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A correlation study to determine the effect of diabetes self management on diabetes outcomes - kurt naugles research project presentation


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Self-Management in this presentation refers to those activities people undertake in an effort to promote health, prevent disease, limit illness, and restore well being. Several investigators contend …

Self-Management in this presentation refers to those activities people undertake in an effort to promote health, prevent disease, limit illness, and restore well being. Several investigators contend that self-management be made a major component of many patient health-care strategy (Glasgow, et al., 2001; Wagner, et al., 2001). Currently, nearly 125 million Americans suffer from chronic debilitating illnesses (Anderson, 2000). These national figures clearly underscore the need to develop a multidimensional approach in regards to disease management. Accordingly, measures that incorporate the patient’s perspective in managing his or her health should be explored.
Diabetes mellitus is among those conditions suspected to be highly influenced by self-management activities (Sprangers, et. al., 2000). If benefits do indeed exist, they need to be fully evidenced. The investigation presented here sought to examine the role self management plays in the health outcomes of individuals living with diabetes.

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  • Patients who were 49 years of age or younger had HbA1C scores 1.13 % higher than those who were 50 years or older (beta= 1.13, SE=0.22, p= 0.026). Male patients presented HbA1C levels 0.94% higher than female patients (beta= 0.94, SE= 0.19, p= 0.041). Patients who indicated no diabetes complications possessed HbA1C scores 2.03% less than those who reported at least one DM complication (beta= -2.3, SE= 0.41, p= 0.037). Patients with a history of DM less than 10 years had HbA1C values 0.01% higher than those with a history greater than 10 years (beta= 0.01, SE= 0.25, P= 0.049). Patients on insulin therapy had HbA1C values 1.53% higher than those who were not (beta= 1.53, SE= 0.63, P= 0.0037). BMI proved to be statistically significant as well. Results demonstrated that with every point increase in BMI, HbA1C values increased by 2.06% (beta=2.06, SE= 0.37, p= 0.009). Table 6 summarizes the “Co-variables x HbA1C” correlation results of the study participants.
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    • 1. A CORRELATION STUDY TO DETERMINE THE EFFECT OF DIABETES SELFMANAGEMENT ON DIABETES OUTCOMES Kurt Naugles, M.D., M.P.H. Tennessee State University College of Health Sciences Department of Public Health
    • 2. Presentation Outline Part I – Diabetes Mellitus Overview 1. 2. 3. 4. What is Diabetes Mellitus Why is Diabetes Mellitus a Public Health Concern Public Health Medicine’s Response Diabetes Self-Management Education Part II – Capstone Internship 1. 2. Capstone Internship Site Capstone Internship Goals and Objectives Part III – Capstone Project 1. 2. 3. 4. Capstone Project Rationale Capstone Project Goals and Objectives Capstone Project Design, Methods, Analysis, and Results Discussion Part IV – Conclusion 1. 2. 3. 4. 5. Study Limitations Recommendations Lessons Learned Acknowledgements References
    • 3. Diabetes Mellitus Diabetes Mellitus (DM)  A collection of disease processes  All characterized by hyperglycemia (glucose >126 mg/dl)  Defects in insulin secretion and/or action  Symptoms: Polyuria, Polydipsia, Weight Loss  Two major types: Type-1 & Type-2
    • 4. Diabetes Type-1 Type-1  Juvenile Diabetes  5-10% of DM cases  Autoimmune disease of the pancreas  Progressive loss of insulin production  Complications -> Acute  Diabetic coma  Keto-acidosis  Treatment  Requires life-long insulin replacement
    • 5. Diabetes Type-2 Type-2  Adult Onset Diabetes  90-95% of DM cases  Insulin deficiency or resistance  Complications-> Chronic  Effects: Heart, Kidneys, Nerves, Eyes, & Blood Vessels  Treatment  Mild – Diet and Exercise  Moderate – Diet, Exercise, & Oral Drugs  Severe – Diet, Exercise, Drugs, & Insulin
    • 6. Public Health Concern? Epidemiology  Incidence and Prevalence  Morbidity and Mortality  Cost
    • 7. Diabetes Incidence & Prevalence Incidence & Prevalence (U.S.)  26 million Americans ( 8.3% )  3 million new cases (2009-11) – Epidemic?  79 million -> Pre-diabetic  Rise in teenage and adolescent cases  Increased association with Obesity  Disparity in Racial/Ethnic Incidence Rates  Native Americans->Blacks->Hispanics->Asians ->Whites
    • 8. Diabetes Prevalence in the U.S. Incidence & Prevalence (U.S.)  Higher Incidence rates reported in the Southern, South-Western, and MidWestern States  Tennessee ranks among the top 5 States with record high incidence rates
    • 9. Diabetes Morbidity & Mortality Morbidity & Mortality (U.S.)  7th leading cause of death  A leading cause of kidney disease, heart disease, & stroke  70% of diabetics suffer from neuropathy  60% of limb amputations due to diabetes
    • 10. Costs Associated with Diabetes Cost (U.S.)  Second biggest driver of Health-care cost  $174 billion in direct and indirect cost  Diabetics spend on average $6,000 annually to treat their condition
    • 11. Public Health Medicine’s Response to Diabetes Healthy People 2020 “Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM.”
    • 12. Public Health Medicine’s Response to Diabetes Diabetes Self-Management  Definition – those activities people undertake in an effort to promote health, prevent disease, limit illness, and restore well being  Rigorous medication compliance  Regular clinical visits  Routine HbA1C testing  Multi-daily blood-glucose self checks  Proper insulin administration  Improved dieting and exercise  Scrupulous foot care  Systematic disease monitoring  Requires  Hard work and Perseverance  Education and Training
    • 13. Diabetes Self-Management Education Diabetes Self-Management Education (DSME)
    • 14. Diabetes Self-Management Education  DSME was designed by a Diabetes Task Force to establish National Standards for DM self-care  Provides the knowledge and training to perform diabetes self- care tasks.  Primary Objective:  Manage “Glycemic Status”  Improve Diabetes Outcome  Recognized by the ADA as an essential part of diabetes care.
    • 15. Diabetes Self-Management Education Theoretically Framework  Health Belief Model ->Perceived susceptibility, severity, barriers, and benefits  Social Support Model ->Emotional, Instrumental, Informational, and Appraisal Support  Social Cognitive Theory - acquisition of knowledge through observation -> Self-Efficacy – the belief in one’s ability to execute a course of action
    • 16. Diabetes Self-Management Education There is no one “best” education program or approach; however, DSME programs are guided by a set of core principles.  Patient-Centered  Objective-Oriented  Age-Specific  Lifestyle and Behavior Based  Culturally-Sensitive  Group-Assisted
    • 17. Diabetes Self-Management Education Why is DSME a good strategy?  How can you effectively self-manage a complex disease without education and training?  Each $1 spent on outpatient diabetes education saves $2 to $3 dollars in hospitalization costs (APhA Foundation 2003 Statistics - JAPhA)  Patients who never received self-management education were 4 times more likely to develop a chronic complication (Nicolucci Study)
    • 18. Impact of Diabetes Education
    • 19. Diabetes Self-Management Question: “Will the relationship (correlation)between Diabetes Self-Management and Diabetes Outcomes seen in the literature be evidenced in other patient populations?”
    • 21. Watts Primary Care Internship Site Watts Primary Care (WPC)  Private Medical Practice  2001 Charlotte Ave.  Internal, Family, and Preventive Medicine  Physicians (2)   Dr. Eli Watts - Internal Medicine Certified; Endocrinology Specialist Dr. Kenneth Williams – Family Medicine Certified; Geriatric Specialist  Medical Receptionist (1)  Medical Clerk (1)  Medical Assistants (3)  Affiliations (3)  Baptist Hospital, Centennial Medical Center, and Skyline Medical Center
    • 22. Watts Primary Care WPC Mission Statement: “Our primary mission is to provide excellent health care to the residents of the Greater Nashville community. We believe health first begins by empowering patients with the knowledge, skills, and support needed to live healthy lifestyles. For this, we are committed to providing quality services for the timely assessment of both acute and chronic illnesses with the primary goal of early prevention and effective treatment. Above all, we take pride in considering the whole patient in determining health needs.”
    • 23. Watts Primary Care Internship Internship Goals  Gain the knowledge, skills and attitude necessary to assess any patient with a general medical illness;  Demonstrate the ability to develop a specific management plan;  Provide this information to the both the healthcare team and the patient.
    • 24. Capstone Project
    • 25. Capstone Project Rationale Why WPC for Capstone Project?  Primary Care Facility  Emphasis on Disease Prevention and Management  Specializes in Endocrinology and Geriatrics  Maintains Electronic Medical Records  Employs a Certified Diabetes Educator  Offers DSME Services  Great Supporting Staff  Wonderful Patients
    • 26. Project Goals & Objectives  Goal: To conduct a correlation study to determine the effect of diabetes self-management on clinical outcomes for diabetic patients served by Watts Primary Care.    The administration of DSMA Surveys with WPC patients. The administration of a Demographic & Physiologic Surveys with WPC patients. The assessment of diabetes clinical outcomes among WPC patients.  Study Questions:   Is there a significant correlation between diabetes self care (DSMA) and diabetes outcome (HbA1C levels) in an adult population group currently receiving medical care? Are any co-variables (demographic characteristics: age, race, gender, education, income; or physiologic characteristics: BMI, duration of diabetes, treatment-type, and diabetic complications) related to diabetes outcome?  Hypotheses:   There will be a statistically significant correlation between self-care and DM outcome. There will be a particular set of subject characteristics related to DM outcome.
    • 27. Diabetes Outcomes & Self-Management: Operational Definitions  Diabetes Outcome is defined as a clinical interpretation of one’s glycemic status, including one’s risk for diabetic complications (Goldstein et al., 2004).  Measured by the Hemoglobin A1C test (<6.5% is Ideal)  Diabetes Self-Management is defined as the performance of a variety of DM self-care activities and skill sets (Toobert & Glasgow, 2000).  Measured by the Diabetes Self-Management Activities (DSMA) survey
    • 28. Diabetes SelfManagement Activities (DSMA) Survey: The DSMA is a 12-item questionnaire frequently used to assess the degree of diabetes self-management in the seven days preceding the questionnaire. Five Sections: dietary habits, exercise routine, self-monitoring of blood glucose (SMBG), foot-care practice, and medication compliance. Combined Scores: 0 to 77 Glasgow reported internal consistency and reliability through inter-item reliability testing.
    • 29. Demographic Survey (DS): In-house questionnaire Demographic characteristics:  Gender, age, income, education, employment status, marital status, medical coverage, and past diabetes self management education. Physiologic characteristics:  BMI, patient and family DM history, treatment regimen, DM complications, and smoking habits.
    • 30. Capstone Project Study Design  Descriptive correlation (observational) study  Independent variables   DSMA: Self-Management Demographic and physiological characteristics  Dependent variable  HbA1C: DM Outcome
    • 31. Project Study Population & Inclusion Criteria  WPC adult patients (>18 years old)  Type 1 or Type 2 DM  Volunteers only: n=148  Preclusions   Pregnant women Patients with a mental illness, on steroid or chemo-therapy, diagnosed with alcoholism, or post-operative.
    • 32. Project Methods  Administration of a Research Packet  Consent Form and (2) Questionnaires  After obtaining written and verbal consent, subjects completed the two surveys.   DSMA DS  HbA1C values were recorded on DS
    • 33. Project Data Analysis Data Analysis: SPSS  Descriptive analysis ->statistical report  Demographic and physiological attributes  Nominal variables   Frequencies Percentages  Continuous variables    Minimum and maximum values Means Standard Deviations (SD)
    • 34. Project Data Analysis Data Analysis: SPSS Mixed-Effect Model  Correlation  Two methods  The unadjusted univariate method assessed the correlation between the independent variables (DSMA, demographic characteristics, and physiological characteristics) and the dependent variable (HbA1C) with random effect.  The adjusted univariate method assessed the correlation between the independent variable (DSMA) and the dependent variable (HbA1C) with covariates that turned statistically significant in the unadjusted univariate method with random effect.  Random effect was assigned to choice of primary care provider.
    • 35. Project Results: Demographic characteristics:  Gender, age, income, education, employment status, marital status, medical coverage, and past diabetes self management education.
    • 36. Project Results: Physiologic characteristics:  Patient and family DM history, treatment regimen, DM complications, and smoking habits.
    • 37. Project Results: Nominal Variables: BMI->Mean=32.42     Underweight <18.5 Normal 18.5–24.9 Overweight 25.0–29.9 Obesity >30.0 HbA1C->Mean=7.91    Normal 4% - 5.6% Risk: 5.7% - 6.4% Diabetes : >6.5% (National Institutes of Health)
    • 38. Project Results: Diabetes SelfManagement Activities (DSMA) Statistics: 1. Medication compliance – 6.81 2. General Dietary Habits – 4.88 3. Specific Diet Habits – 4.06 4. Foot Care – 3.86 5. Blood Sugar Testing – 3.12 6. Exercise Routine – 2.33
    • 39. Project Results: MEM Statistics: Question 1: “Is there a correlation between self care (DSMA) and DM control (HbA1C levels) in an adult population group currently receiving medical care?” Findings: There was no statistically significant correlation between any of the DSMA subscales and HbA1C (p<0.05).
    • 40. Project Results: MEM Statistics: Question 2: “Are any co-variables (demographic characteristics: age, gender, marital status, education, employment, income, and health coverage; or physiologic characteristics: DM history, DM family history, DM medication, DM therapy type, DM education, DM complications, smoking history, and BMI) related to DM control (HbA1C levels)?” Findings: Of the tested co-variables, age, gender, DM complications, DM history, DM therapy type, and BMI demonstrated a statistically significant relationship with HbA1C levels (p<0.05).
    • 41. Project Results  DSMA subscales did not demonstrate any statistically significant correlation with HbA1C scores.  Does not support the hypothesis that diabetic patients who practice DM self-care activities present with improved glycemic numbers compared to patients who do not practice such measures.  The co-variables, age, gender, DM therapy type, DM history, DM complications, and BMI did demonstrated a statistically significant relationship with HbA1C levels .  Supports the hypothesis that certain demographic/physiologic characteristics do indeed influence diabetes outcome.  Significance:  Reduction in HbA1C values by just 1% has proven to reduce diabetic complications by as much as 25% (UKPDS, 1998).
    • 42. Project Discussion  Although not evidenced here, diabetes self-care activities based on DSME standards still might play an important role in glycemic control and reducing DM complications.  One of the many diabetes-related aims of Healthy People 2020 (HP 2020) is to increase the proportion of individuals receiving formal diabetes health education (USDHHS, 2012).  The current national average is 56.8% of diabetic patients receive diabetes health education and the HP 2020 target is 62.5 % by the year 2020 (USDHHS, 2012).
    • 43. Project Limitations Limitations  Observational (versus Experimental Study)  Pros – Observational Studies seem to be less affected by Threats to Internal Validity        Maturation Repeated Testing Instrumentality Regression Towards Means Attrition Diffusion Cons     Not Randomized - Volunteers No Control Group No Baseline Self-Reported Surveys (Instrumentation)  Self-efficacy – not measured  Social Support – not measured
    • 44. Recommendations  Despite this study’s findings, providing patients access to DSME services at WPC has the real potential of improving health outcomes.  Similar clinical models that incorporate DSME could serve as a national model.  WPC should continue offering DSME as part of their current health care services.
    • 45. Lessons Learned  The impact of Social Determinants of Health can never be overlooked: In this study Economic, Social, Service, and Physical Environment could have played a major underlining role; factors such as Self-Efficacy, Life Course, and Food Deserts need to be considered.  To that point, although a movement towards a National Diabetes Education agenda seems promising, in order to reach HP2020 goals additional studies that investigate the role Social Determinants play in DSME and DM outcomes need to be pursued.
    • 46. Acknowledgements  Dr. Eli Watts  Dr. Kenneth Williams  Watts Primary Care Staff  TSU Department of Public Health  Dr. Elizabeth Williams  Dr. Mohamed Kanu
    • 47. Questions
    • 48. References 1.American Association of Diabetes Educators. (2000).The scope of practice for diabetes educators and the standards of practice for diabetes educators. Diabetes Education; 26:25-31. 2.American Diabetes Association. (2000). Type 2 diabetes in children and adolescents. Pediatrics; 105:671-680. 3.American Diabetes Association. (2007). Standards of Medical Care in Diabetes. Diabetes Care; 30(1): S1-S41. 4.American Diabetes Association. (2010). Diagnosis and Classification of Diabetes Mellitus. Diabetes Care; 33(1), S62-S69. 5.American Diabetes Association. (2011). Diabetes Statistics. Retrieved November 22, 2012 from 6.Anderson G. (2000). Partnership for solutions. Better lives for people with chronic conditions. Robert Wood Johnson Foundation and Johns Hopkins University. Retrieved November 22, 2012 from 7.Ary D, Jacobs L, & Razavieh A. (1985). Introduction to research in education (3rd edition). New York: Holt Rinehart and Winston. 8.Baaye R, Davidson D, Bates D. (2008). Mixed-effects modeling with crossed random effects for subjects and items. Journal of Memory and Language; 59:390-412. 9.Bandura A. (1977). Self-efficacy: toward a unifying theory of behavioral change. Psychological Review; 84(2):191-215. 10.Bandura A. (1986). Social foundations of thought and action. New Jersey: Prentice Hall. 11. Bandura, A. (1997). Self-efficacy: The exercise of control: New York: Freeman. 12.Baptist Hospital - About Us. (2012). Nashville, TN. Retrieved Oct 20, 2012, from 13.Beard C, Barnard R, & Robbins D. (1996). Effects of diet and exercise on qualitative and quantitative measures of LDL and its susceptibility to oxidation. Arteriosclerosis, Thrombosis, and Vascular Biology; 16(2):201-7. 14.Berg M, Honkasalo M. (2000). Pregnancy and diabetes - A hermeneutic phenomenological study of women's experiences. Journal of Psychosomatic Obstetrics & Gynaecology; 21:39-48. 15.Buell C, Kermah D, & Davidson M. (2007). Utility of A1C for diabetes screening in the 1999 2004 NHANES population. Diabetes Care; 30:2233-2235. 16.Carver C & Abrahamson M. (2009). Diabetes Mellitus Overview. In K. Weinger & C. Carver (Eds.), Educating Your Patient with Diabetes. Boston: Humana Press. 17.Centers for Disease Control and Prevention. (2007). National Diabetes Fact Sheet. Retrieved November 22, 2007 from 18.Centers for Disease Control and Prevention. (2011). CDC - Get the Facts on Diabetes. Retrieved November 22, 2012 from 19.Clanton T, Dixon G, Drake J, & Gadek J. (1987). Effects of swim training on lung volumes and inspiratory muscle conditioning. Journal of Applied Physiology. 62:39-46. 20.Clement S. (1995). Diabetes self-management education. Diabetes Care 18:1204-1214. 21.Cuijpers P, van Straten A, & Andersson G. (2008). Internet-administered cognitive behavior therapy for health problems: a systematic review. Journal of Behavioral Medicine; 31:169-177. Weerdt I, Visser A, Kok G, & van der Veen E. (1989). Randomized controlled evaluation of an education programme for insulin treated patients with diabetes: effects on psychosocial variables. Patient Education and Counseling; 14:191-215. 23.Diabetes Control and Complication Trial Research Group. (1993).The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The New England Journal of Medicine; 329(14): 977-986. 24.Fowler M. (2008). Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes; 26(2): 77-82. 25.Funnel M, Brown T, Childs B, Haas L, Hosey G, & Jensen B. (2009). National Standards for Diabetes Self-Management Education. Diabetes Care; 32: S87-S94. 26.Funnell M, Tang T, & Anderson R. (2007). From DSME to DSMS: Developing empowerment self-management support. Diabetes Spectrum; 20(4): 221-226. 27.Gephart R. (2004). Qualitative research and the academy of management journal. Academy of Management Journal; 47: 454-462. 28.Gibbons G. (1987). The diabetic foot: amputation and drainage of infection. Journal of Vascular Surgery; 5:791-793. 29.Gill G & Huddle K. (1989). Assessment of glycaemic control in the diabetic clinic. Diabetes Research and Clinical Practice; 6: 77-79. 30.Glanz K, Lewis F, & Rimer B. (1997) Health Behaviour and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass. 31.Glasgow R, Orleans C, & Wagner E. (2001). Does the chronic care model serve also as a template for improving prevention? Milbank Quarterly; 79:579-612. 32.Goldstein D, Little R, Lorenz R, Malone J, Nathan D, & Peterson C. (2004). Tests of Glycemia in Diabetes. Diabetes Care; 27(7): 1761-1773. 33.Guigoz Y, Vellas B, & Garry P. (1994). Mini nutritional assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts and Research in Gerontology; 4(2): 15 -59. 34.Hiatt W. (2001). Medical treatment of peripheral arterial disease and claudication. New England Journal of Medicine; 344:1608-1621.
    • 49. References 1.Health Information Privacy. (2012). Nashville, TN. Retrieved Oct 20, 2012, from 2.InnoLet - Product Information. (2012). Denmark, Europe. Retrieved Oct 20, 2012, from 3.Khaw K, Wareham N, Bingham S, Luben R, Welch A, & Day N. (2004). Association of hemoglobin HbA1C with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Annals of Internal Medicine; 141:413-420. 4.Klein R, Klein B, Moss S, & Cruickshanks K. (1994). The Wisconsin Epidemiologic Study of diabetic retinopathy, XIV: ten-year incidence and progression of diabetic retinopathy. Archives of Ophthalmology; 112:1217-1228. 5.Laing S, Swerdlow A, & Slater S. (2003). Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia;46:760-5. 6.Mariano C. (2000). Case study: the method. Chapter 10. In P. Munhall & C. Oiler Boyd, Eds. Nursing Research. A Qualitative Perspective. 2nd ed. 311-337. Sudbury: Jones and Bartlett Publishers. 7.McCance D, Hanson R, Pettitt D, Bennet, P, Hadden D, & Knowler W. (1997). Diagnosing diabetes mellitus: do we need new criteria? Diabetologia; 40:247-255. 8.Mid-Cumberland Human Resource Agency - MCHRA (2012). Nashville, TN. Retrieved Oct 20, 2012, from 9.Murray E, Burns J, See Tai S, Lai R, & Nazareth I. (2005). Interactive health communication applications for people with chronic disease. Cochrane Database of Systematic Reviews; 4:CD004274. 10.National Diabetes Data Group. (1979). Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Diabetes; 28: 1039-1057. 11. National Diabetes Data Group. (1995). Diabetes in America. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. 2nd ed. Bethesda: NIH. 12.National Heart Lung and Blood Institute. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The evidence report. Obesity Research; 6(2):51S-209S. 13.Orem D. (1995). Nursing: Concepts of Practice. 5th ed. St Louis: C.V. Mosby. 14.Patrick A, Gill G, MacFarlane I, Cullen A, Power E, & Wallymahmed M. (1994). Home glucose monitoring in type-2 diabetes: Is it a waste of time? Diabetic Medicine; 11: 62-65. 15.Pescatello L, Franklin B, Fagard R, Farqijar W, Kelley G, & Ray C. (2004). Exercise and hypertension: American College of Sports Medicine, Position Stand. Medicine and Science in Sports and Exercise; 36:533-552. 16.Peyrot M & Rubin R. (2008). Access to diabetes self-management education. Diabetes Education; 2008; 34(1):90-97. 17.Peyrot M, Piatt G, Zgibor J, Peeples M, Charron-Prochownik D, & Siminerio L. (2006). Using the AADE National Diabetes Education Outcomes System (NDEOS) to identify patient behavior change needs and diabetes educator responses. Diabetes; 55: A30-A30. 18.Philis-Tsimikas A & Walker C. (2001). Improved care for diabetes in underserved populations. The Journal of Ambulatory Care Management; 24(1):39-43. 19.Reichmuth K, Austin D, Skatrud J, & Young T. (2005). Association of sleep apnea and type II diabetes: a population-based study. American Journal of Respiratory and Critical Care Medicine; 172:1590-5. 20.Resnick H, Valsania P, Halter J, & Lin X. (2000). Relation of weight gain and weight loss on subsequent diabetes risk in overweight adults. Journal of Epidemiology & Community Health; 54:596-602. 21.Rosenn B & Miodovnik M. (2000). Glycemic control in the diabetic pregnancy: Is tighter always better? Journal of Maternal-Fetal Medicine; 9:29-34. 22.Satcher D. (2010). Include a Social Determinants of Health Approach to Reduce Health Inequities. Public Health Reports; 125(4): 6-7. 23.Siminerio L. (2009). Models for Diabetes Education. In K. Weinger & C. Carver (Eds.), Educating your Patient with Diabetes. Boston: Humana Press. 24.Singh N, Armstrong D, & Lipsky B. (2005). Preventing foot ulcers in patients with diabetes. Journal of the American Medical Association; 293:217-228. 25.Sprangers M, de Regt E, Andries F, van Agt H, Bijl R, de Boer J, Foets M, Hoeymans N, Jacobs A, Kempen G, Miedema H, Tijhuis M, & de Haes H. (2000). Which chronic conditions are associated with better or poorer quality of life? Journal of Clinical Epidemiology; 53:895-907. 26.Tang Y, Pang S, Chan M, Yeung G, & Yeung V. (2008). Health literacy, complication awareness, and diabetic control in patients with type 2 diabetes mellitus. Journal of Advanced Nursing; 62(1): 74-83. 27.Toobert D, Hampson S, & Glasgow & R. (2000). The summary of diabetes self-care activities measure - Results from 7 studies and a revised scale. Diabetes Care; 23(7): 943-950. 28.Tyni-Lenne R, Gordon A, & Europe E. (1998). Exercise-based rehabilitation improves skeletal muscle capacity, exercise tolerance, and quality of life in both women and men with chronic heart failure. Journal of Cardiac Failure; 4:9-17. 29.TriStar Centennial - TriStar Centennial (2012). Nashville, TN. Retrieved Oct 20, 2012, from 30.TriStar Skyline - Index (2012). Nashville, TN. Retrieved Oct 20, 2012, from 31.U.S. Department of Health and Human Services. (2012). Healthy People 2020: Summary of Objectives. Office of Disease Prevention and Health Promotion. Washington, DC. Retrieved Oct 20, 2012, from 32.UK Prospective Diabetes Study (UKPDS) Group. (1998). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type-2 diabetes. Lancet; 352:837-853. 33.van der Bijl J, van Poelgeest-Eeltink A, & Shortridge-Baggett L. (1999). The psychometric properties of the diabetes management self-efficacy scale for patients with type 2 diabetes mellitus. Journal of Advanced Nursing; 30(2): 352-359. 34.Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, & Bonomi A. (2001). Improving chronic illness care: translating evidence into action. Health Affairs; 20:64-78. 35.Welschen L, Bloemendal E, Nijpels G, Dekker J, Heine R, Stalman W, & Bouter L. (2005). Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. Diabetes Care; 28:1510-1517. 36.Wingard D & Barrett-Connor E. (1995). Heart disease and diabetes. In: National Diabetes Data Group. Diabetes in America. 2nd ed. 429-48. Washington, D.C.: Government Printing Office. 37.World Health Organization. (1985). Diabetes mellitus: Report of a WHO Study Group. World Health Organization Technical Report Series; 727: 1-113. 38.World Health Organization. (1998). Therapeutic Patient Education: Continuing Education Programmes for Healthcare Providers in the Field of Prevention of Chronic Diseases. Report of a WHO Working Group.