disease," the centerpiece of the 1994 Diabetes Month. NEHEP is also planning outreach programs targeting Hispanics and Native Americans, groups with rates of diabetes among the highest in the Nation.

Eight focus groups with subgroups of Hispanics met this summer to make recommendations for the Hispanic program. Planning for the Native American program will begin during fiscal year 1995.

For information about NEHEP, contact Rosemary Janiszewski, NEHEP, 2020 Vision Place, Bethesda, Maryland 20892-3655, (301) 496-5248.

Wellness Camp for Indian Youth

Understanding Diabetes

The rapidly increasing incidence of non-insulin-dependent diabetes mellitus (NIDDM) is one of the most serious health problems facing Native Americans today. For example, among the Pima of Southern Arizona, about 55 percent of adults over age 35 have NIDDM. This disease is increasingly being diagnosed in Native Americans under the age of 30 and as young as 7.

To help Native American youth understand the disease for which they are at risk, the fourth annual, 6-day "Wellness Camp for Indian Youth" (July 24 to 29, 1994) was held at Whispering Pines Camp in Prescott, Arizona. The camp is the only one of its kind in the country.

The camp was sponsored by NARTC at the University of Arizona. Funding was provided by the Schlink Foundation, the Diabetes Research Foundation, the Desert Diamond Casino, and NARTC. The policies and schedule for the camp were developed in cooperation with representatives from each tribal area.

The Participants

The program was open to boys and girls ages 10 to 15 who had NIDDM or were at high risk of the disease and who came from areas with a prevalence of diabetes. Participants and volunteers came from the Gila River Indian Reservation, the Salt River Pima Maricopa Indian Reservation, the Pascua Yaqui Indian Reservation, the Colorado River Tribes Reservation, and the Tohono Oodham Reservation. Campers were Pima, Tohono Oodham, Maricopa, Mohave, and Chemehuevi. Several campers were part or full-blooded Hopi, Zuņi, Pawnee, or Navajo.

Outcomes

The program was able to improve campers diet and weight control, diabetes control, and diabetes knowledge.

Diet and weight control. Thirty-three campers lost weight during the program. The average weight loss was 5.88 pounds. Campers showed improved self-esteem at accomplishing the weight loss, commenting, "I never thought I could lose 6 pounds!" "Moms never going to believe this," or "I did it!" Campers were surprised that they did not need to starve themselves or exercise several hours a day to lose weight. As one 11-year-old girl put it, "I didnt know that losing weight could be fun."

Diabetes control. The camp assisted with personal diabetes management for the nine campers who had diabetes.

At midweek, three girls indulged in an unhealthy snack, but because of the supportive camp environment, the girls were able to reduce their blood sugar to the low 100s within 24 hours.

A 13-year-old girl with diabetes who took insulin twice a day and who had been unable to test her own blood sugar learned to test her own blood sugar and was able to reduce her need for insulin to one dose per day. The camps social support showed her that she had the power and self-control to get off insulin and stay off.

Diabetes knowledge. The camp was able to help most campers understand that diabetes is not contagious and cannot be cured, but that people with diabetes are not powerless in controlling the disease. The overwhelming majority of campers left camp with a realistic perception of the major implications of having diabetes.

Fifteen of the campers on both pretests and posttests felt that people with diabetes were ashamed to talk about it. A possible explanation for this is that, for cultural reasons (fear that they will bring the disease upon themselves), Native Americans do not talk about diseases with people. The campers with diabetes may not have spoken up about their disease for cultural reasons, thus appearing "ashamed." Perception of shame could be the result of the campers personal experiences before arriving at camp. Campers who were not diabetic themselves all had a family history of diabetes; therefore, they may have answered this question based on the actions of a relative with diabetes.

None of the campers believed that diabetes happened only to bad people. More campers learned that, if left uncontrolled, diabetes can cause kidney damage and vision loss. The program has made them better able to make the connection when they see people in their communities suffering from kidney disease, amputations, or blindness.

Campers learned that eating a traditional diet high in complex carbohydrates, such as that of their ancestors, could help control diabetes.

Beyond an increase in knowledge, the staff of the camp noticed a significant positive shift in attitude along with an increase in sociability, self-esteem, and self-confidence among a large portion of the campers.

Interventions such as the camp provide a solid foundation of knowledge and the basis for long-term behavior change. Education and social support groups helped children to change their behaviors and reinforced their understanding of their role in maintaining their own health.

For information regarding the Wellness Camp, contact

Dr. Jennie Joe
NARTC
1642 East Helen Street
Tucson, Arizona 85719.

ADA Targets Diabetes in Hispanics

Perhaps 1 in every 10 Hispanic adults has diabetes. Between the ages of 45 and 74, one out of every four Hispanics has diabetes. Mexican Americans and Puerto Rican Americans are twice as likely as the general population to have diabetes, and diabetic Hispanic women have significantly higher rates of complications and death during pregnancy than the non-diabetic white population.

Hispanics may have trouble receiving adequate diabetes care and education because of their poverty, lack of knowledge in negotiating the health care and reimbursement systems, and language and cultural differences. Other factors may be inadequate community resources and facilities, lack of health care providers and programs sensitive to cultural and ethnic differences, and others racism and racial/ethnic sterotyping. Many Hispanics who need diabetes services are migrant workers who may not know about or understand what adequate diabetes care is or how to receive it.

Under the auspices of the American Diabetes Association (ADA), 40 national organizations serving Hispanic Americans met in February 1994 to consider the increasing problem of diabetes among Hispanics. The result was a Hispanic-focused initiative called the Diabetes Assistance and Resource Program (DAR--dar is also the Spanish word "to give.")

DAR is charged with identifying and reaching the millions of Hispanics affected with diabetes and with improving the care and resources that are available to them. The program, which designs appropriate help for the various Hispanic ethnic groups, forms coalitions and sets up grassroots activities. Coalition members contribute by sharing data and resources to address diabetes among Hispanics.

By increasing diabetes awareness and prevention, the program seeks to curtail the alarming number of diabetes-caused deaths among Hispanics and postpone and eliminate serious complications of the disease. DAR is working to increase the number of sources of diabetes information and assistance, especially in Spanish.

The Program

Volunteer Hispanic hostesses bring together small groups of Hispanic families and friends at Diabetes Home Health Parties. The hostesses provide information on diabetes awareness, risk management, and self-management. The hostesses--lay counselors trained in basic nutrition and exercise programs--provide a video, games, and a meal prepared to show how a healthy diet can taste good.

Participants and volunteers have been enthusiastic about the program. "The presentation was very well organized and agreeable--a very pleasant way to raise awareness and educate." "The visual aids really help peopleto understand." "Its up to me now."

Followup activities give the participants information and referrals. DAR makes pre-party cooperative arrangements with community-based organizations--health clinics, hospitals, government agencies, churches, and schools--to provide continuing information and support to family members of people participating in the Diabetes Home Health Parties. Lay counselors and Hispanic community health organizations develop and disseminate culturally appropriate diabetes materials and help people identify and maintain regular sources of care.

The community-based program was piloted in Arizona, California, Colorado, Florida, New Jersey, New Mexico, Oklahoma, and Texas from May to September 1993. DAR programs are also available in Idaho, northern Illinois, Indiana, Nebraska, upstate New York, and Washington. Eighty-three percent of the Hispanic population in this country lives in these States.

During the next few years, ADA expects to set up DAR in every State. Migrant Health Centers should contact the ADA affiliate in their States for information about how centers can be part of the effort.

DARs comprehensive report, New Perspectives on the Growing Public Health Challenge of Diabetes Among Hispanics, can be obtained through ADA. The report analyzes the attitudes of Hispanics toward diabetes and examines the barriers Hispanics have encountered in obtaining high-quality health care and services.

For more information about DAR, call (800) 232-3472, extension 375. To become involved with DAR locally, contact your local office of ADA, listed in the white pages of your telephone book.

CDC Helps Communities Reach Out

Education makes diabetes prevention and control possible. The Centers for Disease Control and Prevention (CDC) is targeting patients, health care professionals, and the public to receive diabetes information. CDCs Diabetes Control Programs (DCPs) provide leadership in producing new approaches and effective programs to reduce the burden of diabetes. DCPs coordinate their efforts with all parts of the health care community, and they provide interventions through health systems and community-based approaches. There are more than 150 programs run by State health departments in 40 States and Territories. Programs proposed by DCPs range from technical assistance to social action programs such as Diabetes Today. Contact: Rich Gerber, Division of Diabetes Translation (see address below), or call (404) 488-5045.

Project DIRECT

Because diabetes is more prevalent and devastating to racial and ethnic minorities than to whites in the United States, CDC has launched a demonstration project called Project DIRECT in the African American community of Raleigh, North Carolina. The pilot phase began in 1990, andthe full-scale project began in October 1994.

Project DIRECT (Diabetes Intervention: Reaching and Educating Communities Together) aims to increase community awareness of diabetes and its risk factors and appropriate management; create accessible, acceptable intervention opportunities within the community; build grassroots capacity to implement and sustain health-promoting interventions; and facilitate more effective interactions between people with diabetes and their health care providers.

CDC considers Project DIRECT to be the flagship model for community-based diabetes prevention and control programs for urban minority communities--particularly African American communities. Project DIRECT has three complementary diabetes preventions--care, outreach, and health promotion.

Diabetes Care. Project DIRECT works with health care providers to enhance diabetes management, develop patient empowerment programs, identify and reduce barriers to health care among underserved groups, and coordinate existing services to better serve people with diabetes. The project also seeks to improve self-care practices.

Outreach. People are screened in community settings that serve large numbers of African Americans to identify those who are at risk for diabetes. It also identifies people with diagnosed diabetes who are not receiving health care and helps them to reenter the system.

Health Promotion. Targeting African American adults, the project supports healthy lifestyle changes; provides structured community exercise programs; improves the "environment" (e.g., provide walking trails, street lighting, and security measures]; and creates policies that support health promotion.

The Project DIRECT community advisory board provides considerable input and direction. Among those who help direct the project are community leaders, people with diabetes, members of the health care system, community-based organizations, academic centers, and State and local health departments. Contact: Leandris Liburd (see address below).

Diabetes Today: Letting the Community Plan the Prevention

The Diabetes Today program, a nontraditional course that prepares health care professionals and other diabetes advocates to plan and carry out community-based diabetes programs, operates through a partnership of State and local health departments, local community leaders and groups, and CDC. State health department professionals and other diabetes advocates participate in a 4-day, intensive course conducted by staff from CDCs Division of Diabetes Translation.

The course focuses on assessing the community; selecting target groups, priority problems, and goals; planning intervention strategies; and evaluating the resultant program. After the course, participants are ready to direct their own 2-day courses with community leaders who will implement local interventions.

To date, people from 36 States have received this training. In addition, seven major community-based programs funded by the Office of Minority Health have sent participants to the training sessions. CDC will conduct the course again in early 1995. A video of the course is being developed to enable people who are already trained to facilitate the course within their communities.

Diabetes Today fosters prevention programs that not only reach but also actively involve the populations for which they are intended. Programs with this high level of community ownership have a much greater chance of succeeding than more traditional, "top-down" approaches. Contact: Your State health department or Patricia Thompson-Reid, Community Interventionist, Health Communications Section, Division of Diabetes Translation (see address below), or call (404) 488-5015.

For more information on CDC programs, write to the contact person listed above at the following address:

Centers For Disase Control and Prevention
Mailstop K-10
4770 Buford Highway, N.E.
Atlanta, Georgia 30341-3724.

African American Campaign

If you have "sugar," you have diabetes. You CAN take charge of your diabetes--proper diet and exercise and the right medicine can help reduce the risk of diabetes complications.

Funding Alert

The National Cancer Institute invites applications for studies of Culturally Sensitive Intervention Strategies for Promoting or I'mplementing Compliance With NCI Dietary Guidelines Among African Americans. The studies will lead to strategies to help African Americans adopt healthier eating habits. Funding: Not specified. Contact: Dr. Jacqueline Whitted, Division of Cancer Prevention and Control, NCI, Executive Plaza North, Room 232, Bethesda, Maryland 20892-4200, (301) 496-8584. Deadline: Not specified.

The National Institute on Aging invites applications for projects that delve into the causes and extent of malnutrition in the elderly and interventions to prevent it. Research topics include effects of underconsumption or overconsumption on risk of acute or chronic illness; influence of medication on nutrition; the role of socioeconomic, cultural, or behavioral factors as predictors of malnutrition; and efficacy and cost-effectiveness of screening for malnutrition among free-living, hospitalized, or long-term elderly. Funding: Not specified. Contact: Dr. Pamela Starke-Reed, Biology of Aging Program, Gateway Building, Suite 2C231, NIA, Bethesda, Maryland 20892, (301) 496-6402. Deadline: March 1, 1995 and July 1, 1995.

The Public Welfare Foundation, Inc., provides matching funds and seed money and supports operating budgets and special projects in the areas of agriculture, welfare, environment, population, aging, youth, crime, law enforcement, law and justice, health services, disadvantaged populations, legal services, homeless people, hunger, and hospices. Funding: Not specified. Contact: 2600 Virginia Avenue, N.W., Room 505, Washington, D.C. 20037-1977, (202) 965-1800. Deadline: Proposals considered at board meetings in January, April, July, and October. Revolving cycles.

Diabetes--How We Can Fight Back

First symptoms of diabetes may be increased thirst, frequent urination, sudden weight loss, blurred vision, infections that heal slowly, fatigue, and numbness in the feet or legs.

Diabetes, caused by the inadequate secretion or use of insulin by the body, prevents proper use of blood sugar. Diabetes can damage the kidneys, heart, eyes, feet, and hands. The tendency to develop diabetes can be inherited.

To prevent diabetes, eat a sensible, heart-healthy diet, exercise regularly, and don't smoke. Have regular preventive medical checks of your blood pressure, cholesterol, and eyes.

If you have diabetes, you also may need to take further steps. These may include taking appropriate medication as prescribed by your doctor. You will also need to monitor your blood sugar levels, and take care of your feet and check them daily.

Resources

American Diabetes Association Minority Initiative
National Service Center
1660 Duke Street
Alexandria, Virginia 22314
(703) 549-1500

Asian Health Services
310 8th Street, Suite 200
Oakland, California 94607
(510) 465-3273

Food and Nutrition Information Center
National Agricultural Library
10301 Baltimore Boulevard, Room 304
Beltsville, Maryland 20705-2351
(301) 504-5719

Health Watch Information and Promotion Service
3020 Glenwood Road
Brooklyn, New York 11210
(718) 434-5411

Hui No Ke Ola Pono (An Association to Strengthen and Perpetuate Life)
P.O. Box 894
220 I'mi Kala Street, Suite 105
Wailuku, Hawaii 96793
(808) 244-4647

National Coalition of Hispanic Health and Human Services Organizations
1501 16th Street, N.W.
Washington, D.C. 20036
(202) 387-5000

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, Maryland 20892-3560
(301) 654-3327
FAX (301) 907-8906

Native American Research and Training Center
University of Arizona
1642 E. Helen Street
Tucson, Arizona 85719
(602) 621-5075

Closing the Gap is published by the Office of Minority Health Resource Center, a service of OMH. If you have comments please call 1-800-444-6472 with comments, write to OMH-RC, P.O. Box 37337, Washington, DC 20013-7337, or e-mail us at info@omhrc.gov.

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