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Report Title:	Focus Groups - Diabetes and Oral Complications
*Abstract:*	Diabetes is one of the most burdensome and costly chronic diseases of our time. In the United States, an estimated seventeen million people have diabetes and more than three quarters of a million people are newly diagnosed with diabetes each year.1 It is a condition in which the body is unable to either produce or use the hormone insulin, leading to elevated blood sugar levels and potentially serious complications. These complications are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes, kidneys, and nerves. Poor glycemic control can lead to heart disease, stroke, blindness, kidney disease, amputations, and oral disease. The Centers for Disease Control and Prevention (CDC) is dedicated to eliminating the preventable burden of diabetes in the United States. The Division of Diabetes Translation (DDT) works to achieve this mission by combining support for public health-oriented diabetes prevention and control programs (DCPs) with efforts to translate diabetes research findings into widespread clinical and public health practice. Under contract to CDC, ORC Macro conducted a literature review and an environmental scan regarding oral complications of diabetes. Information collected from the literature review and environmental scan suggested specific audience segments on which to focus in further formative research. For more information on the literature review and the environmental scan, see reports entitled Literature Review of Oral, Eye and Foot Complications of Diabetes (April, 2001) and Environmental Scan for Oral Complications of Diabetes (April, 2001). As a result of these activities, CDC determined that focus groups and in-depth interviews should be conducted with an emphasis on African Americans with diabetes and the health professionals caring for these individuals. In this effort, it was critical to solicit information from health professionals who not only have a stake in disseminating the potential materials developed by CDC, but also play a significant role in preventing and treating oral complications of diabetes in African Americans. With this in mind, 4 focus groups were conducted with certified diabetes educators (CDEs), registered dental hygienists, and 8 in-depth interviews were conducted with other important stakeholders addressing oral complications of diabetes, such as practicing dentists (with over 50% of their practice being with African American patients), a representative from a diabetes program of a state health department, and a representative from CDC’s National Diabetes Education Program. Key Findings Relevant to Program and/or Intervention Planning Several important findings have emerged as a result of this formative research. This information will assist CDC in developing communication concepts and materials addressing oral complication of diabetes with the African American population. A selection of these findings follows. Role of CDC Participants envision CDC as a strong organization with which to collaborate in the effort to educate African Americans about oral complications of diabetes. Nevertheless, participants believed that CDC should take a more active approach in addressing oral complications of diabetes; that efforts were needed in increasing access to dental care and developing education in this area. Specifically, participants believed that CDC should become a more visible stakeholder within the dental community; CDC should be more aggressive in disseminating data regarding the link between diabetes and oral health. Specifically, it was suggested that CDC develop a campaign focusing on “the three D’s” – diet, diabetes, and dental care. Finally, participants felt that CDC should take more of a leadership role in disseminating, if not creating and developing, no-cost educational information about diabetes and oral complications for both African American patients with diabetes and for the diabetes care professionals that treat them. Importance of Partnerships and Collaboration Participants believed that every stakeholder trying to eliminate the complications of diabetes (members of the diabetes care team) has a role in improving and promoting the oral health of patients with diabetes. Participants felt that many stakeholders can participate in a continuous quality-improvement cycle; a series of steps designed to enhance processes leading to improved patient and program outcomes at the state level and practice level. Specifically, participants spoke of the merit of programs that involve partnerships between minority faith- and community-based organizations and health care facilities in a collaborative effort that specifically addresses the cultural needs of the African American population. Churches, health fairs, and community centers were repeatedly mentioned as places/opportunities to effectively reach this population in the effort to reduce the effects of diabetes complications. In addition to CDC, participants recognized and recommended the American Dental Association and the American Diabetes Association as key organizations to partner with in any collaborative effort. Content-Specific Knowledge, Attitudes, Beliefs, and Behaviors Knowledge Participants stated that they are knowledgeable about the importance of nutrition/diet and exercise in prevention of diabetes and the delay of complications. They also stated that they regularly emphasize several self-management strategies with their patients including blood glucose control, brushing and flossing of the teeth, and routine dental exams for prevention of oral complications. Attitudes Participants noted that it is essential to develop a rapport, or trusting relationship, with African Americans with diabetes in order for these patients to be receptive to any educational messages provided. Certified diabetes educators believed that it is easier for them to address eye and foot complications than oral complications of diabetes with their patients because patients are more concerned about their eyes and feet and more receptive to messages of preventing blindness and amputation. Similarly, registered dental hygienists believed that patients viewed eye and foot complications of diabetes as being a more serious threat to health compared with oral complications. Overall, participants felt that patients perceive of losing their teeth as a natural part of the aging process. They believed that patients may not be motivated to prevent oral complications of diabetes and that patients believe they will lose their teeth regardless of their actions. Beliefs Participants believed that every member of the diabetes care team, from medical to dental professionals, has a role in improving and promoting healthy behaviors and in supporting the patient’s diabetes care management. Indeed, participants felt very strongly that it is their duty and moral obligation to address issues of concern with African Americans with diabetes. Many mentioned that the disease has affected them or their parents, relatives, or close friends in different ways. Also, participants felt that it is easier for patients to prevent oral complications of diabetes than to prevent eye or foot complications. They believed that patients are less likely to seek dental care when experiencing oral complications than they are to seek medical care when they are experiencing other complications of diabetes. It was noted that patients view dental care as a luxury item and a service that they would not typically seek out. Finally, participants expressed very strong convictions regarding what they perceive as barriers or challenges facing their patients in relation to diabetes care: lack of adequate access to services and information about diabetes, competing demands within a household, low socioeconomic status, and external locus of control and fatalism surrounding diabetes. Behaviors Participants felt that, with oral complications, they are able to provide specific instructions for prevention that can be easily implemented by patients such as brushing and flossing the teeth. A few participants spoke of their current efforts in providing information to patients about oral complications of diabetes; many participants expressed their willingness to gather more information on complications of diabetes via several avenues (Internet searches, calling information 800-numbers, requesting materials, participating in seminars or CME-credit activities, etc.). Need for Specific Materials Participants believed that there was a great need for culturally appropriate materials addressing oral complications of diabetes in the African American population, as well as for all populations with diabetes. Specifically, it was stated there is a great need for hands-on, graphical, educational materials that they could use with their clients. Participants stated that handouts with visual images and photos of a mouth impacted by oral complications of diabetes would be particularly helpful to them when attempting to educate their clients. These culturally-appropriate resources to educate African Americans with diabetes about oral complications can also include tools such as booklets and videos. These resources should be very visual and include many graphical depictions showing how diabetes can affect the mouth. Resources should also include minimal text and be written at an appropriate reading level. Moreover, it was indicated that political support for these resources and the availability of trained staff to develop them were essential to the dissemination of materials. It was also recommended that the American Dental Hygienists’ Association be involved in the development of materials, seminars and other programs focused on this issue. Participants felt that it would be very beneficial to include information about oral complications in newsletters or professional journals received by dental hygienists Obstacles in Working with Various Health Care Providers Overall, participants expressed frustration with their professional relationships with various health care providers, in particular with the diabetes care team. Participants most often referred to primary care physicians’ failure to reinforce the health messages about oral complications of diabetes. In particular, registered dental hygienists expressed frustration with their relationship with dentists. They referred to dentists’ lack of reinforcement of the health messages about oral complications of diabetes. In sum, participants expressed concern about the lack of cohesiveness and collaboration among the medical and dental communities. They believed that a more comprehensive approach to care is needed in which dental care is considered part of overall health care. Emphasis on Prevention, Self-management, and Patient Empowerment A consistent prevention theme can be identified throughout the data collection in this formative research across audiences, campaigns, programs, and materials developed for people with diabetes. More and more, emphasis is placed on prevention of diabetes and its related complications, in particular as a result of the newly published, substantial evidence that type 2 diabetes can be prevented or delayed. As such, Diabetes Self-Management Education is the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes. Self-management implies “taking charge” of diabetes by following nutrition guidelines, engaging in regular exercise, taking medication, undertaking regular check ups and examinations, and aiming for regular communication with the diabetes care team. Central to the concept of self-management is the concept of patient empowerment. In working with the health care provider as a partner or collaborator, patients are afforded the best possible results given the resources available to them. However, education is necessary for patients to take on this role. Recommendations for Program and/or Intervention Planning Stemming from the findings of the focus groups and in-depth interviews, recommendations listed in this report are intended to guide future activities toward message development and dissemination of information regarding oral complications of diabetes. A selection of these recommendations follows. CDC should: · Take a more active approach in addressing oral complications of diabetes, as it has shown in addressing the foot and eye complications (currently, oral health is not one of the National Objectives for the DDT and their agreements with DPCPs). · Become a more visible stakeholder within the dental care community. · Prepare to manage the perceived lack of cohesiveness and collaboration among the medical and dental care communities, in other to make future efforts actionable. Participants believed that these medical organizations understand the need to address oral health as part of overall health. · Create or support programs that involve partnerships between minority faith- and community-based organizations and health care facilities in a collaborative effort that specifically addresses the cultural needs of the African American population. · Continue to direct efforts to support activities targeting prevention of diabetes and its related complications, in particular as a result of the newly published, substantial evidence that type 2 diabetes can be prevented or delayed. · Take more of a leadership role in creating, developing or at a minimum, in disseminating no cost educational information about diabetes and oral complications. · Target the need for culturally appropriate materials addressing oral complications of diabetes in the African American population. Materials should be hands-on, with visual depictions of instructed self-management behaviors so that oral health professionals can use them with their clients.
	Details...
Agency:	Centers for Disease Control and Prevention
Date of Report:	4/1/2003

2

Report Title:	Oral, Eye and Foot Complications of Diabetes: Eye Complications Report
*Abstract:*	Diabetes is one of the most burdensome and costly chronic diseases of our time. In the United States, an estimated seventeen million people have diabetes and more than three quarters of a million people are newly diagnosed with diabetes each year. It is a condition in which the body is unable to either produce or use the hormone insulin, leading to elevated blood sugar levels and potentially serious complications. These complications are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes, kidneys, and nerves. Poor glycemic control can lead to heart disease, stroke, blindness, kidney disease, amputations, and dental disease. The Centers for Disease Control and Prevention (CDC) is dedicated to eliminating the preventable burden of diabetes in the United States. The Division of Diabetes Translation (DDT) works to achieve this mission by combining support for public health-oriented diabetes control programs (DCPs) with efforts to translate diabetes research findings into widespread clinical and public health practice. DCPs in all 50 States and in nine other jurisdictions are funded by DDT as a cornerstone of this strategy. Collectively, these DCPs compose the National Diabetes Control Program. Under contract to CDC, ORC Macro conducted a literature review, an environmental scan, and formative research in eye complications of diabetes. Data collected from the literature review and environmental scan suggested specific audience segments on which to focus in the formative research. A theoretical framework was developed to assist in delineating the parameters of the research, formulating the informal interview questions, and interpreting findings. Studies show health disparities between racial and ethnic groups in the United States in the rate of diabetes and its associated complications. Certain racial and ethnic communities, including African Americans, suffer disproportionately compared with White populations. An emphasis on African Americans with diabetes and health professionals was selected by CDC for the formative research. For more information on the literature review and the environmental scan, see reports entitled Literature Review of Oral, Eye and Foot Complications of Diabetes (April, 2002) and Environmental Scan for Eye Complications of Diabetes (May, 2002). In this effort, it was critical to solicit information from health professionals who not only have a stake in disseminating the potential materials developed by CDC, but also play a significant role in preventing and treating eye complications of diabetes in African Americans. With this in mind, data collection activities were conducted with certified diabetes educators (CDEs), eye care providers (ophthalmologists and optometrists), and other important stakeholders from key organizations addressing eye complications of diabetes. Key Findings Relevant for Program/Intervention Planning Content-Specific Participant’s Knowledge, Attitudes, Beliefs and Behaviors · Diabetes educators indicated familiarity with eye complications of diabetes, its asymptomatic nature and the perceived confusion among patients regarding blurry vision, changes in prescription and diabetic eye disease. · In-depth interviewees noted the complexity of the combination of social, economic and lifestyle factors in listing the challenges faced by that African Americans with diabetes. · Participants indicated their knowledge of the importance of nutrition/diet and exercise in prevention of diabetes and the delay of complications, with special attention at institutionalized populations (prisons for example). They also indicated that they regularly emphasize to their patients several self-management strategies with glucose control and annual dilated eye exams for prevention of diabetic eye disease (diabetic retinopathy, cataracts and glaucoma). · Participants expressed very strong convictions regarding what they perceive are barriers/challenges that their patients face in relation to diabetes care: lack of adequate access to services and information about diabetes, competing demands within a household, low economic financial status, external locus of control and fatalism surrounding diabetes. · Participants believed that every member of the diabetes care team has a role in improving and promoting healthy behaviors and in supporting the patient’s diabetes care management. “One of the things that I think is important with respect to that is to talk to African Americans. I remember when I was involved with the National Eye Health Education Program, I strongly emphasized to them you need to talk to the people who are involved, who you are trying to implement the program to. People want to know that they have input of optometrists, of ophthalmologists, primary care physician. Everybody involved should have input and the patients. Because they will tell you how they want to get the information so that it’s understandable to them.” Eye Care Professional · Participants felt very strongly that it was their duty and moral obligation to address issues of concern of African Americans with diabetes. Many mentioned that they themselves, their parents, relatives or close friends were affected by the disease in many ways. · Diabetes educators expressed their frustration with what they perceive is a limited role with regards to addressing eye complications: they can only conduct educational sessions and check in a follow up visit whether the recommended visit to the eye care practitioner took place. · Diabetes educators also indicated that is easier for them to address the oral or foot complications with their patients than is with eye complications, mainly because they can give specific instructions for prevention that can be easily implemented once patients leave the office (brush and floss their teeth; check their feet and wear protective socks or shoes respectively). Still, some diabetes educators still incorporate “doable” actions, such as taking nutritional supplements in preventing eye complications. · Eye care professionals perceive that speaking about eye complications of diabetes induces more fear than oral or even foot complications, due to the stigma associated with blindness. “There is one little difference. When you emphasize the fact [that] they’ll go blind, it’s amazing the way it will get their attention. They would rather have their arm cut off than go blind.” Eye Care Professional · Eye care professionals indicated that some times they are the first to recommend to the patient to check for diabetes, given the nature of their vision problems. · A few participants across groups indicated their current efforts, and many more expressed their willingness to gather more information on complications of diabetes via several venues (Internet searches, calling information 1-800 numbers, requesting materials, participating in seminars or CME-credit activities, etc.). Need for Materials · Participants believed that there was a great need for culturally-appropriate materials addressing eye complications of diabetes in the African American population, as well as for all populations with diabetes. For African Americans specifically, participants also believed that the links between diabetes and high blood pressure and cardiovascular disease are to be heavily emphasized. “In my practice one of the big factors is just the difference in the education about diabetes between the African-American and the White populations. A lot of my Caucasian diabetics have looked up stuff on the Internet. They’ve been reading books. They know what their blood sugar should be and they know exactly how they should be managing things and it just seems that a lot of the African-American population that do seem to have diabetes have no idea about what’s going on. No one has taken the time before to go over things with them.” Eye Care Professional · Participants also expressed great need for hands-on, visual educational materials that they could use with their clients. Participants stated that photos, short quizzes, or even better, a tool such as a visual model of a healthy eye and an eye with diabetic eye disease would be particularly helpful to them when attempting to educate their clients. “I can definitely use more handouts. One handout that I have that I use has got a lot of words on it, way too many words on it for eye care. Whereas I have another one for foot care that has a lot more pictures, a lot more white space and less words.” Eye Care Professional Partnerships § Participants believed that every stakeholder has a role in improving and promoting eye health of patients with diabetes. Participants felt that many stakeholders can participate in a continuous quality-improvement cycle; a series of steps designed to enhance processes leading to improved patient and program outcomes. “And even more grassroots, I know some of the hospitals, when I was at Baptist, I had an ophthalmologist that did an awful lot of eye, diabetic eye problems. He was an African American and he was wonderful teacher. He would sit down with all of his colored pencils for all the stuff on his paper whatever he saw in the eye he would doodle. He would sit down there and talk with anybody. He would let me go in there and he would show me some, I used to work in the operating room and they have dual magnifiers when they do eye surgery so a second person can look through and see what the surgeon is looking at.” Certified Diabetes Educator · Participants stated that they used materials from CDC and the U.S. Department of Health and Human Services to educate African Americans about eye complications of diabetes. The American Diabetes Association, Eli Lilly & Co., Pritchard and Hall, and the Lions Club were also mentioned as authoring agencies of resources used. Respondents mentioned that they referred to print materials, Web sites, and visual models in their educational efforts. · Certified diabetes educators stated that they would collaborate with some specific national organizations including CDC, NIH (particularly NIDDK), the American Diabetes Association, the American Academy of Ophthalmology, and the National Federation of the Blind. · A few specific resources were mentioned by stakeholders. Diabetes-Sight.org, a patient- and provider-focused website sponsored by Prevent Blindness America providing information for the prevention of vision loss from diabetes, was cited. The Eye Care America Diabetes Project, a public service project sponsored by the Foundation of the American Academy of Ophthalmology providing educational materials and referral services for persons with diabetes, was noted. Materials such as posters and brochures from the National Eye Institute’s National Eye Health Education Program were also mentioned. · Participants indicated the merit of programs that involve partnerships between minority faith and community-based organizations and health care facilities in a collaborative effort to address cultural needs of the African American population. Churches, health fairs, barbershops, community centers, adult day centers, were repeatedly mentioned as places/opportunities to effectively reach this population. “Well, organizations, I mean, I still think of local churches. I just think that there’s not anybody in the African-American community that can have more influence than a trusted minister in a church to reach his parishioners. There are so many of the churches that my patients tell me about now that have health committees and health fairs and all of these kinds of things. If a church had a knowledgeable nurse or dietician in it, then oftentimes that’s an in-road for the message to start getting out there about taking care and preventing complications.” Certified Diabetes Educator Role of CDC · Participants envision CDC as a strong organization with which to collaborate in the effort to educate African Americans about eye complications of diabetes. · Nevertheless, participants were not familiar with many of CDC’s existing public education resources for diabetes (although the National Diabetes Education Program and the Flu Campaign were identified as examples to follow). · Participants believed that CDC should take a more active role in disseminating/distributing no-cost educational information about diabetes and eye complications. · Several eye care professionals noted that CDC will need to build trust within the African American population for this type of campaign to be successful, and referred to the Tuskegee study and the distrust of African Americans associated with health-related studies. Recommendations for Program/Intervention Planning Several important findings have emerged as a result of this formative research, as discussed above. Stemming from that groundwork, the recommendations listed in the report are intended to guide future activities towards message development and dissemination of information about eye complications of diabetes among African Americans. A selection of these recommendations follow: · Eye care providers stated that CDC should solicit the mass media and disseminate public service announcements regarding eye complications of diabetes through multiple channels including radio, television and print sources. The use of a celebrity spokesperson was strongly suggested in this approach. Participants mentioned Jackie Robinson, Gladys Knight, and Halle Berry as well-recognized African Americans with diabetes that could serve in the role of spokesperson. “I was glad, in fact almost euphoric, at the onset of this discussion when you mentioned CDCP, Centers for Disease Control and Prevention. This is what care is all about, not only control but prevention also. As far as the preventive aspect is concerned, I think it’s important to get the diabetic population educated and empowered and one of the ways that it can be done efficiently is through the mass media. We don’t want to have these things just on the health channel. You want them on channel 2. You want to get charismatic people involved. We don’t have Magic Johnson for diabetes. We need someone like that.” · Participants recommended incorporating information about proper nutrition habits in a culturally-appropriate way with cultural sensitivity with regards to body image, food preferences, meal preparation, and ethnic beliefs (supplements, herbal medicines, complementary medicine). · Diabetes educators recommended to CDC to develop a community tool kit with posters, videos, written materials, screening tools, etc. for distribution to diabetes care professionals. · Participants indicated that patient education materials should be written for lower literacy levels and should be highly visual, graphically depicted, with medium- to large-size font. Photos should be appropriate to the African-American population. · Participants recommended the use of multiple outlets to deliver information to patients and diabetes care professionals (eye care providers and diabetes educators). Hands-on materials, videos, models, color pictures, flipcharts and other visual educational materials were mentioned as very helpful for diabetes care professionals to use with their patients. Seminars at professional conferences, CME courses, CD-ROMs, interactive modules and guides, and handouts are more suitable for the professional development of eye care providers and diabetes educators.
	Details...
Agency:	Centers for Disease Control and Prevention
Date of Report:	11/1/2002

3

Report Title:	Oral, Eye and Foot Complications of Diabetes: Foot Environmental Scan
*Abstract:*	Diabetes places a significant health care burden on the United States, where an estimated seventeen million people have the disease and there are approximately 800,000 new cases each year (1,2). The financial burden of such a public health epidemic results in both direct and indirect costs from absenteeism, disability, and premature death totaling $98 billion (1). More than 60 percent of nontraumatic lower-limb amputations in the United States occur among people with diabetes (1). From 1997 to 1999, about 82,000 nontraumatic lower-limb amputations were performed each year among people with diabetes (1). These facts carry frustrating overtones because much of the burden associated with complications of diabetes is preventable. The Division of Diabetes Translation (DDT) of the Centers for Disease Control and Prevention (CDC) is dedicated to eliminating the preventable burden of diabetes in the United States. The division works to achieve this by combining support for public health-oriented diabetes control programs (DCPs) with efforts to translate diabetes research findings into widespread clinical and public health practice. DCPs in all 50 States and in nine other jurisdictions are funded by DDT as a cornerstone of this strategy, and they collectively compose the National Diabetes Control Program. National objectives set by DDT several years ago emphasize prevention of complications through timely foot exams, eye exams, oral care, appropriate immunizations, and HgA1c tests. This focus on screening reinforces the interest of DDT and DCPs in primary prevention approaches but considerably broadens the target populations on which they must focus and the partnerships that must be made to implement effective interventions. Hence, it is essential that good formative research be done to isolate the most effective ways to motivate initiation and maintenance of healthy behaviors by those at risk for diabetes complications. The key tasks of this project fall into two broad phases. The first phase involves conducting a literature review and environmental scan, which lead to the development of a formative evaluation plan. In the second phase, the planned formative research will be conducted, intervention concepts and materials will be designed by the creative contractor and pre tested by the evaluation contractor, and the resulting intervention will be evaluated. For Phase 1, the central charge is to compile existing data; evaluate the quality of the research, interventions, and any gaps that exist; and develop a plan to conduct needed formative research on oral, eye, and foot complications of diabetes, including 1) educational messages and message concepts, 2) printed materials and/or other communications products, 3) dissemination channels, 4) processes and strategies engaged to develop messages, and 5) audiences specifically targeted and the rationale for targeting those audiences. The results of each evaluation will aid CDC and its partners in designing appropriate interventions for oral, eye, and foot complications of diabetes. A literature review describing the relationship between diabetes and each complication was conducted as part of Phase 1 of this project. The purpose of the literature review was to summarize, document, and evaluate the quality of information related to knowledge, attitudes, beliefs, and behaviors pertaining to oral, eye, and foot health and diabetes among people with diabetes, specialists, and general health care providers. To supplement the literature reviews, an environmental scan on each complication was conducted. The Oral Environmental Scan was the first to be commissioned, and it was produced in April 2001. This report deals with the Foot Environmental Scan, which obtained current information on how diabetes and foot complications are portrayed in electronic media and how they are dealt with in political and social environments. Internet resources, such as Web sites and listservs, were scanned for information on diabetes and foot complications. Potentially competitive or duplicative programs, as well as clinical and psychosocial trends that might enhance or threaten future program activities, were researched. Specifically, the environmental scan identified resources that address the foot complications of diabetes. This deliverable includes the environmental scan report, materials collected, and a synthesis of this information to identify key themes and issues on foot complications of diabetes. Within this task, information was collected in a number of defined areas. Legislation, national objectives and initiatives, screening guidelines and treatment algorithms, education programs and media campaigns, the consumer marketplace, and clinical and psychosocial trends were investigated to assess activity that may have an impact on the prevalence of foot complications of diabetes. Several important findings have emerged as a result of this formative research. The focus is on determining where interventions and programs can make a difference or make the greatest difference. The most salient findings are listed as follows. Stakeholders In addition to the Centers for Disease Control and Prevention, a number of stakeholders, including Government agencies and professional organizations, is prominent in addressing issues related to diabetes and foot complications. National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports research on many of the most serious diseases affecting public health. NIDDK’s Division of Diabetes, Endocrinology, and Metabolic Diseases (DEM) provides research, funding, and support for basic and clinical research in the areas of type 1 and type 2 diabetes and other metabolic disorders. NIDDK has developed a number of health education programs, two of which are specific to diabetes. American Podiatric Medical Association The American Podiatric Medical Association (APMA) is the premier professional organization representing the Nation's Doctors of Podiatric Medicine. The APMA represents approximately 80 % of the podiatrists in the country. The primary mission of the APMA is to improve the quality of foot care in the United States. This mission includes attracting qualified young men and women to the field, and to increasing the awareness of the importance of foot health among the general public and other health professionals. American Diabetes Association The American Diabetes Association is the Nation’s leading nonprofit health organization providing diabetes research, information, and advocacy. The mission of the organization is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. American Association of Diabetes Educators The American Association of Diabetes Educators (AADE) is a multidisciplinary organization representing more than 10,000 health care professionals who provide diabetes education and care. The mission of the organization is to advance the role of the diabetes educator and improve the quality of diabetes education and care. Veterans Health Administration An organization of the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA) sponsors and participates in a host of programs that increase the quality of health care for patients. One such program focuses on diabetes. Diabetes has particular importance for the Department of Veterans Affairs because the prevalence among VA patients is substantially higher than in the general population. Thus, VA is the largest integrated health care system providing care to people with diabetes. Nearly all veterans with diabetes are men. The largest group of veterans with diabetes is over 65 years of age. Trends The stakeholders listed in the previous section have been highlighted because they undertake activities aiming to address the burden of diabetes and its complications. As part of an analysis of the context of these activities, a number of clinical and psychosocial trends are apparent. In observing the messages conveyed about diabetes and its related foot complications in our environmental scan, the mechanisms and channels through which these messages are disseminated were also examined. A synthesized list of the trends identified follows. Emphasis on prevention, self-management, and patient empowerment A consistent theme can be identified throughout the campaigns, programs, and materials developed for people with diabetes. More and more, emphasis is placed on prevention of diabetes and its related complications, in particular as a result of the newly published substantial evidence that type 2 diabetes can be prevented or delayed. Although the treatment of diabetes has become increasingly sophisticated with many pharmacological agents available to lower blood glucose, a patient’s success in preventing diabetes depends on his or her behaviors and abilities. Lifestyle modification including physical activity and moderate weight loss are the recommended strategies for diabetes prevention. Self-management of the disease can be reinforced among patients with diabetes through education. Learning more about diabetes can empower patients to better manage the disease and avoid complications. Use of the partnership model Diabetes education and care, the partnership model of promoting health is increasingly common. Numerous initiatives, campaigns, and programs make use of partnerships among Government and private organizations. In the diabetes community, partnerships serve to provide greater strength in working toward a common goal. Interagency partnerships allow for combined ideas, knowledge, experience, resources, and access to target audiences. The collaborative efforts characteristic of partnerships increase the likelihood of achieving the goals of increased awareness, routine screening, and proper treatment of diabetes. More research is needed, however, in examining specifically what makes these partnerships work and in identifying characteristics and indicators that will help form better partnerships in the future. Enhanced communication, stronger links between primary care providers and foot care providers Diabetes affects many different aspects of a person’s life. A total-care approach to diabetes ensures that the person with diabetes receives help from medical professionals trained to focus on the different areas, from head to toe. A health care team allows the person with diabetes to use the health care system to its fullest. However, the primary care provider is often the first point of contact for the person with diabetes. As a result, it is important that the primary care provider and other members of the health care team communicate with one another about the health status of the patient. Multimedia approach to disseminating messages and information Often, the success of a particular campaign or program will depend on its audience reach. Traditionally, television, radio, and print have been the media in the marketing mix through which campaigns disseminate their messages. Today, media campaigns and education programs focusing on diabetes are including the use of computers and the Internet as a medium through which to disseminate their messages. In particular, the use of multiple outlets to deliver information is a strategy that is consistent with research on what it takes to get a message through to people. New examples of how pharmaceutical companies and other organizations are using the Web to promote directly to physicians via e-modalities, including e-detailing and e-events (e.g., CME activity, etc.) are listed in this report. Gaps Identified Although our findings suggest that there is a wealth of information on foot complications of diabetes, gaps in knowledge of this subject do exist. National initiatives and educational programs specifically targeting Hispanic/Latinos with foot complications of diabetes are limited. Although there are national initiatives and educational programs focusing on foot complications, few are targeted toward specific minority populations. Additionally, of the national initiatives and educational programs that do target minority populations, even fewer are developed to specifically address culturally and linguistically diverse needs within the Hispanic/Latino populations. Direct to consumer marketing of pharmaceutical products and supplies for treatment and management of foot complications of diabetes is limited. Unlike the consumer marketplace for general diabetes care, which is flooded with pharmaceutical products, supplies, services and information to help patients manage their blood glucose levels, the consumer marketplace specific to foot complications of diabetes is not heavily saturated. This environmental scan on foot complications of diabetes has identified key pieces of information related to legislation, national objectives and initiatives, screening guidelines and selected treatment algorithms, education programs and media campaigns, and the consumer marketplace, along with clinical and psychosocial trends. Activities that may have an impact on the prevalence of foot complications of diabetes are also described. The information obtained from this environmental scan was used to construct a formative research plan. This plan, which is presented at the end of this report, includes recommendations for conducting formative research on audience selection, message concepts, types of communication products, and dissemination channels for Phase 2 of this task on foot complications of diabetes.
	Details...
Agency:	Centers for Disease Control and Prevention
Date of Report:	5/1/2002

4

Report Title:	Oral, Eye and Foot Complications of Diabetes: Literature Review
*Abstract:*	For a patient with diabetes, defects in insulin secretion and/or insulin action by the pancreas prevent the conversion of sugars and starches into energy, a condition which results in high levels of blood glucose. The first of two main types of diabetes, Type I diabetes, or insulin-dependent diabetes mellitus (IDDM), is most commonly caused by a malfunction of the immune system (1) and accounts for just 5 to 10% of all diagnosed cases. The remaining 90-95% of all diagnosed cases are caused by Type II diabetes, or non-insulin-dependent diabetes mellitus (NIDDM), whose onset is most commonly associated with older age, obesity, family history, race/ethnicity, and lack of physical activity (1). The incidence of diabetes is increasing. With roughly 800,000 new cases diagnosed each year, the prevalence of diagnosed diabetes has increased by 33% between 1990 and 1998 (3). Currently, an estimated 15.7 million people, of whom only 65% have been diagnosed, have diabetes. It is also estimated that by 2025 over 20 million people will have diabetes (21). Accompanying this increased prevalence of diabetes is an increase in the number of associated complications. Diabetes can affect every organ of the body. Poor glycemic control can lead to blindness, lower extremity amputations, and dental disease (6). Diabetes is the leading cause of blindness, and complications related to diabetes account for over half of the lower extremity amputations in the United States. In a synergistic fashion, diabetes and periodontal disease contribute to each other; patients who develop severe periodontitis as a result of their diabetes often struggle to maintain proper glucose control because of tooth loss or oral pain and discomfort. The burdens of diabetes and its associated complications are not distributed equally. Higher rates of the disease are found in minority populations such as Native Americans, African Americans, and Hispanic/Latinos. Prevalence of Diabetes (Both Type I and Type II) among Minority Populations Percentage of diabetes for individuals 20 years and older: African American 10.8%, Mexican Americans 10.6%, Native American 9%, White 7%. Likelihood of developing diabetes compared to whites of the same age (22): African American 1.7 times, Mexican Americans 2-3 times, Native American 2.8 times, White N/A. Risk factors for the development of diabetes and diabetes complications are well-established (10) and include genetic factors, obesity, social and environmental stressors, duration of diabetes and poor glycemic control (for complications). Knowledge of these risk factors allows both health care organizations and practitioners to take preventative measures. Suggestions for such interventions and evidence for their effectiveness are found in the published literature, which also provides reasons for the current prevalence and incidence rates of diabetes. The published literature we reviewed addresses current debates about the systems through which diabetes care is provided, health care providers’ knowledge and practice patterns, diabetes patients’ knowledge and self-management behaviors, diabetes in minority populations, and the enablers and barriers to seeking and receiving appropriate diabetes care. Both a multidisciplinary and single component systems approach have been suggested as ways to improve the care provided to diabetes patients. The multidisciplinary approach is a system of services in which all members of the health care team are devoted to maintaining the overall health of the patient with diabetes. Some examples of single component approaches are the use of care algorithms, critical pathways for care, and risk-categorization schemes. These methods of providing care have been shown to increase the number of appropriate referrals and screening exams physicians provide to patients with diabetes, and to improve the health outcomes of patients with diabetes. Interventions aimed at health care providers have shown that short education classes are effective in educating providers on the current clinical recommendations for appropriate diabetes care and current screening procedures. Because of short appointment times or providers who lack adequate knowledge about the disease, physicians do not always discuss all the relevant issues with their diabetes patients, and thus do not always provide them with adequate care. Interventions targeting the patient with diabetes seek to change knowledge, attitudes, beliefs, and behaviors. Accordingly, several interventions have focused on promoting self-management behavior, which is an important component in diabetes control. Despite findings described in the published literature, gaps in our understanding of why diabetes prevalence is increasing, particularly for minority populations, remain. To fill in these gaps, additional research will be necessary. Besides our review of the literature, we are conducting an environmental scan on oral complications of diabetes. The findings from both these activities will then be used to develop a formative research plan, which will target those who are affected by diabetes, or involved in diabetes care, in order to answer the remaining questions.
	Details...
Agency:	Centers for Disease Control and Prevention
Date of Report:	4/15/2001

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Report Title:	Oral, Eye, and Foot Complications of Diabetes: Oral Environmental Scan
*Abstract:*	The charge of this project is to evaluate current data on diabetes, its associated complications, and its effects on minority populations. The accompanying literature review provides a background on diabetes as a major chronic disease; an overview of its burden across the U.S. population; and a discussion of findings on the foot, eye, and oral complications of diabetes. Also analyzed in this review are interventions aimed at reducing the burden of diabetes complications in minority populations. To supplement our review of the literature, we conducted an environmental scan to obtain current information on how diabetes and its oral complications are portrayed in electronic media and how they are dealt with in the political and social environments. Internet resources, such as Web sites and listservs, were scanned for information on diabetes and oral health. Potentially competitive or duplicative programs were identified, and psycho-social and trend data were gathered. Specifically, the environmental scan identified findings about the oral complications of diabetes and about the comparative efficacy of various systems of care, with a particular focus on findings that targeted primary care providers and minority populations (such as African Americans and Hispanic/Latinos) at high risk of diabetes-related complications. The information obtained from the literature review and environmental scan will be used to construct a formative research plan. This plan will include educational messages and message concepts for printed materials and communication products. Next, dissemination channels will be identified and specific audiences targeted, also on the basis of findings from the literature review and environmental scan. We have found that oral health is one of the least-discussed topics in the literature of diabetes and its complications. Yet diabetes patients who develop severe periodontitis have greater difficulty maintaining proper glucose control. Because of tooth loss and oral pain or discomfort, a diabetes patient who has begun to experience oral complications may select foods that are softer and easier to chew; such foods are often higher in carbohydrate content, however, and they often exacerbate the difficulty of maintaining blood sugar levels and therefore do further damage to the patient's body. In summary, the environmental scan identifies elements in the larger environment that influence, for good or ill, the selected audience segments (Hispanic/Latino and African American populations and diabetes care professionals). The scan also suggests directions for future research on more effective means to communicate health information on the oral complications of diabetes to those audience segments.
	Details...
Agency:	Centers for Disease Control and Prevention
Date of Report:	4/15/2001

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