Living with Diabetes Program Evaluation Report

Prepared by Angela Hyejin Cho

Public Health Intern, Good Samaritan Hospital, Community Health Education

Master of Public Health Candidate, UCLA Fielding School of Public Health

Table of Contents

I. Introduction............................................................................................................................3

a. Problem Statement................................................................................................................3

b. Diabetes Education History..................................................................................................4

c. Living with Diabetes Program and Accreditation................................................................4

II. Target Population...............................................................................................................5

III. Analytical Methodology.....................................................................................................6

a. Data Collection.....................................................................................................................6

b. Data Input.............................................................................................................................7

c. Data Analysis........................................................................................................................7

d. Variables...............................................................................................................................7

IV. Results................................................................................................................................10

a. Fruit and vegetable (FV) intake..........................................................................................10

b. Nutrition knowledge...........................................................................................................10

c. Weight.................................................................................................................................11

d. Blood Pressure....................................................................................................................11

e. HgA1c.................................................................................................................................11

V. Discussion..........................................................................................................................12

References.....................................................................................................................................14

Appendix A. Logic Model...........................................................................................................16

Appendix B. Variables Defined..................................................................................................23

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I. Introduction

a. Problem Statement

The National Diabetes Statistics Report in 2017 by the Center for Disease Control (CDC)

estimated that 30.3 million or 9.4% people have diabetes in the United States.1 With its growing

incidence and prevalence rates, diabetes is a major public health concern in the U.S, especially in

Los Angeles (LA) County with rates of diabetes diagnosis being higher than the national average

(9.8% vs 9.3%).2

Diabetes mellitus is a disease where the body is unable to produce or respond to insulin,

causing impairment for the body’s ability to maintain optimal blood glucose levels and

metabolize carbohydrates.3 Diabetes is a life threatening condition that requires various strategies

for prevention, risk reduction, and management to minimize short and long-term complications.4

Major risk factors for diabetes include age (at or above 45 years), overweight or obese status,

family history of diabetes, and insufficient physical activity (less than 3 times per week).3 Over

90% of diabetes cases in the U.S are Type 2 diabetes which is developed over the life course due

to negative health behaviors and is not hereditary.1 Therefore, while its determinants are

multifaceted, dietary intake and lifestyle behaviors (i.e. physical activity) are modifiable risk

factors for diabetes.

Further, risk factors for diabetes development are beyond individual choices as there are

clear observable health disparities based on socioeconomic status as well as race and ethnicity. In

the LA County, low-income communities and ethnic minority groups experience higher rates of

negative health outcomes including diabetes. The prevalence of diabetes is significantly higher in

adults living below the federal poverty level (FPL) (14.0%) compared to those living at or above

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200% FPL (7.9%) and almost twice as high among Latinos (13.5%) and African Americans

(12.4%) compared to non-Hispanic Whites (6.7%).5

b. Diabetes Education History

Diabetes education for diagnosed patients was available since 1950s in the United States,

mostly on a one on one basis by health practitioners. With a significant influx of patients who

needed continuous and a more comprehensive diabetes education after dispatch for optimal

treatment and management, hospitals began to expand available resources and the number of

trained healthcare professionals.6 However, comprehensive diabetes education remains limited in

the U.S despite evidence that an interdisciplinary team approach in hospital educational

programs contribute to maintenance of a good system of care for diabetic patients.6 Further, there

is a need for diabetes interventions such as preventative and management services that are

culturally appropriate and more accessible to address issues of health disparities among

individuals of specific ethnic minority groups and low-income status.

There is a need for individualized care and an effective integrative system of care in

primary care settings for diabetes. A fundamental component of diabetes care is for patients to

have lifestyle management skills before and after diagnosis. Important skills related to nutrition

knowledge, dietary intake, and lifestyle behaviors could be taught through diabetes self-

management education (DSME) by certified health professionals. Community clinics and

hospitals providing DSME could obtain accreditation through the American Diabetes

Association (ADA) or American Association of Diabetes Educators (AADE).

c. Living with Diabetes Program and Accreditation

The Community Health Education Department at Good Samaritan Hospital offers a 4-

week DSME series, “Living with Diabetes” (LWD), available to outpatients or community

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members free of charge and is seeking program recognition and accreditation through the AADE

Diabetes Education Accreditation Program (DEAP) by December 2018. LWD incorporates an

interactive teaching style and focuses on empowering participants to take ownership of their own

health by providing knowledge for skills to prevent or manage diabetes with topics including

carbohydrate counting, reading food labels, managing healthy blood glucose levels, proper use of

medications, and preventing complications. The LWD curriculum for both English and Spanish

classes have been revised and implemented by trained health care professionals to align with

standards for the AADE DEAP since December 2017. The theoretical background and logic

model for LWD program planning can be found in Appendix A.

This evaluation report aims to discuss the 6-month analytical methods and impact

evaluation of LWD from January to June 2018. Both English and Spanish classes have been

offered once a week regularly during the span of the stated 6-month range. The LWD classes

were taught and managed by health educators Prisca Ho, RD, RN for the English sessions and

Diana Aguirre, MPH for the Spanish sessions. Angela Hyejin Cho is a graduate student Master

of Public Health candidate who was an intern for Good Samaritan Hospital, Community Health

Education Department and a primary contributor to the LWD program evaluation methods and

analysis.

II. Target Population

The Good Samaritan Hospital serves the service planning area (SPA) 4, Metro LA, and

its patients are primarily composed of Latino, African American, and Korean population.

In SPA 4, more than half the population identify as Latino, 24.3% have household

incomes less than 100% of the Federal Poverty Level (FPL), 32% of households with incomes

less than 300% FPL are food insecure, 22.1% are obese (BMI greater than or equal to 30), 34.4%

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are overweight (BMI greater than 25 and less than 30), and 11.6% of adults have been diagnosed

with diabetes.2 In addition, SPA 4 was among the top four rankings for having the highest

diabetes death rate (age-adjusted per 100,000 population) in all of SPAs at 23.5% as compared to

overall rates for LA County at 21.9% and national rates at 21.2%.2

III. Analytical Methodology

a. Data Collection

Data collection was carried out with administered intake and outtake questionnaires

through self-report or interview in the first and last class of the four part LWD class series.

Surveys were completed by paper-and-pen with the supervision of a qualified health educator

staff member who clarified survey questions or assisted with its completion. If a participant

missed a class, the health educator followed up through the phone and encouraged attendance for

future classes that covered specific topics for the missed class.

The English intake survey is a 26-item questionnaire and the outtake survey is a 20-item

questionnaire. The Spanish questionnaires were directly translated from the English version and

reviewed by Spanish speaking staff to ensure cultural appropriateness and accuracy. Both

questionnaires gather information about the participant’s contacts, demographics, diabetes

history, hospital encounters, diabetes management (DM), current health behaviors and risk

factors related to diabetes, current medications prescribed for DM, knowledge such as blood

sugar and HgA1c levels, fruit and vegetable intake, nutrition knowledge, activity, and self-

efficacy in DM.

The anthropometric measurements were taken before the first and last class sessions.

Participants were individually escorted into the next room for confidentiality and a trained staff

or intern assisted with obtaining their blood pressure and anthropometrics. Height was self-

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reported and the Omron body composition analyzer machine was used to obtain a participant’s

weight, body mass index (BMI), body fat percentage, skeletal muscle percentage, and visceral

fat. Measurements were recorded immediately on paper with one copy given to the participant

and results were briefly explained during the encounter.

b. Data Input

Raw data from both the English and Spanish LWD participant questionnaires from

January to June 2018 were inputted and organized by the graduate student intern using Microsoft

Excel.

c. Data Analysis

To analyze relevant variables, raw data was organized and inputted into a separate Excel

sheets for evaluation purposes. The AADE diabetes accreditation requires a report of one

behavioral and one clinical variable outcomes. To encompass a bigger picture of the data and to

help revise the LWD program as needed, multiple variables from both categories were analyzed

and evaluated. Only participants with full data, both intake and outtake data for specified

variables, were used for analysis.

d. Variables

The English and Spanish LWD data were recorded and evaluated both separately and

combined for all variables analyzed. Additional details on the definition and rationale for

variables used for data analysis could be found in Appendix B.

(1) Behavioral

Fruit and vegetable (FV) intake was measured through the survey question “How many

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servings of fruits and vegetables did you eat yesterday?” with answer choices of 5 or more, 4, 3,

2, 1, 0, or I don’t know. The participant’s response from the intake survey was subtracted from

the outtake to calculate the difference in FV servings.

Nutrition knowledge was measured through three survey questions:

(1) “What would you do if your blood glucose goes too low (less than 70 mg/dL)?” with

answer choices of I don’t know, candy bar, sandwich, 4 ounces juice, fruit, insulin, cheese, or

other (free answer). The correct answer is if the participant only checked “4 ounces juice”, and

all other combinations of answers were categorized as incorrect.

(2) “How would you treat your blood glucose if it goes too high? Check all that apply”

with answer choices I don’t know, drink 4 ounces juice, drink water, go walking or other

exercise, eat the right amount of carbs at the next meal, or other (free answer). The correct

answer is to check all three options of “drink water”, “go walking or other exercise”, and “eat the

right amount of carbs at the next meal” and all other combinations of answers were categorized

as incorrect.

(3) “Give an example of 2 snacks that you eat or drink” with a section for a free response.

Two snack items must be correctly identified, being an example of a food combination

incorporating a carbohydrate with a protein and/or fat (i.e. apple and nuts, whole wheat toast and

peanut butter). Insufficient or incorrect combination of snacks to eat or not specifying what fruits

or vegetables were categorized as incorrect.

Nutrition knowledge was evaluated by calculating the difference between the intake and

outtake survey answers to measure positive behavioral change. Spanish free response answers

were translated and evaluated through an online translator or a Spanish speaking staff member.

(2) Clinical

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Weight was measured on the first and last day of class for the LWD series, approximately

4 weeks in between, using the Omron body composition analyzer. Weight was recorded in

pounds (lbs) and converted to kilograms (kg) for analysis. Ideal body weight (IBW) and adjusted

body weight (ABW) were calculated to observe if a participants weight difference from before

and after the LWD series. A significant weight change was considered ½ to 2 lbs a week, or at

least a 2 lbs difference in 4 weeks, and this criteria was determined by referencing the Dietary

Guidelines for Americans.7 If the participant’s weight change was moving towards the IBW or

ABW, it was categorized as a healthy weight change. The formulas used are as follows:

Ideal Body Weight (IBW) =

Male: 50 kg (first 5 ft) + 2.3 kg (for each additional inch)

Female: 45.5 kg (first 5 ft) + 2.3 kg (for each additional inch)

Adjusted Body Weight (AdBW) = IBW + 0.4 * (Actual weight – IBW)

Blood pressure (mmHg) was measured on the first and last day of class for the LWD

series, approximately 4 weeks in between, using a blood pressure monitor machine. The systolic

and diastolic blood pressure levels were inputted separately to calculate the mean and the mean

difference between intake and outtake measurements. Data was evaluated in four different

categories, measuring the number of participants with blood pressure equal to or under (1)

140/90, (2) 130/80, and (3) 120/80 as well as (4) over 140/90. For evaluation purposes, both

systolic and diastolic levels had to meet the criteria to be counted for each category. The number

of people who met the criteria was compared from intake to outtake to observe a positive change

in blood pressure. Refer to references for research used to obtain evaluation measurement

parameters for blood pressure.8, 9

(3) Other

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Hemoglobin A1c (HgA1c) levels for participants were self-reported and confirmed

through paper copies of their most recent lab reports. While HgA1c levels were not evaluated for

improvement or changes due to lack of follow-up during this 6-month evaluation period (January

to June 2018), an increase in participant’s awareness of their HgA1c levels were evaluated. The

evaluation was separated into two categories, (1) the number of participants who did not know

their HgA1c levels before starting the LWD series and (2) those who did not initially know but

found out by the end of the series.

IV. Results

The total number of unique participants in the LWD series from January to June 2018 were

35 in the English classes, 41 in the Spanish classes, and 76 in total combined. Since only

participants with full data (both intake and outtake data) were analyzed for each variable

category, it can be assumed that those participants attended at least 50% or more of LWD series

(2 out of 4 classes). The interpretations of data stated as results below are based on combined

data analysis.

a. Fruit and vegetable (FV) intake

At least 46% (16/35) of LWD participants increased fruit and vegetable intake by one or

more servings a day.

b. Nutrition knowledge

At least 49% (18/37) of LWD participants increased in nutrition knowledge related to what

foods to eat if their blood sugar is too low (hypoglycemic). At least 35% (13/37) of LWD

participants increased in nutrition knowledge related to what foods to eat if their blood sugar is

too high (hyperglycemic). At least 61% (23/38) of LWD participants increased in nutrition

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knowledge related to what foods to as snacks to maintain their blood sugar levels.

c. Weight

The mean weight status for participants was 182.25 lbs on the intake and 181.16 lbs on the

outtake, with a mean difference of -1.09 lbs after participation in LWD. At least 37% (14/38) of

participants showed a healthy weight change of at least 2 lbs or more, moving towards the ideal

body weight (IBW) or adjusted body weight (AdBW).

d. Blood Pressure

The mean systolic blood pressure (mmHg) was 134.45 on the intake and 130.05 on the

outtake. The mean diastolic blood pressure was 78.50 on the intake and 77.88 on the outtake.

The mean difference from outtake to intake measures were -4.40 for systolic levels and -0.62 for

diastolic levels. Negative differences show a positive clinical change, or decrease and

improvement in blood pressure.

The number of participants with blood pressure under 140/90 were 21 on the intake and 24

on the outtake, with a difference of 3 people. The number of participants with blood pressure

equal to or under 130/80 were 13 on the intake and 17 on the outtake, with a difference of 4

people. The number of participants with blood pressure equal to or under 120/80 (normal range)

were 6 on the intake and 8 on the outtake, with a difference of 2 people. Positive differences

show a positive clinical change, or an increase in the number of people who improved their

blood pressure. The number of participants with blood pressure over 140/90 (Stage 2

Hypertension) were 16 on the intake and 13 on the outtake, signifying that 3 people lowered their

blood pressure and thus showed a positive change.

e. HgA1c

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About 16% (5/31) of participants did not know their HgA1c levels before attending LWD. About

6% (2/31) of total participants knew their HgA1c levels after the LWD series when they did not

know previous to participation.

V. Discussion

All of the analyzed behavioral and clinical variables showed a positive change that

indicated participants were moving towards a healthier goal. However, there are some limitations

in this set of data. First, almost half of the participants had missing or incomplete data in all

variable categories. New strategies for both recruitment and retention of participants should be

researched, discussed, and implemented for increased effectiveness and reach of LWD. Second,

due to the LWD series only lasting 4 weeks, the positive changes observed are not high or

statistically significant. To observe more significant differences in behavioral and clinical

changes, a follow-up plan should be created and implemented in the future (i.e. administer a

phone interview or posttest for 3-months, 6-months, 1 year). Third, many of the participants

were not attending over 50% of the time (2 or more classes out of 4 total offered per series).

While exposure to patient health education may be more favorable than no exposure, new

strategies to address factors influencing attendance for DSME classes or patient health education

programs should be researched and discussed for future implementation.

During the process of evaluation, there has been revisions in methodology. In taking

anthropometric body measurements during the last class of the LWD series, the staff or intern

will compare the data with the intake form to scan for any major discrepancies and retake

measurements as needed immediately. Additionally, if a blood pressure reading is over 140 in

the systolic levels, another reading will be taken for accuracy. The health educators will strongly

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encourage all participants to bring in their most recent HgA1c lab reports during phone

recruitment and follow-ups as most of this data was missing from participants.

There has been changes made to the intake and outtake forms. On the body measurement

forms, a section for IBW was added which will be calculated and recorded separately after

sessions by the health educator. Physical activity was not an evaluated variable for January to

June 2018 as the questions on the surveys had to be reworded to ensure proper evaluation in the

future. For the question “How many days a week do you exercise?” an option of “I do not

exercise” was added. The question asking about total minutes of physical activity each time was

changed to ask how many total minutes for each day because length of time may vary each time.

The word “specific” was added for the question asking participants to list 2 examples of snacks

that he or she eats or drinks, to prevent participants from writing a general answer (i.e. fruits and

vegetables) and encourage learning of specific food combinations. For the question “What would

you do if your blood glucose is too low?” the option stating “candy bar” has been changed to

“eat chocolate” and the option stating “eat cheese” has been discarded.

This is the first program evaluation and data analysis of the “Living with Diabetes”

program offered through the Community Health Education Department at Good Samaritan

Hospital. Despite limitations and flaws, this initial program evaluation gave great insight into

revisions and improvement in curriculum, teaching style, patient engagement, and data

collection. Additionally, LWD is a free and accessible DSME for community members in the

surrounding service area who are low-income, uninsured, and primarily Latino or African

American. Approved diabetes accreditation status for LWD will ensure long-term sustainability

and success of the program, being a proponent for closing health gaps for under privileged and

under resourced groups in the Metro Los Angeles region.

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References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017:

Estimates of Diabetes and Its Burden in the United States. Centers for Disease Control and

Prevention, U.S Dept of Health and Human Services; 2017.

2. Los Angeles County Department of Public Health. Key Indicators of Health. In: Office of

Health Assessment and Epidemiology, Ed2017.

3. Sherr D & Lipman RD. Diabetes Educators: Skilled Professionals for Improving

Prediabetes Outcomes. Am J Prev Med. 2013; 44(4): S390-S393. Doi:

10.1016/j.amepre.2012.12.013.

4. American Diabetes Association. Standards of Medical Care in Diabetes. The Journal of

Clinical and Applied Research and Education. 2017; 40(1).

https://professional.diabetes.org/sites/professional.diabetes.org/files/media/

dc_40_s1_final.pdf. Accessed August 30, 2018.

5. Los Angeles County Department of Public Health, Office of Health Assessment and

Epidemiology. Trends in Diabetes: Time for Action.

http://publichealth.lacounty.gov/wwwfiles/ph/hae/ha/Diabetes_2012_FinalS.pdf. Published

2012. Accessed August 30, 2018.

6. Nettles A. Patient Education in the Hospital. Diabetes Spectrum. 2005; 18(1): 44-48. Doi:

10.2337/diaspect.18.1.44

7. Aim for Fitness. Nutrition and Your Health: Dietary Guidelines for Americans.

https://health.gov/dietaryguidelines/dga2000/document/aim.htm. Published 2000. Accessed

August, 28, 2018.

8. ACCORD Study Group. Effects of Intensive Blood-Pressure control in Type 2 Diabetes

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Mellitus. N Eng J Med. 2010; 362:1575-1585. DOI: 10.1056/NEJMoa1001286.

9. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure. Arch Intern Med. 1997; 157(21):2413–2446.

doi:10.1001/archinte.1997.00440420033005

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Appendix A. Logic Model

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Appendix B. Variables Defined

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