Implementation of Healthy Lifestyles a Pilot Program as part of a Diabetes Prevention Effort

Transcription

1 Memorial Medical Center, Conemaugh Health System Implementation of Healthy Lifestyles a Pilot Program as part of a Diabetes Prevention Effort Prepared by: Lori Sutton, MA, CHES Jan Albert, RN, CDE Marlene Singer, RN Reviewed by: Matthew Masiello, MD, MPH Jeanne Spencer, MD, FAAFP

2 Background: Memorial Medical Center (MMC), one of the hospitals of the Conemaugh Health System, is located in a primarily rural area in southwestern Pennsylvania and employs over 4, individuals. The Family Medical Center (FMC) is a modern medical suite, which serves as the primary training site for physicians enrolled in Conemaugh s Memorial Medical Center Family Medicine Residency. The Office of Community Health (OCH) is a public health initiative of the Conemaugh Health System. Its mission is to work collaboratively with local and state health care providers and agencies to evaluate the health care needs of the community, develop programs based on these needs, and critically evaluate the outcomes of these collaborative initiatives. The OCH was asked by the FMC to oversee the monitoring and evaluation of the MMC designed Healthy Lifestyles pilot program. Purpose: To decrease the occurrence of diabetes in Cambria County and to optimize the management of those with diabetes through a FMC designed Healthy Lifestyles pilot program geared towards teens and adults and designed to reach the disparate population. Description of Participants and Setting: The Healthy Lifestyles Program was developed by the Family Medical Center, modeled after the Diabetes Prevention Program. The program was offered to economically depressed community members, employees in the MMC system as well as the adolescent population. Over the past year, the 8-week program has been provided to four cohorts: Cohort 1: referred patients from MMC practice and community members Cohort 2: local senior center members Cohort 3: employees from Memorial Medical Center (MMC) Cohort 4: a selected group of adolescents from a local public school Literature Review: Type 2 diabetes is becoming increasingly common primarily because of increases in sedentary lifestyle and obesity. Only 15% of adults perform the amount of physical activity recommended by the American College of Sports Medicine. More than half of adults in the United States are estimated to be overweight or obese. 1 Consequently, the number of people with diabetes in the United States has doubled in the past decade to 17 million. 1 The prevalence of pre-diabetes among adults 4-74 years of age is approximately 15.8% with the highest rates in people between 6-74 years. Approximately 22% of adults in this country have metabolic syndrome. 2 In Pennsylvania, we are seeing alarming increases in diabetes related hospitalizations with an increase of 16.8% from Cambria Counties rate for diabetes related hospitalizations surpasses the statewide average by 17.7%. 3 In addition, PA is one of the top 1 states with the highest percentage of people with type 2 diabetes above A1C goal of 6.5% or less. 4 Healthy Lifestyles Evaluation Report 2

3 Type 2 diabetes is becoming increasingly prevalent in adolescents and young adults. Since the complications of diabetes occur after prolonged time with the disease, these young people are at extremely high risk of developing complications over their lifetimes. Healthy behaviors including diet and exercise become increasingly difficult to change as a person ages. Improvements in the health of Cambria County s adolescents can have lasting results for the community. 5 One in three children born in the year 2 will develop type 2 diabetes if current obesity trends continue. Obesity rates have doubled in children and tripled in adolescents over the past 2 years with fifteen percent of children and adolescents currently being overweight. 6 An unpublished survey completed by school nurses for the Cambria County Health and Wellness Council found that 28.3% of Northern Cambria County high school students qualified as either overweight or obese. The survey also revealed that 6.18% of elementary students fell into the 97 th percentile or greater for their age group. Studies have shown that lifestyle modification programs can have an impact on preventing or delaying the onset of type 2 diabetes. The Diabetes Prevention Program, a multicenter, randomized trial that was sponsored by the National Institutes of Health (NIH), conducted a study of 3,234 participants who were known to be at risk for type 2 diabetes. The study group reduced the incidence of diabetes by 58%. 7 Smaller studies in China and Finland have also shown a delay in type 2 diabetes for individuals at risk by using diet and exercise. 8 The Diabetes Prevention Program is the first major study that shows that diet and exercise can effectively delay diabetes in a diverse population of overweight individuals with impaired glucose tolerance. 8 Methodology: Identification of high-risk individuals (adults and teens). High risk individuals include: o Individuals with a body mass index greater than twenty-four. o First-degree relatives with diabetes. o Fasting blood sugar mg/dL. o History of hypertension or dyslipidemia Administration of a readiness to change assessment using the Prochaska Transtheoretical Model. Those who are ready to change enrolled in Healthy Lifestyles Program. Program Staff The multidisciplinary team was comprised of a certified diabetes educator, a dietician/exercise specialist, physician, psychologist, Pharm.D, registered nurse and a public health analyst. Program Components The Healthy Lifestyles Program included eight sessions held weekly, for approximately two hours. The program included the following components: Educational Component: Curriculum focuses on diet, exercise, self-esteem, goal setting, food choices, portion control, barriers to exercise/nutrition and behavior modification modeled closely on that used by the Diabetes Prevention Program Research Group. A shopping tour at a local store and cooking class were offered as well. The purpose of the program is to help patients make lasting lifestyle changes. Healthy Lifestyles Evaluation Report 3

4 Exercise: Pedometers were given to each participant and they were required to complete weekly exercise logs, which included either daily steps walked, or daily number of exercise minutes. Each participant also received Therabands and was instructed on the proper use of the bands. In addition, weekly classes included a ½ hour of exercise, including walking, Theraband use, aerobic exercise and pilates. Follow-Up: Following the eight-week sessions, participants are called every three months for one year to monitor progress and achievement of goals and are seen back for individual followup every three months (cohort 1 was followed on a monthly basis). Data Collection: Data was collected to assess the effectiveness of the program. The following data was collected: 1. Participation rates 2. Readiness to change 3. Average age of cohorts 4. Weight loss, Body Mass Index (BMI), and body fat 5. Barriers to healthy eating and exercise (cohort 3 only) 6. 1K-A-Day walking program weekly steps (cohorts, 1,2, & 3 only) 7. Knowledge based questionnaires 8. Follow-Up 3, 6, 9, and 12 months after program completion o To date, Cohort 1 has completed 12-month follow-up o Follow up is by phone monthly and face to face every 3 months Evaluation: From March 25 through March 26, four classes were offered. Three classes targeted the adult population and one class targeted the teen population. 1. Participation Rate Overall, 66 individuals began the Healthy Lifestyles class with 54 individuals completing the program for a completion rate of 82% (based on program goals, a 9% completion rate was set for this pilot program) Although all of the participants were identified as high risk for diabetes, 15 individuals (23%) reported a current diagnosis of diabetes and 23 individuals (35%) reported a family history. Cohort 4 was not aware of their extended family history, so that data is unavailable. The breakdown is as follows: Table 1: Participation Rate Cohort Date # of Participants Starting Program # of Participants Completing Program % Completion Rate* # of Individuals with Current Diagnosis of Diabetes # of Individuals with Family History of Diabetes Cohort 1 March % 6 6 Cohort 2 September % 4 9 Cohort 3 January % 5 8 Cohort 4 March % *NA *NA Total: % * NA Data not Available Healthy Lifestyles Evaluation Report 4

5 2. Average Age of Cohorts: Graph 1: Average Age of Cohorts Each cohort targeted a specific population. Cohort 1 targeted the general adult community population, cohort 2 targeted adults at a community senior citizen center, cohort 3 targeted Memorial Medical Center (MMC) employees and cohort 4 targeted teens at a local school district Average Age Readiness to Change Changing behavior is one of the most difficult things for an individual to do and longterm change is even harder. In order to be effective in changing behavior, it is important to understand the psychology of change and an individual s readiness to change. Unless an individual is ready to change, no program will be successful. 8 The Healthy Lifestyles program used the Prochaska s stages of change model to determine individual participants readiness to change. Determining an individual s stage of change is the best approach to helping them achieve their goals by tailoring programmatic activities to specific needs of the population. Pre-program, participants were surveyed to determine their readiness to change. The five stages of change, based on Prochaska s stages of chage are: precontemplation, contemplation, preparation, action, and maintenance. 9 Table 2 describes each stage. Table 2: Stages of Change Precontemplation Not entertaining thoughts of change Contemplation Readiness to change within 6 months of the start of class Preparation Readiness to change within 3 days and concurrent experimentation with change Action Change initiated within six months prior to class Maintenance Change sustained for six months or longer prior to class Graph 2: Exercise Readiness to Change 7% 6% 5% 4% 3% 2% 1% % 62% 56% 58% 5% 43% 33% 22% 21% 21% 11% 8% 8% 7% % % % % % % Precontemplation Contemplation Preparation Action Maintenance Healthy Lifestyles Evaluation Report 5

6 Graph 3: Nutrition Readiness to Change 6% 5% 4% 3% 2% 1% % 56% 43% 38% 32% 29% 26% 22% 23% 23% 21% 21% 21% 11% 11% 8% 8% 7% % % % Precontemplation Contemplation Preparation Action Maintenance 4. Weight Loss, BMI, Body Fat and Waist Circumference One of the focuses of the program is decreasing weight, Body Mass Index (BMI), and overall Body Fat and waist circumference. It is promising to see that all four cohorts showed a remarkable decrease in weight ranging from 97.5 pounds down to 1 pounds. The employee cohort, (cohorts 3) showed the largest decrease in weight with 97.5 pounds. The senior population (cohort 2) showed the least amount of weight loss at 1 pounds, which may indicate that the senior population may not be the best population to target with diabetes management programs. As stated earlier, healthy behaviors, including diet and exercise become increasingly difficult to change as a person ages. 5 Graph 4: Average Weight Loss Weight Loss in Pounds BMI, a screening tool that can Table 3: Adult BMI Chart help identify possible weight problems for adults, BMI Weight Status is calculated using a person s weight and height. Below 18.5 Underweight Although BMI does not measure body fat directly, Normal it is a reliable indicator of body fatness for people Overweight and due to its inexpensiveness, it is one of the best 3. and Above Obese methods for population assessment of overweight and obesity. A BMI under 25 is recommended for optimum health. A BMI over 3 or higher is considered obese. For adults over the age of 2, BMI is interpreted using standard weight status categories that are the same for both men and women. 1 The standard weight status categories adult BMI ranges are shown in table 3. Healthy Lifestyles Evaluation Report 6

7 When looking at BMI weight categories, 1% of cohorts 1 and 2 fell into the obese or overweight categories. Seventy-seven percent (77%) of cohort 3 fell into the obese or overweight categories and twenty-three percent (23%) fell into the normal category. However, it should be noted that all four participants (23%) were on the high end of the normal category for weight status and 2 out of 4 (5%) of these participants had a family history of diabetes. Graph 5: BMI: Weight Categories for Cohorts 1-3 1% 8% 6% 4% 2% % 9% 7% 65% 3% 23% 1% 12% % % % % % Cohort 1 Cohort 2 Cohort 3 Underweight Normal Overweight Obese Children and teens have a different labeling system for BMI ranges above a normal weight (at risk of overweight and overweight). BMI is calculated from a child s weight and height, however, once a BMI number is obtained, it is plotted on a BMI for age growth chart (for either girls or boys) to obtain a percentile ranking. Percentiles are the most commonly used indicator to assess the size and growth patterns of individual children. Table 3 shows the BMI-for-age weight status categories and the corresponding percentiles. 11 Table 4: Child BMI Chart Weight status category Underweight Healthy weight At risk of overweight Overweight Percentile range Less than the 5 th percentile 5 th percentile up to the 85 th percentile 85 th to less than the 95 th percentile Equal to or greater than the 95 th percentile For cohort 4, 93% of participants were in the overweight category and 7% were in the at risk for overweight category. Graph 6: BMI: Weight Categories for Cohort 4 1% 8% 6% 4% 2% % % % Cohort 4 7% 93% Underweight Healthy Weight At Risk of Overweight Overweight Graph 7: BMI: Decrease for Program Participants from pre to post program implementation BMI Decrease 5.7 Healthy Lifestyles Evaluation Report 7

8 Body composition is the ratio of lean body mass to fat body mass. Health problems, such as heart disease, diabetes, high cholesterol and other serious conditions can be the result of too much body fat. For women, a body fat of 1-12% is essential, 14-2% is considered a healthy range for athletes, 21-24% is healthy for fitness, 25-31% is considered an 'acceptable' range and anything above 32% is considered obese. For men, 2-4% body fat is essential, 6-13% is an athletic body fat range, 14-17% is considered a 'fit' range, and 18-25% is acceptable. Above 26% for men is considered obese. 12 Over the 8-week program, a decrease in body fat was seen for all four cohorts, with cohort 3 showing a 42.2 decrease in body fat. Cohorts 1 and 4 showed a 16 and 15.1 decrease in body fat and cohort 2 showed a 1.3 decrease (graph 6). Graph 8: Body Fat: Decrease for Program Participants from pre to post program implementation Body Fat Decrease Waist circumference is the distance around your natural waist (just above the navel). If an individual s BMI is greater than or equal to 25 kg/m 2, their goal for waist circumference should be less than 4 inches for a man and less than 35 inches for a woman. 12 Cohort 3 showed the largest decrease in waist circumference with a 36 inch decrease followed by cohort 4 with a 2.5 inch decrease and cohort 1 with a 9.75 inch decrease. Cohort 2 showed a 6-inch decrease in waist circumference. Graph 9: Waist Circumference: Decrease for Program Participants from pre to post program Waist Circumference Decrease (in inches) 5. Barriers to Healthy Eating and Exercise Individuals face many barriers when it comes to achieving a healthy lifestyle. By identifying barriers, program personnel can develop strategies, programs and/or materials to encourage individuals to engage in physical activity, adopt healthy eating habits, and achieve and maintain a healthy weight. Studies have shown that some of the most common identified barriers to health eating include; lack of time, availability and lure of fast foods, cultural issues, giving up favorite foods, and willpower. Some of the more common identified barriers for lack of exercise include: lack of time, lack of motivation, and not finding exercise enjoyable. 14, 15 Healthy Lifestyles Evaluation Report 8

9 Barriers to healthy eating and exercise were discussed with all four cohorts, however, only cohort 3 completed weekly questionnaires designed to determine barriers for that particular week. After the barriers were identified, program staff modified program content to include information on reported barriers. For healthy eating, nine barriers were identified pre program implementation. By program completion, 8 out of 9 (89%) of these barriers were reduced. Four barriers were identified for exercise pre program implementation. All four barriers (1%) were reduced by program completion. Graph 1: Reduction of Identified Barriers to Healthy Eating by Participants 8% 7% 6% 5% 74% 53% 58% Pre Program Implementation Post Program Implementation 47% 4% 3% 2% 1% % 33% Willpower Busy Lifestyle 21% 7% 7% Irregular work hours 13% Giving up foods that I like 26% 7% Cooking skills % Limited choice when I eat out 21% 21% 7% Not enough to satisfy hunger % Healthy food is more perishable Graph 11: Reduction of Identified Barriers to Exercise by Participants 8% 7% 6% 5% 4% 3% 2% 1% % 42% Pre Program Implementation 37% 13% 13% 42% Post Program Implementation 27% 37% 2% Too Tired Lack of Motivation Lack of Time Unfavorable Weather 6. 1K-A-Day Walking Program Weekly Steps Physical activity, done regularly, can substantially reduce the risk of dying from coronary heart disease, which is the nation s leading cause of death, as well as decrease the risk for diabetes, high blood pressure, stroke, and colon cancer. 16 Coronary heart disease is not only the nation's leading cause of death, but it is the #1 killer of people with diabetes. 17 Although the benefits of physical activity are known, more than 5% of adults do not get enough physical activity to provide health benefits. In the United States, it is estimated that approximately 25% of adults are not active at all. Physical inactivity is most common in women and older adults. 18 Walking is one of the most popular of all physical activities. Most adults average 2-4 steps each day, which is equivalent of Healthy Lifestyles Evaluation Report 9

10 only 1-2 miles. Walking 1, steps a day, or more, has been shown to help control weight, reduce disease risk, increase energy, enhance mood, and improve sleep. 19 As part of the Healthy Lifestyles Program, participants were given pedometers in week one and instructed to strive for 1, steps a day or exercise equivalent to 1, steps. All three adult cohorts, 1, 2, & 3 completed weekly exercise logs. Cohort 4, the teen cohort, was instructed to wear pedometers, but it was found that this was a difficult group to monitor walking steps. The participants often forgot their pedometers, lost them, or just didn t want to wear them. Step data is not available for the teen cohort. Overall, cohort 1 showed the largest increase in daily steps pre to post program implementation. Cohorts 2 and 3 showed little change in the number of daily steps pre to post program implementation (graph 9). Individually, 5 out of 1 (5%) of individuals in Cohort 1 doubled their daily steps. For Cohort 2, 2/13 (15%) doubled their steps and 1/19 (5%) for cohort 3. Graph 12: Average Number of Steps: ,16 7, Cohort 1 Cohort 2 Cohort 3 Pre Program Post Program 7. Knowledge Based Questionnaire A 1-question survey was designed to measure nutrition and fitness knowledge preprogram implementation as well as post-program implementation. Each cohort participated in the survey, with cohorts 1-3 receiving identical surveys. The survey was modified for Cohort 4, which consisted of the teen population. Cohorts 1-3 showed an increase in knowledge ranging in the 6-percentile range pre program implementation and increasing to the 8-percentile post program implementation. Cohort 4, the teen population, showed the largest increase in knowledge from 41% pre program implementation to 74% post program implementation. Graph 13: Knowledge Based Survey (percent correct responses) Cohorts 1-4 1% 5% 82% 84% 81% 64% 66% 69% 41% 74% Pre Test Post Test % Pre Test 64% 66% 69% 41% Post Test 82% 84% 81% 74% Healthy Lifestyles Evaluation Report 1

11 8. Follow-Up To date, Cohort 1 has completed one full year of follow-up with data collected at 3, 6, 9, and 12-month intervals. Out of the ten original participants, seven (7%) completed a 12-month follow-up. Follow up was conducted by phone monthly and face to face every 3 months. After completion of the 8-week program, cohort 1 showed a total weight loss of 5.7 pounds. At the 3-month interval, an additional weight loss of 16.2 pounds was seen and an additional 24.3 pounds at the 6-month interval. Participants weight steadied during the 9-month interval with an additional 1.2 pounds of weight loss at the 12-month interval. Overall, after a year of follow-up, participants showed an overall weight loss of 11.4 pounds. Graph 14: Additional Weight Loss at each Follow-Up Interval (Program Completion, 3, 6, 9, 12 Months) Total Pounds Lost 1.2 Program Completion 3 Month 6 Month 9 Month 12 Month Graph 15: Total Weight Loss after 12-Month Follow-Up Total Pounds Lost 11.4 Program Completion 3 Month 6 Month 9 Month 12 Month After program completion, BMI decreased by Follow-up BMI data was collected on the seven follow-up participants 12 months after program completion. An additional 3.6 BMI decrease was seen for an overall decrease of Graph 16: BMI Decrease after 12-Month Follow-Up Program Completion BMI Change Month TOTAL Body fat showed a decrease of 16% after program completion. However, after 12 months of follow-up, body fat increased by 6.8% for an overall decrease of 9.2% after one year. Healthy Lifestyles Evaluation Report 11

12 Graph 17: Body Fat Change after 12-Month Follow-Up(percentage) Body Fat Change Program Completion 12 Month TOTAL Cohort 1 showed a 9.75-inch decrease in waist circumference after the 8-week program. After a complete year (12 months), participants showed an additional decrease of 6 inches for an overall decrease of inches in waist circumference. Graph 18: Waist Circumference Change after 12-Month Follow-Up Waist Circumference Change Program Completion 12 Month TOTAL During follow-up sessions, participants completed a 1-question survey regarding continued nutrition and exercise behaviors. After 12 months, participants showed a 1% rate for continuation of their exercise program, an 88.9% rate for continuation of watching their diet and a 1% rate of reading food labels. Table 5 shows complete data for 3,6,9,and 12-month intervals. Table 5: Follow-up Survey 3 Month n=9 6 Month n=8 9 Month n=9 12 Month n=9 1. Continued Exercise Program 1% 75% 1% 1% 2. Continued Use of Exercise Video 42.9% 25% 75% 33.3% 3. Continued Use of Exercise Bands 85.7% 85.7% 25% 33.35% 4. Continuing to Watch Diet 1% 1% 1% 88.9% 5. Know Foods Which are Carbohydrates 88.9% 1% 1% 77.8% 6. Watching Portion Sizes 1% 1% 1% 88.9% 7. Manage Diet when Eating Out/ Special 75% 87.5% 66.7% 66.7% Occasions 8. Reading Food Labels 88.9% 1% 1% 1% 9. Managing Health Causes Stress in Life 37.5% 62.5% 22.2% 33.3% Healthy Lifestyles Evaluation Report 12

13 Summary: This Healthy Lifestyles pilot program consisted of four cohorts, each focusing on a different age group or population. The results vary from group to group At the end of the 8-week program, the following can be stated about each cohort. Cohort 1: General community members and FMC patients Average age was 5. Based on the Prochaska model, scored high in the Action and Preparation stages. Showed weight loss, averaging 5.1 pounds per person for a total of 5.7 pounds. Showed decreases in BMI, body fat and waist circumference. Increased their number of steps from pre program to post program implementation. Increased their knowledge from pre to post program implementation in regards to nutrition and exercise. After one year, this group has continued to exercise regularly (1%) and use their exercise videos and exercise bands that were given as part of the program. Cohort 2: Senior citizens at local senior center Average age was 63. Based on the Prochaska model, though a high percent felt prepared to make changes, their action and maintenance numbers were around 8%. It was difficult for this population, with their other health problems to adopt regular exercise into their lifestyle, especially since it has not previously been there. Their average weight loss was less than one pound per person with BMI, body fat and waist circumference changes minimal. Walking was an exercise they were comfortable with and were able to do regularly. Increased their knowledge in regards to exercise and nutrition. Their interest in providing follow-up information to FMC is minimal. Coh ort 3: Employee group at MMC and community members Average age was 46. Based on the Prochaska model, 21% were already in the maintenance stage for exercise and nutrition. Many participants came with a friend so there was a good deal of support among the participants. Their average weight loss was 5.1 pounds per person for a total of 97.5 pounds. Showed significant decreases in BMI, body fat and waist circumference. This cohort was the first to report weekly on barriers to healthy eating and exercise. Twelve (12) barriers were significantly decreased by the end of the 8-week session. Although they did not increase their steps walked, they were already a very active group to begin with. Increased their knowledge in regards to nutrition and exercise. Healthy Lifestyles Evaluation Report 13

14 Cohort 4: Adolescent group at local public school Average age was 15. Based on the Prochaska model, 93% were in action or maintenance for exercise. Forty-nine percent (49%) were in preparation for nutrition education and were very receptive to the educational presentations that went along with that. Their average weight loss was 5 pounds per person for a total of 58 pounds. Showed significant decreases in BMI, body fat and waist circumference. Difficult to control barriers as their parents do the meal planning, shopping and the school cafeteria doesn t always provide healthy choices. This group was composed mostly of softball and football players. Although they didn t use the pedometers and walk, they were active on a daily basis with sports. They had a 3% increase in knowledge which was the highest of the four groups. Based on the above data, it was determined that the senior citizen population was not an effective group to target with Healthy Lifestyles. Although the senior s wanted to participate in the Healthy Lifestyles program, they were not receptive to changing attitudes and behaviors regarding diet and exercise. They were also not receptive to follow-up questions and meetings. With the success demonstrated with the younger adult and adolescent populations, future programming will target these groups. Healthy Lifestyles Evaluation Report 14

15 References: 1. U.S. Department of Health and Human Services. Healthy People 21: Understanding and Improving Health 2 nd.ed. Washington DC: U.S. Government. Printing Office, November Franz, MJ. Diabetes in the Life Cycle and Research. Core Curriculum for Diabetes Education 5 th Edition Pennsylvania Health Care Cost Containment Council 21, Data Nov State of Diabetes. Stave of Diabetes in American, Strivig for Better Health. diabetes.com/state_compare.htm 5. Bureau of Community Health Systems Division of School Health 19 Aug Pennsylvania Department of Health, PA BRFSS National Institute of Diabetes & Digestive & Kidney Disease. Diet and Ecercise Dramiaticallly Delay Type 2 Diabetes: Diabetes Medication Metformin Also Effective Cardium Health. States of Change Nolan, R. CRHSPP. Clinical Applications of the Transtheoretical Model of Readiness for Change. Ottawa General Hospital/University of Ottawa Center for Disease Control, BMI Body Mass Index: About BMI for Adults Center for Disease Control, BMI Body Mass Index: About BMI for Children/Teens What s Your Body Fat American Heart Association. Body Composition Testing Center for Weight Loss and Health, University of California, Berkeley Lappalainen,R. et al. Difficulties in trying to eat healthier: descriptive analysis of perceived barriers for healthy eating. European Journal Clinical Nutrition, 1997 Sep;51(9): Center for Disease Control, Fact Sheet, ( th 17. Franz, MJ. Diabetes and Complications (a core curriculum for diabetes educators 5 ed, chapter 6 (Macrovascular Disease) 23. American Association of Diabetes Educators, Chicago IL. 18. Center for Disease Control, Fact Sheet, Health Enhancement Systems, Healthy Lifestyles Evaluation Report 15