DIABETES DETECTION AND PREVENTION, WA, PA (2010/2011)

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: OTHER GRANTS
• Reporting Frequency: Annual
• Accession No.: 0221674
• Grant No.: 2010-45043-20849
• Proposal No.: 2010-01520
• Project Start Date: Sep 1, 2010
• Project End Date: Aug 31, 2013
• Grant Year: 2010
• Program Code: [SK]- Diabetes Detection, Prevention, WA, PA

Recipient Organization
PENNSYLVANIA STATE UNIVERSITY
208 MUELLER LABORATORY
UNIVERSITY PARK,PA 16802

Performing Department
Extension

Non Technical Summary
An estimated 54 million U.S. adults aged 20 or older have pre-diabetes. Many people who have Type diabetes 2 do not know they have the disease until they experience complications. According to the Bureaua of Health Statistics in Pennsylvania, diabetes was the sixth leading cause of death in the state of Pennsylvania in 2005. It is estimated 1,120,345 Pennsylvanians have been told by a doctor they have diabetes and an additional 25% (almost 281,000) have diabetes but have not been diagnosed. In addition, The Burden of Diabetes in Pennsylvania report noted that diabetes accounted for $673,000,000 in hospital care costs for the year 2004. Although there has been a decrease in the incidence of Type I diabetes in Pennsylvania, Type 2 diabetes incidence is on the increase. Approximately 90% of people with diabetes have Type 2. According to data from the CDC, only 50 to 55 % of adults with diabetes in Pennsylvania have attended a diabetes self-management class. Dining with Diabetes is a program offered for adults with type 2 diabetes and their families by Penn State Cooperative Extension, in partnership with registered dietitians or certified diabetes educators. The program addresses the following objectives: 1. Increase knowledge of healthy food choices for people with diabetes. 2. Present healthy versions of familiar foods. 3. Demonstrate cooking techniques that use more healthful ingredients. 4.Promote behavior changes by offering demonstrations and tasting of healthy foods. 5.Increase knowledge of essential medical tests associated with diabetes management. 6.Promote physical activity as a component of diabetes control. 7. Encourage self-management and self-efficacy skills. 8.Provide opportunities for participants to share and learn from one another. Classes are offered weekly for four consecutive weeks, with a three-month follow-up class. Participants have the opportunity to have their A1C, lipids, blood pressure and waist circumference measured. Measurements are taken at the first and follow-up classes. Evaluation also includes a pre and post survey to measure knowledge, awareness, attitude and behavior. In addition to class handouts and test results, participants also receive the following resources: Exercise DVD, pedometer, resistance band for exercising,Joslin Diabetes Center educational materials, complete collection of Dining with Diabetes recipes, and Plate Method placemat. Expected impacts of the program are: enhancing knowledge to empower individuals to self-manage diabetes, improving behavior changes in food intake and physical activity to improve control of daily blood glucose, hemoglobin A1C (HgA1C), waist circumference, and lipoprotein profile (high density lipoprotein, low density lipoprotein, triglyceride, cholesterol), improving self-efficacy in diabetes self-management as a result of knowledge gained, reducing long-term complications of diabetes and enhancing quality of life by limiting diabetes complications.

Animal Health Component

100%

Research Effort Categories

Basic

(N/A)

Applied

100%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
701	5010	1010	10%
702	5010	1010	10%
703	5010	1010	40%
724	5010	1010	40%

Knowledge Area
703 - Nutrition Education and Behavior; 724 - Healthy Lifestyle; 702 - Requirements and Function of Nutrients and Other Food Components; 701 - Nutrient Composition of Food;

Subject Of Investigation
5010 - Food;

Field Of Science
1010 - Nutrition and metabolism;

Keywords

type 2 diabetes

hypertension

hyperlipidemia

physical activity

hemoglobin a1c

blood pressure

blood glucose

self-management

diabetes education

Goals / Objectives
The overall goal of this project is to increase awareness, identification and proper management of diabetes by providing screening and diabetes education to underserved areas of the population in Pennsylvania. Selection of priority counties is made using a metric involving various determinants related to diabetes. Objectives: 1. Increase awareness, identification and proper management of diabetes. 2. Facilitate the use of services for diabetes management. 3. Implement educational programs using the "Dining with Diabetes" curriculum which incorporates the Joslin developed "On the Road to Living Well with Diabetes" curriculum and Cooperative Extension developed instructional materials. 4. Evaluation educational programs to determine their impact in addressing project outcomes. 5. Monitor and track participant's follow-through with their self-management of diabetes through data analysis of evaluation forms. 6. Identify and build working relationships with community partners. 7. Provide screening opportunities for populations at risk. 8. Test new educational modules developed by Joslin for use in programming. Results expected: Based upon the results of the pilot, it is expected that nutrition and physical activity education classes will increase the self-efficacy of individuals to manage their diabetes and to understand what actions to take to reduce the risk of complications. Additionally, it is expected that knowledge of portion sizes and food composition will increase among participants. It is also expected that the participants will make healthier food choices, as well, as increase their use of food labels. Level of physical activity amongst participants is also expected to increase. Long term anticipated results will include improvements in care and diabetes self-management, reduction of risk of complications such as blindness, and increased productivity of people with diabetes. The program is expected to show increased utilization of available community resources, improved diabetes control, positive change in health care beliefs and better understanding of diabetes risk reduction. Additionally, it is expected that screening family members will lead to the discovery of pre-diabetes or diabetes amongst some who have not been previously diagnosed.

Project Methods
Through a partnership with the Joslin diabetes Center and Penn State Cooperative Extension, a Diabetes Awareness, Education and Screening Project has been established. By combining education, coaching and hands on experience, individuals with diabetes will participate in a program addressing healthy lifestyle choices focusing on nutrition education and physical activity that will help support their medical treatment regimes. Strong emphasis is placed on knowing important numbers related to diabetes management. To expand the project further, an increased emphasis on screening will be implemented in this next phase of programming to include family members who attend the Dining with Diabetes program. Many people who have pre-diabetes are unaware of their condition. Risk for pre-diabetes and diabetes is greater for family members of people with diabetes. Twenty-two county educators and their healthcare partners received training in the revised version of Dining with Diabetes in Pennsylvania. An additional 15-20 counties will be trained by the fall of 2010. Participants enjoy the social support of group classes, which are provided in settings that are conducive to relaxed learning at a slower pace. The participants will gain knowledge and skills to improve their food and activity choices to improve their diabetes management and control. Teaching methods will include lecture, demonstration and experiential learning. Sessions are not meant to replace individual diabetes counseling, but rather to augment it. The "Dining with Diabetes" curriculum which incorporates "On the Road to Living Well with Diabetes" includes lessons on meal planning and preparation and involves hands on learning by the participants. This curriculum was implemented by Penn State Cooperative Extension Educators in a pilot of the program during the spring of 2009. In the fall of 2009, an additional 22 counties were trained. Another 15-20 will receive training by the fall of 2010. Classes with approximately 15-20 participants will be conducted on a quarterly basis and will involve food preparation, menu analysis, food shopping and label reading, as well as general diabetes management. Participation at health fairs, industry health days, and senior citizen centers will serve as venues for recruiting class participants. Screening will be offered for family members who attend classes.

Progress 09/01/10 to 08/31/13

Outputs
Target Audience: Over the last year, 93 diabetes education programs were conducted covering 40 of 67 rural, suburban, and urban counties. Seventy-five percent of program participants were female, and the vast majority were Caucasian (88%). Focused within the urban corners of the state, 7% of participants were African-American, and 2% were Latino or Hispanic in ethnicity. Over two-thirds of participants (67%) self-reported that they had been diagnosed with diabetes, 8% of whom had baseline A1C readings greater than 9.0, and 9% of whom had blood pressure readings equal to or greater than 140/90. Ages of participants ranged from 19 to 100; the median age was 68 years old. Changes/Problems: Some educators tried different class scheduling options. Some decreased the number of meetings from four to three in hopes of improving attendance and engagement. Others chose to add an additional introductory meeting during which they introduced participants to the program and collected point-of-care information (A1C and blood pressure) as well as consent form signatures and baseline questionnaire data. Both options have their benefits; fewer meetings can be appealing to certain audiences, while the addition of the introductory session provides a laid-back environment during which baseline data is collected before the official start of the program. What opportunities for training and professional development has the project provided? Extension educators receive email updates regarding new research pertaining to diabetes. They have attended sessions during their professional association annual conferences, as well as, have attended webinars offered by various health organizations. How have the results been disseminated to communities of interest? County-level impact reports are compiled by a Penn State Extension data manager at the request of an educator and/or his/her partnering agency. Results have been shared with College and Extension Administration, as well as, with elected officials and advisory boardsin counties where the program has been held. Program participants received the state annual impact report which helps them see a summary of participant's involvement in the program. An article in the PA Office of Rural Health magazine featured the program. http://www.porh.psu.edu/publications/documents/PRH_Magazine_Spring_2013_200_Website.pdf What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? More than 1154 participants took part in Pennsylvania’s 93 Dining with Diabetes programs during the 2013 fiscal year, far exceeding the program’s annual goal of 800 participants. Based on the 1027 participants in the dataset, 18% of returning participants decreased their A1C readings from within a 5.7 to 6.4 window to less than 5.7, implying that they are at a lower risk for developing diabetes-related complications. Nearly half (48%) of the returning participants experienced a desired decline in their A1C measurement. In terms of blood pressure achievements, 58% of participants with baseline readings of >=140/90 managed to decrease their blood pressure to less than 140/90. Upon exiting, program participants exercised more frequently and ate a variety of fruits and vegetables more often when compared to baseline reports. More than four out of five participants (86%) were confident that they could explain their A1C result to someone else either “Somewhat Well” or “Very Well” compared to only 62% at baseline. Confidence and awareness levels also increased as 91% of returning participants with diabetes agreed that diabetes is a serious condition and 70% were confident that they could keep their diabetes under control. The Dining with Diabetes program waslisted by theArea Agency on Agingas an approved program which meant that the program could be offered to citizens who attend their agency program.

Publications

• Type: Websites Status: Other Year Published: 2013 Citation: http://extension.psu.edu/health/diabetes
• Type: Journal Articles Status: Published Year Published: 2011 Citation: Cooper, J. A., J. N. Cox, and M. A. Corbin. 2011. Social media in diabetes education: a viable option J. of Extension, Volume 50, Number 6, Article Number 6RIB3. http://www.joe.org/joe/2012december/rb3.php.

Progress 09/01/11 to 08/31/12

Outputs
OUTPUTS: Programming for Dining with Diabetes continued during the 2011/12 year at a reduced level due to decreased funding and personnel resources. A total of 17 programs were delivered in 14 counties by 8 educators and their healthcare partners or program assistants. An additional class was offered in Spanish in Chester County as a pilot, though not data was collected on this group since not all parts of the curriculum had be translated into Spanish. As a result of a partnership with Community Health Collaborative in Philadelphia, all materials have now been translated and efforts will be specifically focused on the Latino populations in key areas of the state. Even with the reduced funding, 216 participants completed the Dining with Diabetes program with an additional 15 more who completed the Spanish class. A one day workshop was offered in Lancaster County that yielded a good response, though very few of attendees were from the Latino community. New partnerships have been established within Philadelphia, Montgomery, Chester and Berks Counties that should assist in recruitment of this high risk population. Additionally, Penn State Extension continues to partner with Joslin Diabetes Center and submitted a grant application for the Healthcare Innovation Award in February 2012. Funding was awarded beginning July 2012 to specifically target the Medicare and Medicaid audiences in Pennsylvania. While 4% of current participants receive Medicaid, the expectation is that this will increase to 13% over the next 3 years. New connectionw have been made with Federally Qualified Health Centers, local food banks, EFNEP educators and other organizations that work with these specific populations. Connections with the PA Department of Health continue and they plan to assist in promoting the Spanish version of DWD with primary care providers and diabetes educators across the state. PARTICIPANTS: Jill Cox, MS, RD continues as PI/Program Manager. Marilyn Corbin, PhD is coPI. Julie Cooper continues as Data Manager and Suzanne Glenn for data entry. There are currently 15 educators and program assistants trained in the program. The CMS funding will allow for hiring of new staff to cover areas of the state where personnel resources have been reduced. New organizations for partnership include Providence Hospital Systems in Washington, DC which is part of the Joslin CMS funding. Other new partnerships include the YMCA of Centre County, FQHCs, Pottstown Area Health and Wellness Foundation and the Pennsylvania Medical Society. Other organizations who have been in communication include Health Partners and the Pennsylvania Academy of Primary Care Physicians. Educators participate in quarterly phone calls for program updates. A professional development opportunity was provided by Sharon McDonald, MS, RD who attended the West Virginia Diabetes Symposium and provided a webinar on the highlights of the symposium. TARGET AUDIENCES: Of the 216 participants who were enrolled in the Dining with Diabetes program this year, 93% were white and the remaining 7% were of mixed races. With the new CMS funding, the goal will be to significantly increase the number of participants who are from high risk racial backgrounds and to increase the percentage of racial diversity of attendees. Since the program has been translated now into Spanish, efforts to address the more urban and Latino populations in the state are underway. Seventy-one percent of participants had less than a four year college degree and 56% had a household income less than $50,000. Currently, 4% of participants have been Medicaid recipients and the expectation is that will increase to at least 13%. The average age of participant over the course of the project has been 65. This dropped slightly this past year to 63, which is good news since a goal of the program had been to increase recruitment of the 55-64 age range. PROJECT MODIFICATIONS: The most significant project modifications during this reporting period were the Wait-list Control Group project conducted under the direction of Joslin Diabetes Center and the translation of the program into Spanish. Ninety-one participants were recruited and randomly assigned to a spring or summer class for Dining with Diabetes. The spring group immediately began the program upon recruitment and the summer class waited for three months to begin. Pre/post measurements were completed for the Spring class. Pre measurements were completed for the summer group upon recruitment and then at the beginning of the class three months later. Post measurements were taken for the summer group three months following the first class. Analysis of these data sets are ongoing. Translation of the program has taken approximately 8 months to complete. Training for bi-lingual educators is scheduled to occur at the end of November 2012.

Impacts
According to Joslin Diabetes Center, the consistent improvements seen in A1C and blood pressure levels in addition to knowlege, behavior and attitude changes observed upon completion of the DWD program by participants is ultimately what made the program eligible for the funding from the Centers for Medicaid and Medicare Services. From the pilot phase in 2009 forward, participant have seen statistically significant improvements in A1C levels as well as blood pressure measurements. Participants also have shown a statistically significant improvement in waist circumference (a measure of fitness). Since family members have been encouraged to attend with participants who have prediabetes or diabetes, they have also benefited from the program. Analysis of their data over the 2011/12 year showed a slight increase in the percentage who are considered at high risk for diabetes (A1C > or = 6.0) at 32% as compared with 26% previously. As a result of screening of at risk family members, prediabetes or diabetes have been diagnosed leading to earlier intervention and prevention of complications from uncontrolled diabetes. For people previously diagnosed with diabetes, the most significant attitude changes were seen between baseline and follow-up in the acknolwedgement that diabetes is serious, self-efficacy in caring for their diabetes and the sense of feeling less down, depressed or hopeless. For all participants, significant behavior changes between baseline and follow-up were seen in taking medications as directed to lower blood sugar, eating a variety of fruits/vegetables and evercising for 20 minutes or more on several days of the week. Ninety five percent of participants reported and increase in knowledge regarding the five test that assit in controlling the risks of diabetes complications and the desiraable levels of these tests.. The majority (95% and 98% respectively) reported an increase in understanding of how carbohydrates affect your blood sugar and using heart healthy fats in food preparation.. Ninety-five percent also reported gaining new information regarding ways to reduce salt and sodium in cooking.

Publications

• Berger, M. and J. Cox. 2012. American Diabetes Association 72nd Scientific Session. The Effect of Blood Pressure Control. Poster Presentation. Philadelphia, PA. June 8, 2012. http://extension.psu.edu/healthy-lifestyles/diabetes/publications/cop y_of_diatebes-notes-volumn-2-issue-2-summer-2011/view and http://extension.psu.edu/healthy-lifestyles/diabetes/publications/dia betes-notes-issue-1-volume-3-spring-2012/view.

Progress 09/01/10 to 08/31/11

Outputs
OUTPUTS: Dining with Diabetes has been offered in 56 counties in Pennsylvania and a total of 178 classes to date have reached over 1700 adults with diabetes and their family members. A marketing video and additional marketing brochures have increased the recruitment of the target audience. Social media and search engine advertising have also significantly increased recruitment. Oral presentations were given regarding outcomes of the program at the Penn State Institute for Diabetes and Obesity Research Forum, Centers for Disease Control Diabetes Translation Conference, Pennsylvania Diabetes Action Plan meeting, and at the National Extension Association for Family and Consumer Scientists. Additionally poster presentations were given at the Penn State Diabetes and Obesity Research Summit, Pennsylvania Dietetics Association and the Pennsylvania State Extension Annual Conference. Adobe presenter recordings of classes and food demonstration videos have been archived for participants who miss a class or need review. A closed social networking site for past and current participants has been developed and is under university review for launch in the near future. The purpose of this site is to continue the social support for participants upon completion of the program. Spanish translation of the program is underway as is preparing supplemental pieces for the curriculum allowing it to achieve approval status from the American Association of Diabetes Educators for diabetes self-management education. PARTICIPANTS: Marilyn Corbin, PhD continues as PI and Jill Cox, MS, RD as co-PI and project manager. Julie Cooper manages the database for evaluation. Partnerships include Joslin Diabetes Center, West Virginia University Extension, and Temple University. Several partnerships exist at the local level through community grants, foundations and supporting organizations that provide in-kind support and are too numerous to list. New potential partnerships exist with Puentes De Salud, a clinic for hispanic populations in Philadelphia as well as Capital Blue Cross. Professional development for the project was provided by Mary Alice Gettings, CDE, RD during 2011 to update educators on recent information related to type 2 diabetes. TARGET AUDIENCES: The use of social media and search engine advertising allowed marketing efforts to be geared toward a more specific target audience of adults who are 18 years old and above who have type 2 diabetes and their family members. Increased efforts to reach certain ethnic populations who are considered at increased risk have been initiated such as areas of the state that have significant hispanic populations. Efforts have also been made to reach African American communities as well. PROJECT MODIFICATIONS: With the development of the Bayer A1C Now Self-check blood test kits, point of care testing is now available for participants in Pennsylvania. Due to decreased funding, participants pay an additional fee to have the A1C testing until new funding sources can be identified. Recent employee lay-offs have required educators to cover a wider geographical region for program delivery and use of more technology-based education methods is forseeable in the future.

Impacts
Marketing efforts through social media and search engine advertising resulted in a 200-400 percent increase in traffic to the Dining with Diabetes website. All registrations for the program are now conducted online using Cvent registration, which will allow for increased evaluation of marketing techniques. Over 1700 participants have benefited from the Dining with Diabetes program in Pennsylvania as evidenced by the statistically significant improvements in A1C, waist circumference and blood pressure measurements. Inclusion of at risk family members has resulted in identifying those who have pre-diabetes or diabetes (26 percent of family members attending). This subgroup has also shown statistically significant improvements in their bio-markers. All participants have shown statistically significant improvements in health-related behavior changes such as increased physical activity and healthier food choices, increased knowledge and improved attitudes related to diabetes care and prevention.

Publications

• Cox, J. N. and M. A. Corbin. 2011. Extension Educators partner for diabetes education in PA. J. American Association of Family and Consumer Sciences 103(1):19-21.
• Cooper, J. A., J. N. Cox, and M. A. Corbin. 2011. Social media in diabetes education: a viable option J. of Extension (In Review).