Tennessee Taming the Diabetes Crisis: The Tennessee Journey to Better Health

Tennessee Taming the Diabetes Crisis: The Tennessee Journey to Better Health Susan R. Cooper MSN, RN Commissioner Tennessee Department of Health NCSL July 23,2009

Adult Diabetes Diabetes Prevalence, Tennessee and U.S. 1995-2008 12.0 Percent of Adults 10.0 8.0 6.0 4.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year US Diabetes Rate TN Diabetes Rate Source: Behavioral Risk Factor Surveillance System Survey

Adult Obesity Obesity Prevalence, Tennessee and U.S. 1995-2008 35.0 Percent of Adults 30.0 25.0 20.0 15.0 10.0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year US Obes ity Rate TN Obesity Rate Source: Behavioral Risk Factor Surveillance System Survey

Childhood Obesity Overweight and Obese Children Tennessee and the United States, 2007 (NSCH) 50 45 Percent 40 35 30 25 20 36.5 31.6 15 10 5 0 Tennessee United States

Health Care Costs: Overview Obesity is a major risk factor for Type II Diabetes, giving us two different ways to think about health care costs from a obesity perspective or from a diabetes perspective

Health Care Costs: Obesity Perspective Additional health care costs due to overweight and obesity $19 for every overweight pound $1,038 for every overweight individual (Source: Humana 2009 estimates) Approximately 68% of adult Tennesseans (over 3 million people) are overweight this translates into over $3 billion in added health care costs for the state (Source: Humana 2009 estimates applied to TN) Obesity attributable Medicaid ($488 million) and Medicare ($433 million) costs in Tennessee totaled over one billion dollars in 2004 (Source: Finkelstein et al. 2004))

Health Care Costs: Diabetes Perspective Estimated at $116 billion nationally, including $27 billion for care to directly treat diabetes, $58 billion to treat diabetes-related chronic complications, and $31 billion in excess general medical costs. People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than those without diabetes. The 2007 per capita annual costs of health care for people with diabetes in the United States is $11,744 a year, of which $6,649 (57%) is attributed to diabetes Approximately 10% of adult Tennesseans are diabetic this translates into over $5.6 billion in adult health care costs, of which $3 billion are attributed to diabetes (Source: American Diabetes Association)

Health Care Costs: Conclusion From either perspective, obesity and/or diabetes cost Tennessee over $3 billion in excessive health care costs.

Children Born in the Year 2000 1 in 3 will develop Type 2 Diabetes That number is 1 in 2 if you are African American or Hispanic It is a preventable disease Our Vision: By 2018, Tennessee will be the first state in the nation where all children will graduate at a HEALTHY WEIGHT

Health Outcomes Associated with Diabetes Leading cause of nontraumatic amputation Leading cause of new onset adult blindness Contributing factor to End Stage Renal Disease Matches 1:1 with Cardiovascular events Neurovascular complications

Prevention Model Policies and Systems National, State, Local laws and policies Community Physical, social and cultural environment Organizations Schools, Worksites, faith based Relationships Family, peers, social networks Individuals Knowledge, beliefs, attitudes

Fundamentals of Initiatives Policies: Putting health in all policies. Programs: Putting policies into action by utilizing and building the evidence base. Partnerships: Building and succeeding together.

Health Diabetes Prevention and Health Improvement Act of 2006 Cover Tennessee Products: Risk assigned based on Age, Weight, and Tobacco Use TennCare: Policies support Weight Watchers and other Healthy Weight Programs for children and their parents Disease management contractually required for obesity Child and teen newsletters include information on healthy food choices and exercise Governor Bredesen vetoed a bill which would have prohibited local boards of health in cities and counties from requiring restaurants to post nutritional information. (7/09)

Education Coordinated School Health: Mandated for all school systems, Fully Funded (1 st State in nation to fully fund) Tennessee is one of 19 states with nutritional standards for school meals and snacks that are stricter than federal requirements. Tennessee is one of 27 states with nutritional requirements for foods sold in school vending machines or in school bake sales. Physical Education Requirements=90 minutes per week BMI or health information collected Health Education requirements

Transportation and Agriculture Safe Routes to Schools Under ARRA, building sidewalks with roads Farm to School Programs

Project Diabetes Fundamental Goals Decrease the prevalence of overweight/obesity across the State to prevent or delay the onset of Type 2 diabetes and/or its consequences Educate the public about current and emerging health issues linked to diabetes Promote community, public-private partnerships to identify and solve regional health problems related to obesity and diabetes Advise and recommend policies and programs that support individual and community health improvement efforts Evaluate the effectiveness of improvement efforts/programs that address overweight, obesity, pre-diabetes and diabetes Disseminate best practices for diabetes prevention and health improvement

Intervention Programs Cherokee Health Systems Change for Life Program October 2008 March 2009 Target = children at risk for diabetes Goal = prevention of diabetes among underserved children via an integrated primary care approach 2,885 well child checks 234 at risk children referred 106 children enrolled in program 40 enrollees rechecked at 3 months 45% decreased their BMI 33% ate more fruits; 23% ate more vegetables 35% increased their physical activity 38% decreased time spent watching TV

Intervention Programs St. Thomas Family Health Centers Healthy Lifestyles Program October 2008 June 2009 Target = adult diabetes patients Goal = reduce the severity of and complications due to diabetes through education, healthy lifestyle changes and regular exercise 238 diabetic patients enrolled 66% achieved an hemoglobin A1C less than 7.0 39% decreased their BMI by 5% 96% reported physical activity twice per week

gotrybetn.com

Step U.P. to Health Center for Diabetes Prevention & Health Promotion Board Cordell Hull Building, Tennessee Room Tuesday, May 28 th, 2008, 9am Collaborative Partners

Step U.P. to Health Where did stepping originate? West African Gumboot Dance Tribal dance of celebration Form of story telling Modern Use of Step 1940 s by H.B.G.L.O., aka Divine Nine Intricate Words and Movements Unity through competition Use within program Aerobic Physical Activity Team concept, discipline

Step U.P. to Health Pilot Program, 2006 in East Nashville Built on N.S.S.A. step team foundation Reach 300 at risk youth, 11-15 Increase s Physical Activity Execution of Strategic Health Curriculum Addresses Self Efficacy & Self Esteem Issues Support for Academic Excellence Teams in 15 community centers

GetFitTN.com GetFitTN is a statewide awareness program developed by Governor Bredesen to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, like obesity. Focused on educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and a healthier diet. March to the Moon State employees walked approximately 155,000 miles in at 31 day period www.getfittn.com

GetFitTN.com

Golden Sneaker Program Focus of Initiative Target population: 0-5 years of age, as there seems to be less emphasis on encouraging healthy behaviors in this group Goal: to enhance policy related to physical activity and nutrition within Tennessee s licensed child care facilities and target development of healthy living skills Encourages licensed child care facilities to voluntarily adopt policies relative to physical activity, media viewing, and ensuring appropriate feeding patterns for infants and children including breastfeeding, adequate portion sizes, adequate meal times and reward systems associated with food and activity Partnership between Department of Health, Department of Human Services, and Child Care Resource and Referral Centers

Golden Sneaker Initiative $100,000 grant received from National Governor s Association Goal: to enhance policy related to physical activity and nutrition within Tennessee s licensed child care facilities and target development of healthy living skills Encourages licensed child care facilities to voluntarily adopt policies relative to physical activity, media viewing, and ensuring appropriate feeding patterns for infants and children including breastfeeding, adequate portion sizes, adequate meal times and reward systems associated with food and activity Partnership between Department of Health, Department of Human Services, and Child Care Resource and Referral Centers

Diabetes Funding Funding Activities as of June 2009 Target Population Number of Grants Funding Level High Risk for Diabetes 10 $2 million Diabetes Management 15 $2.6 million Children or School Setting 20 $2.7 million

So What???? 2008 data show, adult diabetes rate in Tennessee has fallen from 11.9 percent to 10.3% In 2008, 71.3% of diabetic adults in Tennessee reported checking their blood sugar daily, exceeding the Healthy People 2010 objective of 60% (#1 nationally) In 2008, 83.2% of diabetic adults in Tennessee reported having an annual hemoglobin A1C check, exceeding the Healthy People 2010 objective of 65% The percentage of adult Tennesseans who reported no physical activity during the past month decreased between 2005 and 2008 33.1% to 28.9%

Modeling Behaviors Participated in hundreds of community events ranging in size from 40-5000 participants Partnerships with schools, business community, community and faith based organizations, county/city governments, other state agencies Every moment is a teachable, get fit moment Message is consistent: Start where you are everyone can do something Fitness can be fun Learnings: Most people want to do the right thing they just don t know how to get started Most people do not know the data must make it personal your child, grandchild, or student

The Future Lots of progress made, but we have a long way to go to better health Continue to focus on translating research into practice clinical and community preventive health recommendations Community based participatory research Communicate, coordinate, collaborate Develop a working strategic plan to address overweight and obesity Innovate, innovate, innovate!!!

Questions???

Tennessee by the Numbers 2009 Population Estimates Total Population: 6,202,803 10 17: 657,515 (10.6%) 18 54: 3,189,110 (51.4%) 55 64: 737,300 (11.9%) 65 and older: 813,702 (13.1%) Males: 3,029,968 (48.8%) Females: 3,172,835 (51.2%) White: 5,041,974 (81.3%) Black: 1,038,967 (16.7%)

Fruits and Vegetables Ate Fruits and Vegetables Less Than 5 Times Per Day Tennessee, 1998-2007 (BRFSS )* Percent 100 90 80 70 60 50 40 30 20 10 0 77.8 70.3 71.6 73.5 73.6 65.9 62.9 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year *Data on fruit and vegetable consumption not available for 1999, 2004, or 2006.

Physical Activity 60 50 No Physical Activity During the Past Month Tennessee, 2000-2008 (BRFSS ) Percent 40 30 32.7 35.1 33.6 29.8 29.7 33.1 28.8 31.5 28.9 20 10 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Diabetes Management Daily Blood Sugar Check Tennessee, 1999-2008 (BRFSS ) Percent 100 90 80 70 60 50 40 30 20 10 0 79.1 75.4 75.1 69.5 69.5 71.3 65.1 63.0 63.0 64.6 Healthy People 2010 Objective: 60% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Diabetes Management Annual Dilated Eye Exam Tennessee, 1999-2008 (BRFSS ) Percent 100 90 80 70 60 50 40 30 20 10 0 81.4 76.0 72.5 72.3 72.9 72.6 68.5 69.0 71.3 71.9 Healthy People 2010 Objective: 76% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Diabetes Management Annual Foot Exam Tennessee, 1999-2008 (BRFSS ) Percent 100 90 80 70 60 50 40 30 20 10 0 97.9 70.6 69.8 66.6 65.7 65.5 67.8 59.6 60.0 62.4 Healthy People 2010 Objective: 91% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Diabetes Management Annual Hemoglobin A1C Check Tennessee, 1999-2008 (BRFSS ) Percent 100 90 80 70 60 50 40 30 20 10 0 87.1 89.3 89.5 84.6 86.4 82.7 83.2 75.0 72.1 70.3 Healthy People 2010 Objective: 65% 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year

Adult Diabetes Diabetes Prevalence, Tennessee and U.S. 1995-2008 Year TN Diabetes Rate US Diabetes Rate 1 TN National Rank 2 1995 5.2 4.4 38 1996 5.0 4.5 32 1997 4.4 4.8 18 1998 5.9 5.4 36 1999 6.0 5.6 31 2000 7.2 6.1 47 2001 7.7 6.5 43 2002 8.5 6.5 47 2003 9.4 7.1 48 2004 8.4 7.0 46 2005 9.1 7.3 45 2006 10.7 7.5 48 2007 11.9 8.0 50 2008 10.3 8.2 46 1 Nationwide calculation based on data from states and the District of Columbia 2 Ranking of lowest to highest percentage among states Source: Behavioral Risk Factor Surveillance System Survey

Adult Obesity Obesity Prevalence, Tennessee and U.S. 1995-2008 Year TN Obesity Rate US Obesity Rate 1 TN National Rank 2 1995 18.4 15.9 44 1996 17.4 16.8 31 1997 17.7 16.5 34 1998 19.2 18.3 30 1999 20.5 19.6 33 2000 22.9 20.0 43 2001 23.4 20.9 42 2002 24.5 21.9 43 2003 25.0 22.9 42 2004 27.2 23.2 46 2005 27.4 24.4 42 2006 28.8 25.1 44 2007 30.7 26.3 47 2008 31.2 26.6 47 1 Nationwide calculation based on data from states and the District of Columbia 2 Ranking of lowest to highest percentage among states Source: Behavioral Risk Factor Surveillance System Survey

Tennessee Specific Data 36.5% 10 to 17 year olds are overweight or obese, 5th highest rate in nation (F as in Fat 2009: How Obesity Policies are Failing in America, Trust for America s Health). BMI Screening through Coordinated School Health 16,513 students Year 1 Ranged in age from 7 to 16 years 24% overweight (above 95 th percentile) 18% at risk for overweight (85 th 95 th percentile) 42% total overweight and at risk 56% normal weight (above the 5 th and below the 85 th percentile) 2% underweight (below the 5 th percentile)

More boys (26%) were overweight than girls (22%) A greater proportion of black students (29%) were overweight than white (24%) Black girls had the highest proportion of overweight or at risk for overweight (50%) White girls had the lowest proportion of overweight or at risk for overweight (40%) Only age group with combined proportion of overweight and at risk for overweight less than 40%: Students under age 7

BMI Screening Results The proportions of overweight and at risk for overweight were considerably higher than those reported for Tennessee high school students in the 2005 Youth Risk Behavior Surveillance System (YRBSS) 42% BMI Project versus 32.1% YRBSS 2 nd year screening has been completed on 25,640 students, data under analysis

Immediate Steps for Confronting the Epidemic: State and Local Governments Establish an interdepartmental task force and coordinate federal/state actions Develop nutrition standards for foods and beverages sold in schools Apply for state based nutrition and physical activity grants with strong evaluation components Expand and promote opportunities for physical activity in the community through changes to ordinances, capital improvement programs, and other planning practices Work with communities to support partnerships and networks that expand the availability of and access to healthful foods

Schools: Coordinated School Health: Mandated for all school systems, Fully Funded (1 st State in nation to fully fund) Nutritional Standards for all meals Nutritional standards for all competitive foods Physical Education Requirements=90 minutes per week BMI or health information collected Health Education requirements Vending machine laws