Diabetes in the Homeless Population

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Diabetes in the Homeless Population

• Maureen Shevlin Gutierrez
• September 25, 2006

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Why?

• Diabetes mellitus is the sixth leading cause of
  death in the United States.
• In 1997, 124 million people were estimated to be
  living with diabetes worldwide the projected
  worldwide prevalence for the year 2010 is 221
  million.
• From the 1997 data, 7 of the United States
  population was thought to have diabetes, (roughly
  20.7 million people).

3
What has been done

• Many studies have been conducted eval education
  and the corresponding modification of behaviors
  on glycemic control.
• Patient education has variable impact on changing
  health beliefs and behaviors. Post-education
  glycemic control is not significantly improved.
• Wooldridge et al Diabetes education had a
  positive impact on changing patients health
  beliefs. Clients reported improvements in their
  perceived severity of diabetes, their ability to
  carry out rec behaviors, and their perceived
  benefits of treatment. HbA1c values were
  improved. However, this improvement was not
  directly associated with patients self-reported
  improved adherence3.
• Polly In a study designed to examine the
  relationship between patients health beliefs
  with their adherence and glycemic control, there
  were no significant associations4.

4
The Questionnaire

• 47 diabetic patients completed a questionnaire
  assessing their diabetes knowledge, exercise, and
  dietary habits. This information was then
  compared to their HgA1cs and BMIs.
• Nine multiple-choice questions.
• Identify symptoms of hyper- and hypoglycemia.
• Does stress affect glycemic control?
• How many times each day the patients checked
  their blood sugar?
• Exercise
• Beverages choice (i.e. soda, diet soda, water,
  juice)
• Diet

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• For both questions 1 and 2, identifying more
  symptoms was associated with higher HgA1cs, i.e.
  almost two-thirds of the patients who knew 5-9
  and 3-5 symptoms of hyper- and hypoglycemia,
  respectively, had a HgA1c equal to or greater
  than 6.5 mg/dL. Thus, knowledge itself does not
  appear to be a factor in tight glycemic control.
  Rather, patients with poor glycemic control may
  be more knowledgeable by either personal
  experience with the symptoms, or by education by
  professionals attempting to modify patient
  behaviors.

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Conclusions

• Pts with elevated HgA1cs are more likely to know
  the symptoms of both hyper hypoglycemia
• Pts who recognized that stress and infection
  effect glycemic control are more likely to have
  HgA1c less than those who do not, but patients
  unsure of the answer have the lowest HgA1c of all
  3 groups.
• Pts who check their blood glucose twice a day
  have lower HgA1cs than patients who do not check
  their glucose, however, patients who check their
  sugar more than twice each day have poorer
  glycemic control.
• Exercise was not related to better glycemic
  control or lower BMIs.
• Finally, there was no consistent relationship
  between either dietary choices or BMI.

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What now

• Future efforts may be more effective if focused
  on more frequent appointments and medication
  adherence rather than on patient education.
• Rhee et al. conducted a retrospective evaluation
  of appointment keeping and medication adherence
  and found that compliance with both resulted in
  lower HgA1cs5.
• Schectman et al likewise found an association
  between medication adherence and HgA1c
  (specifically, for each 10 increment in
  medication adherence, HgA1c decreased by 0.16)
  6.
• Can the importance of patient education be
  discounted, or more likely, does the flaw lie
  within the accuracy of patient-reported
  adherence?

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Resources

• 1. Amos AF, McCarty DJ, Zimmet P. The rising
  global burden of diabetes and its complications
  estimates and projections to the year 2010.
  DiabetMed. 199714 Suppl 5S1-85
• 2. http//diabetes.niddk.nih.gov/dm/pubs/statisti
  cs/7
• 3. Wooldridge KL, Wallston KA, Graber AL, Brown
  AW, Davidson P. The relationship between health
  beliefs, adherence, and metabolic control of
  diabetes. Diabetes Educ 1992 Nov-Dec19(6)495-500
  
• 4. Polly RK. Diabetes health beliefs, self-care
  behaviors, and glycemic control among older
  adults with non-insulin-dependent diabetes
  mellitus. Diabetes Educ. 1992 Jul-Aug18(4)321-7
  
• 5. Rhee MK, Slocum W, Ziemer DC, Culler SD, Cook
  CB, El-Kebbi IM, Gallina DL, Barnes C, Phillips
  LS. Patient adherence improves glycemic control.
  Diabetes Educ. 2005 Mar-Apr31(2)240-250
• 6. Schectman JM, Nadkarni MM, Voss JD. The
  Association Between Diabetes Metabolic Control
  and Drug Adherence in an Indigent Population.
  Diabetes Care. 2002 June 25(6)1015-1021