Julie C. Will

Provider Counseling, Health Education, and Community Health Workers: The Arizona WISEWOMAN Project

BACKGROUND The Arizona Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) project used provider counseling, health education, and community health workers (CHWs) to target chronic disease risk factors in uninsured, primarily Hispanic women over age 50. METHODS Participants were recruited from two Tucson clinics participating in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Women were randomly assigned into one of three intervention groups: (1) provider counseling, (2) provider counseling and health education, or (3) provider counseling, health education, and CHW support. At baseline and 12 months (1998-2000), participants were measured for height, weight, waist and hip circumference, and blood pressure. Blood tests were conducted to check blood glucose, cholesterol, and triglyceride levels. At each time point, participants also completed 24-hour dietary recalls and questionnaires focusing on their physical activity levels. RESULTS A total of 217 women participated in baseline and 12-month follow-up. Three fourths were Hispanic. All three intervention groups showed an increase in self-reported weekly minutes of moderate-to-vigorous physical activity, with no significant differences between the groups. Significantly more women who received the comprehensive intervention of provider counseling, health education, and CHW support progressed to eating five fruits and vegetables per day, compared with participants who received only provider counseling or provider counseling plus health education. CONCLUSIONS All three interventions increased moderate-to-vigorous physical activity but not fruit and vegetable consumption. The intervention group with provider counseling, health education, and CHW support significantly increased the number of women meeting national recommendations for fruit and vegetable consumption.

Trends in Diabetes and Diabetic Complications, 1980–1987

OBJECTIVE Although diabetes is a major source of morbidity and mortality in the United States, only recently has a unified national surveillance system begun to monitor trends in diabetes and diabetic complications. RESEARCH DESIGN AND METHODS We established a diabetes surveillance system using data for 1980–1987 from vital records, the National Health Interview Survey, the National Hospital Discharge Survey, and the Health Care Financing Administrations records to examine trends in the prevalence and incidence of diabetes, diabetes mortality, hospitalizations, and diabetic complications. RESULTS From 1980 through 1987, the number of individuals known to have diabetes increased by 1 million—to 6.82 million. Age-standardized prevalence for diabetes increased 9% during this period, from 25.4 to 27.6/1000 U.S. residents (P = 0.03). The incidence of diabetes increased among women (P = 0.003), particularly among those > 65 yr old (P = 0.02). Age-standardized mortality rates (for diabetes as either an underlying or contributing cause) per 100,000 individuals with diabetes declined 12%, from 2350 to 2066. Annual mortality rates from stroke (as an underlying cause and diabetes as a contributing cause) and diabetic ketoacidosis declined 29% (P = 0.003) and 22% (P < 0.001), respectively. During these 8 yr, hospitalization rates for major CVD and stroke (as the primary diagnoses and diabetes as a secondary diagnosis) increased 34% (P = 0.006) and 38% (P = 0.01), respectively. Also during this period, hospitalization rates increased 21% for diabetic ketoacidosis (P = 0.01) and 29% for lower-extremity amputations (P = 0.06). From 1982 through 1986, treatment for end-stage renal disease related to diabetes increased > 10% each year (P < 0.001). The prevalence of diagnosed diabetes was nearly twice as high in blacks as in whites (P = 0.04). Blacks also had increased rates of lower-extremity amputation (P = 0.02), diabetic ketoacidosis (P < 0.001), and end-stage renal disease (P = 0.01). CONCLUSIONS Diabetes surveillance data will be useful in planning, targeting, and evaluating public health efforts designed to prevent and control diabetes and its complications.

Is diabetes mellitus associated with prostate cancer incidence and survival

Results of two recent prospective incidence studies have suggested that certain subgroups of men with diabetes mellitus may be protected from developing prostate cancer. Two earlier studies, however, concluded that diabetes increased the risk of mortality from prostate cancer. With hundreds of thousands of male respondents, the 1959-1972 Cancer Prevention Study provided a unique opportunity to explore whether men with diabetes were more likely to develop prostate cancer during a 13-year follow-up period than were men without diabetes. After adjusting for factors associated with prostate cancer in previous studies, we found little association between diabetes at baseline and prostate cancer incidence [incidence density ratio (IDR) = 1.05; 95% confidence interval (CI) = 0.81-1.36]. Men who had diabetes mellitus for 5 or more years, however, had a higher incidence of prostate cancer than did men without diabetes (IDR = 1.56; 95% CI = 1.02-2.38). Among all study participants who were diagnosed with prostate cancer, men with diabetes were only slightly more likely to die from prostate cancer than were men without diabetes (IDR = 1.11; 95% CI = 0.76-1.62).

Health promotion interventions for disadvantaged women: overview of the WISEWOMAN projects.

BACKGROUND The Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program aims to remove racial and ethnic disparities in health by addressing the screening and intervention needs of midlife uninsured women. This paper describes the WISEWOMAN program requirements, the design of the 12 projects funded in 2002, the use of a standardized data reporting and analysis system, risk factors among participants, effective behavioral strategies, and plans for the future. METHODS The WISEWOMAN demonstration projects are examining the feasibility and effectiveness of adding a cardiovascular disease (CVD) prevention component to the early detection of breast and cervical cancer. Women aged 40-64 are eligible if they are enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in selected U. S. states and are financially disadvantaged and lack health insurance. The primary outcome measures are blood pressure, lipid levels, and tobacco use. Intermediate measures include self-reported diet and physical activity, measures of readiness for change, and barriers to behavior change. RESULTS During 2002, the 10 projects that were fully operational screened 8164 financially disadvantaged women and developed culturally and regionally appropriate nutrition and physical activity interventions for a variety of racial and ethnic backgrounds. Twenty-three percent of the women screened had high total cholesterol, with 48% of these being newly diagnosed. Thirty-eight percent of the women had high blood pressure, with 24% being newly diagnosed. Approximately, 75% of participants were either overweight or obese, and in some sites up to 42% were smokers. CONCLUSIONS The WISEWOMAN demonstration projects have been successful at reaching financially disadvantaged and minority women who are at high risk for chronic diseases. These projects face challenges because they are generally implemented by safety net providers who have limited resources and staff to conduct research and evaluation. On the other hand, the findings from these projects will be especially informative in reducing health disparities because they are conducted in those settings where the most socially and medically vulnerable women receive care.

Racial/Ethnic Disparities in Coronary Heart Disease Risk Factors among WISEWOMAN Enrollees

BACKGROUND We used the baseline data collected for the Well-integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) participants to provide a snapshot of cardiovascular disease (CVD) risk on enrollment and to address racial/ethnic disparities in the following CVD risk factors: body mass index (BMI), systolic and diastolic blood pressure, high-density lipoprotein (HDL) and total cholesterol, diabetes and smoking prevalence, 10-year coronary heart disease (CHD) risk, and treatment and awareness of high cholesterol, hypertension, and diabetes. METHODS We used linear regression analysis to (1) assess the presence of racial/ethnic disparities and test whether existing disparities can be explained by (2) differences in individual characteristics or by (3) differences in individual and community characteristics. RESULTS Our results reveal a high degree of CVD risk among the WISEWOMAN participants and statistically significant racial/ethnic disparities in risk factors. Black participants were at the greatest risk of CVD, and Hispanic and Alaska Native participants were healthier in terms of CVD risk than white participants. Some racial/ethnic disparities were explained by differences in individual and community characteristics, but other disparities persisted even after controlling for these factors. CONCLUSIONS Because differences in community characteristics explain many of the racial/ethnic disparities in CVD risk factors, eliminating disparities may require community-wide interventions. Successful WISEWOMAN projects are likely to not only reduce CVD risk factors overall but also to lessen racial/ethnic disparities in these risk factors.

Cardiovascular disease risk reduction: the Massachusetts WISEWOMAN project.

BACKGROUND This report presents the effectiveness of the Massachusetts Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) Project (MWWP) in reducing the cardiovascular disease (CVD) risk of uninsured and underinsured women aged > or =50. METHODS Healthcare sites were randomly assigned to an enhanced intervention (EI) or minimum intervention (MI). Women enrolled at all sites received CVD risk factor screening, onsite counseling, education, referral, and follow-up as needed. Women enrolled at EI sites received additional services and specially designed interventions, including one-on-one nutritional and physical activity counseling and group activities, such as walking groups, nutrition classes, and cultural festivals. We report results for 1443 women who attended the initial screening in 10 study sites. Blood pressure, total cholesterol, number of servings of fruits and vegetables, and level of moderate or vigorous physical activity were assessed at baseline and 12-month follow-up screenings. Baseline data were collected between March and June 1996; follow-up data were collected 12 months later. RESULTS The comprehensive screenings significantly lowered the overall prevalence of hypertension, resulting in a 7% reduction in high blood pressure among women at the EI sites (p = 0.02) and a 9% reduction at MI sites (p = 0.009). A significantly greater percentage of women became physically active at the EI sites (18%) than at the MI sites (6%) (p = 0.04). CONCLUSIONS MWWP is a promising model for providing comprehensive preventive healthcare to uninsured and underinsured women.

Effects of a Tailored Follow-Up Intervention on Health Behaviors, Beliefs, and Attitudes.

BACKGROUND The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns. Computer-tailored health messages that are mailed to participants or given in brief telephone calls offer an innovative and time-efficient alternative to ongoing face-to-face contact with healthcare providers. METHODS Following a 1-year behavior change program, 22 North Carolina health departments were randomly assigned to a follow-up intervention or control condition. Data were collected from 1999 to 2001 by telephone-administered surveys at preintervention and postintervention for 511 low-income, midlife adult women enrolled in the Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program at local North Carolina health departments. During the year after the behavior change program, intervention participants were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Main outcomes of dietary and physical activity behaviors, beliefs, and attitudes were measured. RESULTS Intervention participants were more likely to move forward into more advanced stages of physical activity change (p = 0.02); control participants were more likely to increase their level of dietary social support at follow-up (p = 0.05). Both groups maintained low levels of reported saturated fat and cholesterol intake at follow-up. No changes were seen in physical activity in either group. CONCLUSIONS Mailed computer-tailored health messages and telephone counseling calls favorably modified forward physical activity stage movement but did not appreciably affect any other psychosocial or behavioral outcomes.

Diabetes Mellitus among Navajo Indians: Findings from the Navajo Health and Nutrition Survey

Noninsulin-dependent diabetes mellitus is a major health problem among most American Indian tribes. This is the first population-based reservation-wide study of the Navajo that has used oral glucose tolerance testing to determine diabetes status. Employing WHO criteria, we found an age-standardized prevalence of diabetes mellitus (DM) of 22.9% among persons aged 20 y and older. This prevalence is 40% higher than any previous age-standardized estimate for the Navajo and four times higher than the age-standardized U.S. estimate. More than 40% of Navajo aged 45 y and older had DM. About one third of those with DM were unaware of it, with men more likely to be unaware than women. Among persons with a medical history of DM, almost 40% had fasting plasma glucose values > or = 200 mg/dL. Persons with DM were heavier, more sedentary and more likely to have a family history of DM than were persons without DM. Persons with DM had more hypertension, lower HDL levels and higher triglyceride levels than their counterparts without DM. Insulin usage was infrequent among persons with a history of DM, and about one third of women with such a history used no medical therapy to control their diabetes. Although important measures to combat diabetes have already been undertaken by the Navajo, additional efforts are required to slow the progression of this disease and prevent its sequelae.

Intentional Weight Loss and 13-Year Diabetes Incidence in Overweight Adults

Observational studies have established that obesity is associated with a substantially increased risk of developing type 2 diabetes.1 Whether intentional weight loss reduces the risk of obese persons’ developing diabetes remains unclear, however. Two randomized controlled trials for the primary prevention of type 2 diabetes in adults have included lifestyle intervention arms emphasizing modest weight loss.2,3 Relatively few observational studies have examined the association of weight loss with diabetes risk,4 and no published observational study has differentiated the effects of intentional weight loss from those of unintentional weight loss. This is important because unintentional weight loss may be associated with the clinical onset of diabetes.5 This is the first observational study to use data on weight-loss intention in examining the prospective relationship between weight change and the incidence of diabetes in overweight adults.

Recording of diabetes on death certificates: Has it improved?

OBJECTIVE To determine whether the recording of diabetes on death certificates improved from 1986 to 1993. METHOD Comparison of two National Mortality Follow-back Surveys that selected independent samples of death certificates with the purpose of obtaining information from informants about the decedents. RESULTS The recording of diabetes on death certificates did not improve from 1986 to 1993. CONCLUSION Periodic monitoring of the accuracy of death certificates is essential for proper interpretation of mortality statistics which are routinely used to describe the burden of diabetes in our society.