Diabetes Prevention and Control:
A Public Health Imperative

Basic Infrastructure for Diabetes Control

• Surveillance and Evaluation
  
  
• Strategic Plans
  
  
• Partnerships
  
  
• Policy
  
  
• Professional Development and Training

Several components are necessary to ensure a complete program in diabetes. The impact of programs is maximized when all of these components have been put into action.

Surveillance and Evaluation
A complete program must have information available to 1) define the nature and extent of the diabetes burden (surveillance), 2) focus intervention efforts, and 3) determine if interventions are having an impact (evaluation).

Surveillance
In June 2000, the Council for State and Territorial Epidemiologists published a list of indicators for diabetes surveillance (Table 1). These indicators cover a wide range of issues important for monitoring diabetes trends and for planning and evaluating diabetes program efforts. Other important indicators to follow include levels of physical activity and obesity, diabetes education, and self-monitoring of blood glucose. Programs should also monitor environmental changes that affect the course of diabetes, including state and federal health policy changes. In general, surveillance data are critical for monitoring state and national progress, including progress toward meeting Healthy People 2010 objectives.

Table 1. Diabetes Surveillance Indicators

The following are the best-developed and most widely used sources of diabetes-specific state surveillance data:

Behavioral Risk Factor Surveillance System (BRFSS), including the diabetes module. BRFSS is a state-based, random-digit-dialed telephone survey designed to yield representative population samples for each state. Each state should administer the BRFSS annually (including the special diabetes module) to monitor the extent of and trends in the diabetes burden, behavioral risk factors, and preventive care practices.

Hospital discharge data. These data are available in most states, sometimes for a fee, and are important for monitoring diabetes-related illness. However, hospital discharge data should be viewed as comple-mentary to BRFSS and other data rather than as a sole source of information.

State vital records data. Data from death certificates and birth certificates are used for monitoring diabetes-related death rates and pregnancy outcomes. However, only about 40% of people who die with diabetes have diabetes listed on their death certificate. As a result, death certificate data cannot be used to monitor death rates, causes of death, and relative risk for death among people with diabetes unless the death certificate has been modified to collect data on decedents’ diabetes status. The new standard birth certificate scheduled to be implemented in 2003 will collect data on whether the mother had either preexisting or gestational diabetes (diabetes diagnosed during pregnancy). This new information will help to determine the effects of diabetes on pregnancy and trends in diabetes-related birth defects.

Partnering health organizations such as provider groups, managed care organizations, and community health centers can be important sources of diabetes surveillance data. Programs are encouraged to supplement existing data with data from specialized surveillance efforts, such as special surveys of minority and other populations not adequately represented in available data sources.

Evaluation
Diabetes programs need to conduct evaluations to determine how effective their activities are in producing desired short-term and long-term effects. Logic modeling is a recommended tool for this purpose (Figure 1).¹⁸ Because diabetes and its complications can take many years to develop and diabetes mortality data tend to be inaccurate, programs need to use intermediate measures of success as part of their evaluations.¹⁹ Good process evaluation is also essential to understanding why a program is or is not achieving results and how to adjust the program accordingly.²⁰ Ultimately, however, the success of a program is determined by its long-term success in reducing diabetes incidence, illness, complications, and deaths. Evaluation of progress toward more intermediate objectives should always be conducted with those long-term objectives in mind.

Figure 1. Diabetes Prevention and Control Program

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Strategic Plans
The development of a strategic plan is critical to the success of diabetes programs. Stakeholders should be actively involved in developing, reviewing, and evaluating the plan. Once developed, plans should be reviewed and updated as progress is made or circumstances change. Ideally, the plan’s goals and objectives should be tailored to national, state, and local needs, and strategies for achieving these goals and objectives should be based on proven and evaluated experiences whenever possible.

The diabetes objectives in Healthy People 2010 (Chapter 5) ²¹ provide a template for national, state, and local efforts to prevent and control diabetes.

Plans should address the primary, secondary, and tertiary prevention of diabetes and should describe the roles and responsibilities of the various partners. At a minimum, these roles should be described as supportive or leadership. For diabetes programs, this distinction is especially useful in primary prevention activities, because leadership for some interventions to reduce obesity in the general population is more suitable for other public programs.

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Partnerships
State diabetes programs should collaborate with partners to facilitate and coordinate various efforts to prevent and control diabetes. Programs can bring together partners through special initiatives, topical meetings, and issue-specific planning. Partners can include professional organizations, voluntary diabetes organizations, community health centers, employers and other health care purchasers, community organizations, businesses, schools, and faith-based organizations.

If possible, diabetes programs should also establish an advisory board consisting of representatives of partnership groups and other key members of the diabetes community. The activities and membership of these boards should be strategically planned to strengthen and help guide program efforts. Population-level changes invariably require action by particular groups. Therefore, engaging these groups in strategy and planning is key to selecting appropriate and effective interventions and securing commitments of resources. In addition, advisory boards can help coordinate diabetes control efforts with similar efforts of other private- and public-sector partners across the state.

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Policy
Another important role of diabetes programs is to help private organizations and federal, state, and local agencies design policies that optimize the health of people with and at risk for diabetes. Most commonly, these programs provide guidance about a population’s need for diabetes care services and resources. They also should provide information, on request, to state legislators and governors as they develop regulations concerning insurance benefits for people with diabetes (e.g., for diabetes supplies and self-management education) or expanded coverage for people at risk for diabetes (e.g., for nutrition counseling for people with impaired glucose tolerance). By tracking changes in laws and regulations over the years, monitoring their health impact, and offering technical assistance to public- and private-sector policy makers, state diabetes programs can substantially influence the development of new policies. To be effective in this role, however, state programs must be able to provide accurate assessments of science and public health initiatives related to diabetes.

The role of diabetes programs in policy change efforts varies from case to case. When the policy in question relates exclusively to diabetes, diabetes programs should take the lead. However, when the policy in question involves broader public health concerns, including diabetes, it may be more appropriate for the program to play a supporting role in larger partnership efforts.

Examples of policy initiatives include those that

• Promote work environments conducive to healthy eating and exercise for people with or at risk for diabetes.

• Provide more support and flexibility for people with diabetes to administer insulin injections or monitor blood glucose levels at school or at work.

• Increase the accessibility of safe places to exercise (e.g., expanded availability of community and school resources for physical activity).

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Professional Development and Training
Professional development for staff involved in diabetes prevention and control is essential to program success. Because of the rapid pace of scientific change in the field of diabetes, state programs are encouraged to establish minimal requirements for staff training and development. Staff should receive ongoing training in the latest developments in health systems change strategies, community interventions, health communications, the pathophysiology of diabetes, team building, and diabetes surveillance and evaluation. The following is a list of just some of the organizations that offer multidisciplinary diabetes professional training:

The American Diabetes Association sponsors numerous courses for health professionals throughout the year.
Web site: www.diabetes.org

CDC’s Division of Diabetes Translation sponsors an annual conference and provides numerous professional development resources.
Web site: www.cdc.gov/diabetes

Wichita State University’s Division of Continuing Education, Wichita, KS, offers Diabetes Education Update, a didactic workshop addressing clinical, educational, and psychosocial issues.
Web site: webs.wichita.edu/continuinged/deu_form.htm for course curriculum and registration information

The International Diabetes Center, Minneapolis, MN, offers concise diabetes update courses for health professionals.
Web site: www.parknicollet.com/diabetes/professionals/index.html

The National Diabetes Education Program (NDEP) offers electronic professional educational materials through a portion of its Web site.
Web site: www.ndep.nih.gov

NIH’s National Institute of Diabetes, Digestive, and Kidney Diseases, offers professional education materials through the NIH Information Clearinghouse.
Web site: www.niddk.nih.gov

The American Association of Diabetes Educators offers certification for diabetes educators and sponsors courses for diabetes educators and health professionals.
Web site: www.aadenet.org/index2.html

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