Leadership Perspective: Prediabetes Tsunami — We Can’t Just Wait For It to Hit

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Editor’s Note: This post is part of the “Leadership Perspectives” series on the Center for Total Health blog —  a collection of guest blog posts from Kaiser Permanente leaders all about why we need to take a Total Health approach.

Today’s guest author is Trina Histon, PhD, senior principal consultant with the Kaiser Permanente Care Management Institute, who shares her thoughts on prediabetes.


 

Few would deny the burden diabetes places on those who suffer from it and their loved ones who support them as they manage this disease. Estimates suggest that Americans with diabetes spend about $6,000 out of pocket per year managing their disease, monies that could be put to other use if we had more comprehensive ways implemented nationwide to prevent diabetes.

Trina Histon, PhD

Trina Histon, PhD

Many liken the next wave of diabetes as a tsunami that will hit the United States and its citizens, so let’s play that analogy through. Recent weather patterns have shown how devastating tsunamis are in the world, so much so, that efforts have been put in place to create sophisticated warning systems. So should another tsunami strike, countries will have advance warning so they are able to evacuate low-lying coastal areas and get people to safety.

In the U.S., the screening equivalent of that warning system for diabetes is an a1C test and the ADA has established a range of 5.7-6.4 as placing the individual in the “prediabetes” range. There are other tests, such as fasting blood sugar, but more and more health care is moving away from fasting blood work as it’s hard for people to fast for long periods of time. So this a1C range is our early warning system, and like most systems, it’s not perfect. In the literature this year, a few articles that discuss diabetes care and BMI have called into question the value of addressing prediabetes. These critiques are valid and perform an important function in both advancing the science and dialogue of where we want to spend our precious health care dollars.

Preparing for a Disaster We Know is on the Horizon

Kaiser Permanente today has 600,000 members with diabetes. We have also developed a cohort of just under one million members with lab values in the prediabetes range. Rather than wait for perfect science on exactly who needs an intervention, we feel ethically that if someone has a risk we should inform them and partner with them to address that risk, should they choose. One of the complexities of determining prediabetes risk is the prediabetes range has varying origins. For example, an a1C of 5.8 does not necessarily mean you will convert to diabetes, but you are at higher risk, and clearly are showing early signs of beta cell damage. What we do see is those with an a1C of 6.0 and higher and with BMIs in the obese range are most likely to convert. We are looking at our own data to see how we can further subtype the prediabetes risk spectrum and then subtype the interventions.

The Powerful Effect of Lifestyle Changes

The good news is lifestyle is the first line of treatment. The original diabetes prevention program (DPP) and subsequent translation trials show that those who lost 5 to 7 percent of their weight and increased their activity to 150 minutes/week prevented or delayed diabetes in 58 percent of participants over a three-year period – and 52 percent over 10 years. For most people, that translates to a 12- to 15-pound reduction, more attainable than the 30-40 percent of weight people might like to lose as reported on consumer surveys.
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Exercise is the New Vital Sign!

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Since the dawn of the doctor’s visit, taking vital signs has been a mainstay. Height, weight, temperature, heart rate, blood pressure. It’s a routine process that we participate in almost without thinking.

But at Kaiser Permanente, after the blood pressure cuff comes off, you’ll get questions that might surprise you: how many days a week do you exercise moderately or strenuously? How many minutes a day do you exercise at this level?

Come again? At first thought, asking about physical activity levels might seem unorthodox. Unlike other vital signs, it’s measuring a behavior, not a body part. But conventional thinking about health and health care has changed, and systems like Kaiser Permanente recognize that addressing personal behavior and lifestyle is just as important as addressing biology.

A new KP Policy Story from Benjamin Wheatley of the Kaiser Permanente Institute for Health Policy highlights our “Exercise as a Vital Sign” (EVS) initiative. Since 2009, Kaiser Permanente providers have asked patients about their exercise habits during routine office visits. Taking this “vital sign” encourages ongoing conversations between patients and providers about physical activity, and serves as a gateway for referring patients to activities such as yoga, Zumba classes or hiking clubs. Recent research shows positive results of the EVS initiative: in 2013, we found that asking about exercise habits is associated with modest weight loss in overweight patients and improved glucose control among diabetics.

You can read the story in its entirety at the Institute for Health Policy site.

The Best Community Spaces come from the Community

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Artistic rendering of 11th Street Bridge Park courtesy of Ed Estes, Washington, DC Office of Planning

Artistic rendering of 11th Street Bridge Park courtesy of Ed Estes, Washington, DC Office of Planning

Editor’s Note:  We have invited Scott Kratz, director of 11th Street Bridge Park to share with us some of his experiences as he takes this vision of a shared community space that supports health from concept to reality.  This is his second post with us. You can see his first post here.

Walking in a city park, have you ever experienced that frustrating moment? Maybe there’s no place to sit down. Or no shelter from the sun. Or there’s no family-friendly restroom in sight. The best civic spaces respond to the needs and desires of the community, but too often residents are left out of the design process. At the 11th Street Bridge Park, we’re working to change that with our new civic space in nation’s capital.

Together with the Washington, D.C. city government and a local non-profit organization “Building Bridges Across the River at THEARC” we’re transforming an aged-out freeway into a new park over the Anacostia River. After an extensive community outreach effort with more than 350 community meetings to date, we have created an amazing list of ideas for our park that were incorporated into a nation-wide design competition.

A primary goal of the 11th Street Bridge Park is to improve public health with this iconic new space. It will offer a safe place to play in a neighborhood that has the highest rates of obesity, and will incorporate healthy edible landscapes that can serve as a backdrop for farmers markets and planting/ harvest festivals for residents that have the lowest access to fresh fruits and vegetables in the region.

The design competition jury shortlisted four teams earlier this year, made up of the best landscape architects, architects and structural engineers in the country. After working all summer and meeting repeatedly with community stakeholders, the four teams submitted their renderings last week.

Now we want to hear from you. After reviewing the concepts here, tell us what you think! Take a short survey evaluating how each design meets our four key project goals. The results will be shared with our competition jury as it makes the final selection. We’ll announce the selected team on October 16. Stay tuned!

Reversing the Epidemic of Inactivity

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EVS Pic - Black Bold SmallerIn the final installment of her seven-part series on Exercise as a Vital Sign (EVS), Kaiser Permanente physician Latifat Apatira blogs about how far we have come and the long road ahead toward reversing what she describes as “the epidemic of inactivity.”

She writes that health care providers have a duty to evaluate each patient’s physical activity habits. And that Kaiser Permanente is moving in the right direction through efforts to work closer with community partners on a wide range of initiatives aimed at promoting exercise and healthy living.

“To combat inactivity, we need programs like EVS,” Dr. Apatira writes. “But we also need changes in our policies, built environments, and culture to reframe the role physical activity plays in our lives every day.”

Physical activity, she writes, needs to be something that people do not only because it’s the healthy choice, “but because it’s the easy choice, the comfortable choice, or the fun choice.”

Read the blog in its entirety:

How Innovation brought Exercise as a Vital Sign to Life

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Two years ago, a team from Kaiser Permanente’s Innovation Consultancy was given the task of transforming patient data on exercise into actionable information that health care providers could use to encourage healthy behaviors. They called this initiative Project Move.

In part five of her seven-part blog series on Exercise as a Vital Sign (EVS), Dr. Latifat Apatira describes how the Innovation team went about the work of better understanding patients’ barriers and motivations regarding exercise.

The Innovators traveled to several Kaiser Permanente regions to analyze interactions between health care providers and members. They learned that patients are less active because of busy lifestyles. As for health providers, it was determined that they did not have time nor established resources to address their inactivity.

The group came up with several ideas to make EVS more actionable that are outlined in detail in the EVS blog, including screening questions from medical assistants and licensed vocational nurses that get entered into the medical record and passed along to the next level of care. Depending on how members answer the first round of questions, follow-up questions can lead to exercise prompts or referrals to health and wellness coaches.

While the results of the work are still being analyzed, new innovations are underway, including a website that helps members find resources for physical activity.

The Thursday Dish: Healthy Stuffed Rainbow Peppers

By | Food, Healthy Living, Obesity Prevention & Treatment | No Comments

Stuffed-Rainbow-Peppers_593x473pxToday, it’s another tasty recipe from the Food for Health blog — but this one has a twist.

There’s a great story behind this recipe, one that features a 12-year-old being recognized for her culinary creativity with an invitation to dine with First Lady Michelle Obama at the White House.

According to our friends at Food for Health:

Grace Wetzler is a budding chef and healthy cooking advocate who took on the First Lady’s 2014 Healthy Lunchtime Challenge and decided to submit her recipe for healthy stuffed rainbow peppers into the contest.

“I was on spring vacation when I heard about the contest from my cousin. I thought about it and thought about it and tried to come up with some recipe ideas. And then the recipe just came to me on a whim. I put the ingredients together and it just worked! So I submitted my entry.”

Indeed, out of approximately 1,500 entries that were submitted, Grace’s delicious and nutritious stuffed rainbow peppers were among the 54 winners that made the cut. Grace was eventually notified that she was a winner and that she’d be headed to the White House to celebrate and enjoy a State Dinner with the First Lady and other dignitaries.

This colorful recipe is a great example of how Grace is already showing imagination in her cooking.  And it has the nutritional stats to back it up — 392 calories, 10 grams of fat, 40 grams of carbohydrates, and 27 grams of protein.

Check out the recipe here.

Helping patients ‘Find Their Thing’ is key to Exercise as a Vital Sign

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Latifat T. Apatira, MD, MPH, fourth-year internal medicine and preventive medicine resident, believes that in order for Exercise as a Vital Sign (EVS) to succeed, health care providers need to help connect patients with resources in the communities where they live – outside of the exam room.

Part four of her seven-part blog highlights the community-clinic component of EVS, in which health care providers point their patients to a wealth of diverse programs and initiatives for fitness – what Dr. Apatira calls “finding their thing.”

The blog features several examples of community-clinic integration that Kaiser Permanente is exploring, as well as Dr. Apatira’s ideas of how to link patients to community resources.

Resources include:

  • City/Community Listings – Most official city websites have listings for activities that support physical activity.
  •  Parks Prescription – A movement to strengthen connections between the health care system and United States public lands, Park Prescription works with providers to encourage patients to get physically active at their local public parks.

Read the full blog to see more of Dr. Apatira’s health and fitness tips, including apps that track exercise levels.

Making Healthy Food Available in Every Community

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For those of us who live within walking distance or a short drive from multiple grocery stores, the idea of not having access to fresh produce is almost impossible to imagine.

Yet there are people throughout the United States for whom the distance to fresh fruits and vegetables is prohibitive.  Without access in what are called ‘food deserts,’ they simply go without.  For more than 1 million California residents, access to fresh produce is more than a 20-minute drive from their homes.

Residents living in food deserts have higher rates of obesity, diabetes, heart disease, cancer, and many other chronic illnesses than those in neighborhoods where healthy food is easily accessible. Bringing permanent sources of fresh foods such as supermarkets into food desert communities can significantly improve healthy food access for residents for the long-term.  One innovative collaboration is looking at ways to make these improvements a reality.

The California FreshWorks Fund is a unique public-private partnership loan fund created in 2011 to bring greater access to healthy foods in underserved communities, spur economic development that supports healthy communities, and inspire innovation in healthy food retailing.

In just three years, they’ve made great strides.  Access to fresh produce — in some cases at farmers markets — has improved throughout the state, with neighborhoods that include Long Beach, Inglewood, Compton and West Oakland, among others.

Interested in hearing more about their projects and follow their progress?  Their website is a terrific resource on information around food access issues and grocery gaps.  You can learn more here.

Doc Talk: Finding the Right Way to Discuss Exercise as a Vital Sign

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Talking about the benefits of physical activity is a win-win-win proposition for doctors and patients. Members gain the benefits of physical activity first hand. Clinicians have a technique for incorporating exercise into every visit. And the system as a whole wins when quality improves.

This is the impetus behind Kaiser Permanente’s Exercise as a Vital Sign initiative, in which medical assistants or primary care providers ask patients how many minutes they exercise per day and per week.

But finding the right way to talk about exercise during an appointment – when members have lots of pressing things on their mind – can be a challenge, especially given the limited time available for this very important interaction.

Dr. Latifat Apatira’s latest blog, the third in a seven-part series, addresses clinicians’ concerns about how to bring up physical fitness during an appointment. She offers techniques for ways to get in a few sentences about exercise while examining other vital signs, and likens doctors and medical assistants encouraging physical activity to dieticians counseling members on nutrition.

During each visit, despite a variety of circumstances, Dr. Apatira makes an effort to incorporate Exercise as a Vital Sign, an important component of Kaiser Permanente’s Total Health vision that looks at an individual’s physical, mental, and social wellbeing.

Washington Post Takes on Public Health Benefits of Built Environments

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Wondering just how much where we live, work and play affects our health — and what cities and community organizations are doing to improve that environment?  The Washington Post recently wrote a great piece on that topic, and in it, they reference the 11th Street Bridge Park project — highlighted on this very blog back in March in a post authored by the organization’s director, Scott Kratz, called, “Connecting Health with Place.

Kratz has promised us another update on the project in September, when the finalists will submit their final drawings for the competition.  Stay tuned.