Public Comment - Healthy People 2020

View Proposed Objectives on Diabetes

Anonymous on 1/11/2010 2:55:00 PM

Proposed Objective Text: Increase capacity and numbers of Public Health Work Force

Rationale: In the past 10 years there has been a precipitous decline in public health professionals and resources with resulting negative impact on the health of Americans, particularly in rural and under served areas.

Proposed Data Source(s): HRSA Workforce Data

Public Health Seattle and King County on 12/31/2009 5:22:00 PM

Proposed Objective Text: Reduce smoking rate among people with diabetes.

Rationale: we are not able to comment at this time.

Proposed Data Source(s): we are not able to comment at this time.

American Academy of Audiology on 12/31/2009 3:35:00 PM

Proposed Objective Text: The American Academy of Audiology proposes a new objective: “Increase the proportion of persons with diabetes who have at least an annual audiologic evaluation.”

Rationale: This objective is important because individuals with diabetes have an increased likelihood of sensorineural hearing loss.

Proposed Data Source(s): Numerous research studies have documented the increased incidence of sensorineural hearing loss in individuals with diabetes.

Anonymous on 12/31/2009 12:29:00 PM

Proposed Objective Text: Proposed by Agnes Richerson, Maiden, NC
I propse that adults being tested for Diabetes be increased over the next 10 years.
HP2020 objectives recommends an increase in the number of adults with diabetes Type 2 Diabetes. I propose adding screening for diabetes be in the Healthy People 2020 proposal.

Rationale: People aged 45+ who are overweight and have at least one or more additional risk factors for diabetes.

Adults aged 65+ who have already been tested for diabetes should be screened again.

Proposed Data Source(s): Propose valid, reliable, nationally representative data and data systems for this objective.

Anonymous on 12/31/2009 9:10:00 AM

Proposed Objective Text: Increase the proportion of adults ages 65 and older who have been tested for diabetes according to the Medicare standard for screening (being age 65 or older and having one additional risk for diabetes).

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:
• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program, a major NIH clinical trial , found participants in the lifestyle intervention group-those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification-reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/31/2009 8:56:00 AM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes.
• Adults any age who are overweight or obese, and have one or more additional risk factor for diabetes.
• Adults ages 45 and over who have been tested for diabetes at least once in the preceding three years

Proposed Data Source(s): Same as D HP 2020-2: National Health and Nutrition Examination Survey, CDC, NCHS

Kristin Granquist on 12/30/2009 11:38:00 PM

Proposed Objective Text: Increase the percentage of school-age children and adolescents with diabetes who have access to a school nurse while at school.

Rationale: Given the complexity of diabetes care, youth with diabetes need access to health providers who can assist them with their care and support their self-care. And given the amount of time that youth spend in school, this support should be provided by a school nurse. Yet few students attend schools in which school nurses are routinely available to them.

Proposed Data Source(s): I have no suggestion in this area.

National Changing Diabetes Program on 12/30/2009 5:46:00 PM

Rationale: The vision of Novo Nordisk's National Changing Diabetes® Program (NCDP) is changing diabetes and improving the lives of people affected by this disease by creating change in the U.S. system of health care and moving it toward an ideal diabetes environment that fully supports all aspects of diabetes prevention, treatment and care. NCDP works to promote collaboration between all parties in the health care system to elevate diabetes on national health agendas and improve the lives of people with diabetes.

That said, NCDP has reviewed all 16 objectives specific to diabetes and, although we are happy to see two new objectives included which target prevention (D HP2020-11 & D HP2020–16), we feel that there is a very important objective missing: one that focuses on diabetes screening.

Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program – a major NIH clinical trial found participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Cowie, et. al., “Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988–1994 and 2005–2006,” Diabetes Care, February, 2009.
http://www.cms.hhs.gov/DiabetesScreening
http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram
Diabetes Prevention Program Research Group, “10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study,” The Lancet, 14November2009.
http://www.cms.hhs.gov/PrevntionGenInfo/20_prevserv.asp

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

National Changing Diabetes Program on 12/30/2009 5:43:00 PM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes;

• Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes

• Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years (phrasing aligns with ADA recommendations)

Rationale: The vision of Novo Nordisk's National Changing Diabetes® Program (NCDP) is changing diabetes and improving the lives of people affected by this disease by creating change in the U.S. system of health care and moving it toward an ideal diabetes environment that fully supports all aspects of diabetes prevention, treatment and care. NCDP works to promote collaboration between all parties in the health care system to elevate diabetes on national health agendas and improve the lives of people with diabetes.

That said, NCDP has reviewed all 16 objectives specific to diabetes and, although we are happy to see two new objectives included which target prevention (D HP2020-11 & D HP2020–16), we feel that there is a very important objective missing: one that focuses on diabetes screening.

HP 2010 described four transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis, yet there was no screening objective in HP 2010 nor is there one in HP 2020, despite the fact that the transition points remain the same.

While there is an HP 2020 objective recommended to “increase the proportion of adults with diabetes whose condition has been diagnosed” (D HP2020-2), there is no means identified to accomplish this objective. Adding a screening objective, while important in and of itself, would also help reach this goal.

There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

• Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications

• Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

VSP Vision Care on 12/30/2009 5:43:00 PM

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program, a major NIH clinical trial, found participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

VSP Vision Care on 12/30/2009 5:41:00 PM

Proposed Objective Text: Increase the proportion of adults with diabetes who have an annual dilated eye examination, and increase the number of adults who are screened for diabetic retinopathy by setting specific goals for Medicare patients.

Rationale: Diabetic retinopathy is the leading cause of blindness among adults. Getting an annual dilated eye exam is an important part of managing diabetic retinopathy, yet less then 50% of individuals at risk receive regular eye exams.

Proposed Data Source(s): Workshop on implementation of screenings and eye exams for diabetic retinopathy, Proceedings Report, February 27-28, 2001.

VSP Vision Care on 12/30/2009 5:41:00 PM

Proposed Objective Text: Increase the proportion of high risk population receiving and reporting dilated eye exams.

Rationale: Diabetic retinopathy can occur up to seven years before diagnosis of type 2 diabetes. Early detection and treatment through an annual eye exam can prevent most vision loss related to diabetes.

Proposed Data Source(s): American Diabetes Association

VSP Vision Care on 12/30/2009 5:39:00 PM

Proposed Objective Text: Reduce the proportion of undiagnosed diabetes by using comprehensive dilated eye exams as a diagnostic method.

Rationale: An eye exam provides a clear view of a patient's blood vessels which can show early signs of chronic diseases, such as diabetes. It’s estimated only 21% of adults receive a preventive health exam annually, while 61% of working American adults with coverage receive annual eye exams. An eye exam provides an opportunity for earlier diagnosis of both diabetes and pre-diabetes. [1]
Research has shown:

Diabetic retinopathy can occur up to seven years before diagnosis of type 2 diabetes.[2]
Up to 21% of people with type 2 diabetes have detectable retinopathy when they’re first diagnosed with diabetes.[3]
Approximately 8% of people with pre-diabetes (4.6 million) have signs of retinopathy that could be detected in an eye exam.[4]
In a recent study in Columbus, GA, a panel of optometrists participated in a public vision care outreach campaign. In addition to providing an eye exam, the eye doctors also screened patients for other health risks and referred at-risk patients to a medical clinic for additional testing and diagnosis 97% of the patients referred to the clinic were diagnosed with a metabolic disorder, demonstrating the diagnostic efficacy of comprehensive eye exams.[5]

Proposed Data Source(s): [1]VSP, the U.S. Census and the National Center for Health Statistic, Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis;
[2]Diabetes Care, Vol 15, Issue 7 815-819, Copyright © 1992 by American Diabetes Association);
[3] ADA 65th Annual Scientific Sessions: Late-breaking trials. Presented June 12, 2005;
[4]Medco Health Solutions Research, Medical Care Journal, Volume 43, Number 6, June 2005; Centers for Disease Control and Prevention;
[5] Improving the Nation’s Vision Health. http://www.cdc.gov/diabetes/pubs/pdf/vision.pdf.; Columbus Research Foundation

Anonymous on 12/30/2009 5:24:00 PM

Proposed Objective Text: Reduce the proportion of undiagnosed diabetes by using comprehensive dilated eye exams as a diagnostic method.

Rationale: An eye exam provides a clear view of a patient?s blood vessels which can show early signs of chronic diseases, such as diabetes. It?s estimated only 21% of adults receive a preventive health exam annually, while 61% of working American adults with coverage receive annual eye exams. An eye exam provides an opportunity for earlier diagnosis of both diabetes and pre-diabetes. [1]
Research has shown:

? Diabetic retinopathy can occur up to seven years before diagnosis of type 2 diabetes.[2]
? Up to 21% of people with type 2 diabetes have detectable retinopathy when they?re first diagnosed with diabetes.[3]
? Approximately 8% of people with pre-diabetes (4.6 million) have signs of retinopathy that could be detected in an eye exam.[4]

In a recent study in Columbus, GA, a panel of optometrists participated in a public vision care outreach campaign. In addition to providing an eye exam, the eye doctors also screened patients for other health risks and referred at-risk patients to a medical clinic for additional testing and diagnosis 97% of the patients referred to the clinic were diagnosed with a metabolic disorder, demonstrating the diagnostic efficacy of comprehensive eye exams.[5]

Proposed Data Source(s): [1]VSP, the U.S. Census and the National Center for Health Statistic, Onset of NIDDM occurs at least 4-7 yr before clinical diagnosis;
[2]Diabetes Care, Vol 15, Issue 7 815-819, Copyright ? 1992 by American Diabetes Association);
[3]ADA 65th Annual Scientific Sessions: Late-breaking trials. Presented June 12, 2005;
[4]Medco Health Solutions Research, Medical Care Journal, Volume 43, Number 6, June 2005; Centers for Disease Control and Prevention;
[5]Improving the Nation?s Vision Health. http://www.cdc.gov/diabetes/pubs/pdf/vision.pdf.; Columbus Research Foundation

ACOG on 12/30/2009 12:49:00 PM

Proposed Objective Text: Increase the number of postpartum women who had gestational diabetes mellitus who are screened for diabetes at 6-12 weeks postpartum. Gestational diabetes mellitus affects 2-10% of all pregnancies in the U.S. Approximately 15-50% of women with GDM will develop diabetes in the decades following the affected pregnancy.

Rationale: Gestational diabetes mellitus affects 2-10% of all pregnancies in the U.S. Approximately 15-50% of women with GDM will develop diabetes in the decades following the affected pregnancy.

Proposed Data Source(s): Create a HEDIS measure

Mike Mawby on 12/30/2009 12:07:00 PM

Proposed Objective Text: As noted in an earlier submission, Novo Nordisk is a company with a vision to defeat diabetes by finding better methods of diabetes prevention, detection and treatment.

The theme of “changing diabetes” permeates our culture and work. We are committed to improving the lives of people affected by this disease by creating change in the US system of health care and moving it toward an ideal diabetes environment that fully supports all aspects of diabetes prevention, treatment and care.

As we examined the proposed set of 16 objectives for diabetes, we noticed one critical omission – there is no objective specifying diabetes screening and detection. For all the reasons noted in our first recommendation, having diabetes screening-related objectives among the Healthy People 2020 objectives would significantly help further the cause of appropriate screening.

Therefore, we also propose the following objective:

Increase the proportion of adults ages 65 and older who have been tested for diabetes according to the Medicare standard for screening (ie, having any two risk factors for diabetes including being age 65 or older and having one additional risk factor for diabetes.

Rationale: It bears repeating that Novo Nordisk has been committed to appropriate screening for all adults through activities of the National Changing Diabetes® Program, and for older adults in Medicare through support of the Medicare Diabetes Screening Project (www.screenfordiabetes.org). Novo Nordisk has made an additional significant contribution to promoting use of Medicare’s benefits for diabetes screening through its “Ask.Screen.Know” program (www.askscreenknow.com). We believe that with the establishment of Healthy People 2020 objectives for diabetes screening, we could engage other companies and organizations to work collaboratively with the public health and clinical care communities in cooperative projects to identify and assist people with pre-diabetes who could be helped with community-based, cost-effective interventions, and those with undiagnosed diabetes, who could be appropriately counseled and treated.

The rationale for pursuing an objective such as we are proposing is compelling. Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program – a major NIH clinical trial found participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

1. Cowie, et. al., “Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988–1994 and 2005–2006,” Diabetes Care, February, 2009.
2. http://www.cms.hhs.gov/DiabetesScreening
3. http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram
4. Diabetes Prevention Program Research Group, “10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study,” The Lancet, 14November2009.
5. http://www.cms.hhs.gov/PrevntionGenInfo/20_prevserv.asp

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/30/2009 12:06:00 PM

Proposed Objective Text: Increase the proportion of individuals with lesser-known risk factors for diabetes who are screened for and receive counseling regarding diabetes.

Rationale: As noted above, data recently have emerged to substantiate that psoriasis is not just a disease of the skin and joints, but is a systemic, inflammatory autoimmune disease that is connected with a range of co-morbidities, including diabetes, independent of factors such as obesity, hypertension and high cholesterol. Of note, for example, is that diabetes is more prevalent in patients with severe psoriasis than in those with mild disease. As such, the Psoriasis Foundation advocates that any policies, programs or other initiatives, such as HP2020, that address diabetes should include or address psoriasis.

Proposed Data Source(s): Data: NIH and CDC

Anonymous on 12/30/2009 12:04:00 PM

Proposed Objective Text: Increase the proportion of health care professionals aware of the risk factors of diabetes and knowledgeable about associated conditions, such as psoriasis, so they can identify such characteristics among their patients and provide appropriate information and interventions.

Proposed Data Source(s): Data: NIH and CDC

Mike Mawby on 12/30/2009 11:53:00 AM

Proposed Objective Text: Novo Nordisk is a company with a vision to defeat diabetes by finding better methods of diabetes prevention, detection and treatment.

The theme of “changing diabetes” permeates our culture and work. We are committed to improving the lives of people affected by this disease by creating change in the US system of health care and moving it toward an ideal diabetes environment that fully supports all aspects of diabetes prevention, treatment and care.

We work actively to promote collaboration among all parties in the healthcare system in order to achieve our common goals. It is in this spirit that we are submitting comments to the Healthy People 2020 process. We believe the diabetes objectives that will be established for Healthy People 2020 will be important “north stars” for steering and motivating the public health and clinical care communities toward making progress in reducing diabetes incidence and preventing long-term complications in those diagnosed with diabetes.

As we examined the proposed set of 16 objectives for diabetes, we noticed one critical omission – there is no objective specifying diabetes screening and detection.

In the preamble of the diabetes chapter of the government’s current document on Healthy People 2010 objectives, the authors described four transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis:
• “Opportunities to meet the challenges of diabetes lie in four transition points in the natural history of this disease and the preventive interventions that target them: primary prevention, screening and early diagnosis, access, and quality of care (secondary and tertiary prevention).” (From Healthy People 2010, Chapter 5, Diabetes, in the “Opportunities” section).
Yet the set of diabetes objectives for 2010 did not contain an objective for screening; nor does the proposed set of diabetes objectives for 2020.

This is puzzling, given that for other important areas of public health, such as HIV/AIDS, cholesterol, and some forms of cancer, specific screening and testing objectives are proposed for Healthy People 2020. It seems logical to ask, “why not a screening-related objective for diabetes?”

Indeed, the diabetes community can point to a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

• Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT)? and United Kingdom Prospective Diabetes Study (UKPDS)? show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications.

• Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.³

Additionally, positive data from the DEPLOY study by Ronald Ackerman, MD, MPH and David Marrero, PhD show that primary prevention interventions can be cost effectively delivered in community-based settings such as YMCAs.? These data underscore the need for appropriate screening for pre-diabetes to identify the candidates most likely to benefit from any future investments in such community-based interventions.

Having diabetes screening-related objectives among the Healthy People 2020 objectives would significantly help further the cause of appropriate screening. We propose the following objective:

1. Increase the proportion of adults who have been tested for diabetes;

• Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes

• Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

?Nathan, et al, “Intensive Diabetes Treatment of Diabetes and Cardiovascular Disease in Patients with Type 1 Diabetes,” New England Journal of Medicine, 353; 25, December 22, 2005, pp. 2643-2653.

?Holman, et al, “10-Year Follow-up of Intensive Glucose Control in Type 2 Diabetes,” New England Journal of Medicine, 359;15, October 9, 2008, pp. 1577-1589.

³Diabetes Prevention Program Research Group, “10-Year Follow-up of Diabetes Incidence and Weight Loss in the Diabetes Prevention Program Outcomes Study,” The Lancet, published online, October 29, 2009, DOI:10.1016/S0140-6736(09)61457-4

?Ackermann, et al. 2008 American Journal of Preventive Medicine 35 (4), pp. 357-363

Rationale: Novo Nordisk has been committed to appropriate screening for all adults through activities of the National Changing Diabetes® Program, and for older adults in Medicare through support of the Medicare Diabetes Screening Project (www.screenfordiabetes.org). Novo Nordisk has made an additional significant contribution to promoting use of Medicare’s benefits for diabetes screening through its “Ask.Screen.Know” program (www.askscreenknow.com). We believe that with the establishment of Healthy People 2020 objectives for diabetes screening, we could engage other companies and organizations to work collaboratively with the public health and clinical care communities in cooperative projects to identify and assist people with pre-diabetes who could be helped with community-based, cost-effective interventions, and those with undiagnosed diabetes, who could be appropriately counseled and treated.

HP 2010 described four transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis, yet there was no screening objective in HP 2010 nor is there one in HP 2020, despite the fact that the transition points remain the same.

While there is an HP 2020 objective recommended to “increase the proportion of adults with diabetes whose condition has been diagnosed” (D HP2020-2), there is no means identified to accomplish this objective. Adding a screening objective, while important in and of itself, would also help reach this goal.

There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

• Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications

• Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.

Proposed Data Source(s): Data source for measuring the objective
Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/30/2009 11:48:00 AM

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of peopole 65 and older who are screened for diabetes because:

Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes (1).

Coverage: the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes (2).

Prevention: The Diabetes Prevention Program, a major NIH clinical trial, found participants in the lifestyle intervention group-those effective diet, exercise, and behavior modification-reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent (3). Follow-up studies show prevention of delay of diabetes with lifestyle intervention can persist for at least 10 years (4).

Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit (5).

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.
(1) Cowie, et.al., "Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988-1994 and 2005-2006," Diabetes Care, February, 2009
(2) http://www.cms.hhs.gov/DiabetesScreening
(3) http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram
(4) Diabetes Prevention Program Research Group, "10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study,"The Lancet, 14 November 2009
(5) http://www.cms.hhs.gov/PreventionGenInfo/20_prevserv.asp

Anonymous on 12/30/2009 10:40:00 AM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes;

Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes

Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/29/2009 6:34:00 PM

Proposed Objective Text: Expand the evidence based Diabetes Self Management Program created by Stanford University and administered by lay and professional instructors. This program can change the lives of persons living with diabetes at reasonable costs utilizing existing payment schedules. This can be done if only health care professionals will release the program for wide spread implementation.

Rationale: Too often addressing health care issues is an exercise in running up costs at the expense of grass roots investments in life changing behavoiral approaches to managing ones own care and support. The Chronic Disease Self Management Program, Diabetes module is able to make a difference utilizing a solid scripted program that is tested and proven to make a difference if practiced right, using lay and professional instructors (including those who are manageing their own diabetes using the program) and at locations that are accessible and comfortable in non medical settings (medical settings are too costly and too sterile to be meaningful to many patients).

Proposed Data Source(s): See Stanford University Kate Lorig RN PhD

The American Diabetes Association on 12/29/2009 11:34:00 AM

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program – a major NIH clinical trial found participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

1. Cowie, et. al., “Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 1988–1994 and 2005–2006,” Diabetes Care, February, 2009.
2. http://www.cms.hhs.gov/DiabetesScreening
3. http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram
4. Diabetes Prevention Program Research Group, “10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study,” The Lancet, 14November2009.
5. http://www.cms.hhs.gov/PrevntionGenInfo/20_prevserv.asp

The American Diabetes Association on 12/29/2009 11:32:00 AM

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/28/2009 11:19:00 AM

Proposed Objective Text: Increase access to environments that support physical activity and weight management programs for people diagnosed with pre-diabetes and diabetes.

Rationale: Increasing physical activity and promoting weight loss is an effective blood glucose control strategy.

Proposed Data Source(s): NHANES, CDC,

Anonymous on 12/22/2009 5:03:00 PM

Proposed Objective Text: Individuals diagnosed with diabetes be instructed to carefully check all surfaces of their feet each twice weekly for evidence of blister, callous, or breakdown.

Rationale: The prevention of diabetic foot ulcers.

Proposed Data Source(s): Primary care provider office (physician, nurse practitioner, immediate care office, VA physician, etc).

Anonymous on 12/22/2009 1:34:00 PM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes. A) Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes. B) Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

Rationale: Increasing the proportion of adults with diabetes who are diagnosed is a goal of the HP 2020 initiative. HP 2020 needs a concrete target to drive action towards that goal. The objective above aligns with the American Diabetes Association's recommendations and common sense. If we commit to testing those at risk (however you choose to define that risk), then the rate of diagnosis will increase.

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/22/2009 12:32:00 PM

Rationale: The Black Hawk County, IA Board of Health proposes this objective in support of one (of the four) critical transition points regarding screening and early diagnosis.

Proposed Data Source(s): Same as D HP2020-2: National health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/22/2009 12:29:00 PM

Proposed Objective Text: 1. Increase the proportion of adults who have been tested for diabetes:
a) Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes, including racial and/or ethnic disparity;
b)Among all adults, ages 20 and over, who have been tested for diabetes at least once in the preceding three years.

Rationale: The Black Hawk County, IA Board of Health proposes this objective in support of one (of the four) critical transition points regarding screening and early diagnosis; including risk associated with racial and ethnic disparity and age test of adults 20 years and older.

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS

Anonymous on 12/18/2009 7:48:00 PM

Proposed Objective Text: Increase rate of exclusive breastfeeding in infants born to families experiencing diabetes to 90%
75% of general population will be aware of protective benefits of breast milk and risks of formula feeding

Rationale: Breastfeeding reduces diabetic risk in both infants and mothers who experience gestational diabetes

Proposed Data Source(s): CDC and WHO data

Sheri Colberg PhD on 12/18/2009 12:05:00 PM

Proposed Objective Text: Increase the number of adults and youth with diabetes who participate in regular physical activity to help manage blood glucose control and prevent health complications

Rationale: Participation in regular physical activity/exercise has been shown to improve blood glucose control in most people with diabetes, prevent or delay the onset of type 2 diabetes, and lower the incidence of diabetes-related health complications. The published data in these areas are strong and will be reinforced in a revised, joint position stand by the American Diabetes Association and the American College of Sports Medicine to be published in 2010. Physical activity is even more critical to optimize health and enhance longevity in a diabetic population and should be considered an essential part of care for these individuals. Activity can also prevent onset of diabetes in high-risk, pre-diabetic individuals, of which there are more than 54 million in the United States. The incidence of diabetes is expected to double in the near future, with costs of caring for diabetes tripling in the same time frame. Many cases of diabetes are preventable and complications avoidable with inclusion of regular physical activity (aerobic and resistance training) into a daily or weekly routine. For all these reasons, physical activity needs to be included in the "Diabetes" objectives and not just in the "Physical Activity" section.

Proposed Data Source(s): Monitor physical activity participation via NHANES and other data monitoring systems already in place that collect information about diabetes status, health problems, and physical activity levels.

Anonymous on 12/18/2009 11:29:00 AM

Proposed Objective Text: Increase the proportion of adults ages 65 and older who have been tested for diabetes according to the Medicare standard for screening

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

• Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
• Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
• Prevention: The Diabetes Prevention Program, a major NIH clinical trial, found participants in the lifestyle intervention group—those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification—reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
• Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/18/2009 11:27:00 AM

Rationale: Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

?Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
?Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
?Prevention: The Diabetes Prevention Program, a major NIH clinical trial, found participants in the lifestyle intervention group?those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification?reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
?Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/18/2009 11:24:00 AM

Proposed Objective Text: ncrease the proportion of adults who have been tested for diabetes:
- Among adults of any age who are overweight or obese, and have one or more additional risk factors for diabetes
- Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

Rationale: HP 2010 described four transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis, yet there was no screening objective in HP 2010 nor is there one in HP 2020, despite the fact that the transition points remain the same.

While there is an HP 2020 objective recommended to “increase the proportion of adults with diabetes whose condition has been diagnosed” (D HP2020-2), there is no means identified to accomplish this objective. Adding a screening objective, while important in and of itself, would also help reach this goal.

Therefore, this proposal supports D HP2020-2. It should be pointed out that D HP2020-11 as currently written; Reduce the annual number of new cases of diagnosed diabetes in the population is not consistent with D HP2020-2: Increase the proportion of adults with diabetes whose condition has been diagnosed. D HP2020-2 will serve to increase the prevalence of diabetes within the population. HP2020-11 as currently written is attempting to demonstrate success through reduced prevalence. A possible solution is that Objective D HP2020-11 could be reworded as follows: Reduce the number of cases of individuals with known pre-diabetes from converting to overt diabetes.

There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

• Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications

• Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.

• The no cost, Medicare annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to data from the Centers for Medicare and Medicaid Services (CMS), in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

CMS – diabetes screening benefit data tracked annually by CMS claims data

Anonymous on 12/18/2009 11:20:00 AM

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

American Optometric Association on 12/16/2009 4:36:00 PM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes:
- Among adults of any age who are overweight or obese, and have one or more additional risk factors for diabetes
- Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years (Phrasing aligns with ADA recommendations)

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

CMS – diabetes screening benefit data tracked annually by CMS claims data

Anonymous on 12/11/2009 2:36:00 PM

Proposed Data Source(s): An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/11/2009 7:03:00 AM

Proposed Objective Text: Diabetes Screening for high risk individual.
More research on outcomes of pre-diabetes study.

Rationale: We are in a crises related to diabetes complications and healthcare cost. We need to be pro-active.

Proposed Data Source(s): Propose valid, reliable, nationally representative data and data systems for this objective.

Anonymous on 12/10/2009 2:15:00 PM

Proposed Data Source(s): Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/9/2009 1:49:00 PM

Proposed Objective Text: Increase the proportion of adults ages 65 and older who have been tested for diabetes according to the Medicare standard for screening

Rationale: HP 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:
. People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: 32% of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% have pre-diabetes.
. The Medicare RX Drug, Improvement and Modernization Act (MMA) of 2003 expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
.The DPP, a major NIH clinical trial, found participants in the lifestyle intervention group reduced their risk of developing diabetes by 58%. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71%. Follow-up studies show prevention or delay of diabetes with lifestule intervention can persist for at least 10 yrs.
.The free annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): An increase in the percentage of adults age 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/9/2009 1:30:00 PM

Proposed Objective Text: Increase the proportion of adults who have been tested for diabetes;
Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes
Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding 3 years

Rationale: HP 2010 described 4 transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis, yet there was no screening objective in HP 2010 nor is there one in HP 2020, despite the fact that the transition points remain the same.
While there is an HP 2020 objective recommended to "increase the proportion of adults with diabetes whose condition has been diagnosed (D HP2020-2), there is no means identified to accomplish this objective. Adding a screening objective, while important in and of itself, would also help reach this goal.
There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:
Accumulating data from follow-up studies to the DCCT and UKPDS show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications.
Also, recently released data from the DPPOS prove that long-term (10 yr.), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes

Proposed Data Source(s): D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS

Dr. Hulphers on 12/9/2009 12:13:00 PM

Proposed Objective Text: Diabetes is greatly impacted by the amount of physical activity a person achieves daily. The objectives for diabetes are all about the screening process, but nothing about physical activity. Knowledge and understanding about the impact of physical activity and diabetes control would help improve the amount of physical activity.

Rationale: Increase the number of people who understand the impact of physical activity has on diabetes.

Proposed Data Source(s): Propose valid, reliable, nationally representative data and data systems for this objective.

Anonymous on 12/8/2009 8:41:00 PM

Proposed Objective Text: Increase Diabetic eye screen among Diabetics.

Rationale: Eye damage from Diabetes is a preventable condition, inexpensive and easily done.

Proposed Data Source(s): ADA

Anonymous on 12/8/2009 6:39:00 PM

Proposed Objective Text: Increase the use of non-accredited facilities that screen and prvide preventive services for those at risk for diabetes.

Rationale: Accredited facilities focus on treatment and physician referred patients. This is already too late. We need to focus on prevention of diabetes altogether and not simply the prevention of complications.

Proposed Data Source(s): ADA Diabetes Data; BRFSS

Anonymous on 12/8/2009 3:02:00 PM

Proposed Objective Text: Increase the number of people with diabetes who have a blood pressure of less than 130/80 mmHg

Rationale: * As many as 2 out of 3 adults with diabetes have high blood pressure.

* High blood pressure increases your risk for heart attack, stroke, eye problems, and kidney disease.

Proposed Data Source(s): BRFSS

Anonymous on 12/8/2009 3:00:00 PM

Proposed Objective Text: Increase the number of people with diabetes who have a blood pressure of less than 130/80 mmHg

Rationale: As many as 2 out of 3 adults with diabetes have high blood pressure.

High blood pressure increases your risk for heart attack, stroke, eye problems, and kidney disease.

Proposed Data Source(s): BRFSS

Anonymous on 12/8/2009 12:49:00 PM

Proposed Objective Text: Objective
Increase the proportion of adults who have been tested for diabetes;

• Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes

• Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

Rationale: There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

• Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications

• Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.

Proposed Data Source(s): Data source for the measuring of the objective:
Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/8/2009 11:00:00 AM

Rationale: Rationale
Healthy People 2020 should establish a national goal to increase the percentage of people 65 and older who are screened for diabetes because:

? Prevalence: People 65 and older have the highest prevalence of diabetes and pre-diabetes of any age group: Thirty-two percent of adults 65 and older have diabetes and 46% of them are undiagnosed. An additional 40% of those 65 and older have pre-diabetes.
? Coverage: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes.
? Prevention: The Diabetes Prevention Program, a major NIH clinical trial, found participants in the lifestyle intervention group?those receiving intensive individual counseling and motivational support on effective diet, exercise, and behavior modification?reduced their risk of developing diabetes by 58 percent. Lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by 71 percent. Follow-up studies show prevention or delay of diabetes with lifestyle intervention can persist for at least 10 years.
? Low utilization: The free, annual screening benefit is underutilized, especially given the large percentage of Medicare beneficiaries who are at risk. According to CMS data, in 2006 just 9.6% of beneficiaries used the Medicare diabetes screening preventive benefit.

Proposed Data Source(s): Data source for measuring the objective
An increase in the percentage of adults 65 and older who utilize the diabetes screening benefit can be tracked annually by CMS claims data.

Anonymous on 12/8/2009 10:58:00 AM

Proposed Objective Text: Objective
Increase the proportion of adults who have been tested for diabetes;

? Among adults of any age who are overweight or obese, and have one or more additional risk factor for diabetes

? Among all adults, ages 45 and over, who have been tested for diabetes at least once in the preceding three years

Rationale: Rationale
HP 2010 described four transition points that are critical for making a difference in diabetes. One of these transition points was screening and diagnosis, yet there was no screening objective in HP 2010 nor is there one in HP 2020, despite the fact that the transition points remain the same.

While there is an HP 2020 objective recommended to ?increase the proportion of adults with diabetes whose condition has been diagnosed? (D HP2020-2), there is no means identified to accomplish this objective. Adding a screening objective, while important in and of itself, would also help reach this goal.

There is a growing body of evidence that underscores the need for intensified efforts in appropriate diabetes screening to identify people with undiagnosed diabetes and pre-diabetes:

? Accumulating data from follow-up studies to the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS) show the long-term benefits of early, intensive intervention in diabetes treatment to prevent or delay complications

? Also, recently-released data from the Diabetes Prevention Program Outcomes Study (DPPOS) prove that long-term (10-year), significant reductions in onset, or delay of onset, of type 2 diabetes can be obtained among people with pre-diabetes.

Proposed Data Source(s): Data source for the measuring of the objective:
Same as D HP2020-2: National Health and Nutrition Examination Survey, CDC, NCHS.

Anonymous on 12/3/2009 5:34:00 PM

Proposed Objective Text: Reduce the number of people who are overweight.

Rationale: More Americans are overweight leading to the complications of poor glycemic control.

Proposed Data Source(s): Propose valid, reliable, nationally representative data and data systems for this objective.

Sarah YoungXu on 12/2/2009 8:52:00 PM

Proposed Objective Text: increase the proportion of diabetics that are engaged in aerobic exercise at least 3 times per week

Rationale: improve cardiovascular outcomes

Proposed Data Source(s): provider reports of patient's exercise habits

Anonymous on 11/29/2009 4:16:00 PM

Proposed Objective Text: To decrease the one in three 65 and above who fall each year to one in four, and then one in five, etc. by increasing the awareness of exercise programs that can address the root cause of falling, education and testing using Physical Therapy, Occupational Therapy and Speech Language Pathology to make sure that everyone who is 65 and above is tested for fall risk factors identified by Mary E. Tinetti, M.D. in the New England Journal of Medicine, July 17, 2008. Effectice strategies have been identified but are under utilized.

Rationale: There has been no mention of falling or aquatic exercise in these very comprehensive objectives listed by the committee. There are 10 million swimming pools and 350,000 seasonal swimming pools that provide easy access to all 300 million Americans. The proposal made by Dr. Tinetti is being looked at and studied at every Physical Therapy Program in the United States and the Aquatic Therapy Institute headed by Ruth Sova, member of the President's Council on Physical Fitness. If we acknowledge that the energy cost of swimming a given distance is four times greater according to William McArdle, Professor, Department of Health and Physical Education at the Queens College of the City of New York, it follows that this would necessitate the addition of Aquatic Exercises to address the 67% of the Country struggling with Obesity according to the Prevalence and Trends in Obesity Among U.S. Adults, 1999-2009, by Katherine M. Flegal, PhD. The increasing percentages over the past decade, from the National Center for Health Statistics at the Center for Disease Control and Prevention in Hyattsville, Md. would indicate that offloading compressive forces is indicated while exercising with increased girth and mass.

Prior to the current increase in BMI measurements pools were strategically built in all the major population centers with the idea of encouraging aquatic benefits. It is effective with Tai Chi in the water by a study with Mau-Roung Lin, Hei-Fen Hwang, in Physcial Therapy, Vol. 86, Number 9, Sept. @006, Gait Patterns and Muscle Activity in the Lower Extremities of Elderly Women during Underwater Treadmill Walking against Water Flow in the Journal of Physiological Anthropology by Tomoki Shono 26(6):579-586, 2007.

In the Sport Sci Health Journal 20 July 2004 proposed a pilot study examining and measuring the quantitative effects of a water exercise program in subjects with knee osteoarthritis.

Aquatic therapy facilitates progression of occupational performance skills , including functional transfer training, occupational performance skills, bending and reaching, coordination, static and dynamic balance in sitting, standing and lying positions. Examples of practicing quick reciprocal movement patterns to enhance the balance necessary to develop righting reactions to prevent falls on land (Simmons and Hansen, 1996.)

While performing these tasks good posture requires constant energy expenditure, which tends to become increasingly difficult with age and health complications. Buoyancy, Hydrostatic and Hydrodynamic Pressure, along with Thermal Sensory Input make this a very important consideration for the committee.

Proper breathing mechanics which can contribute to better sleep (Tilden 2005) can also be enhanced with Aquatic Exercise because abnormal respiration can discourage relaxation due to overused inspiratory muscles reinforce many pain syndromes of the head, neck, and shoulders. (Gallagher, 2005.) By incorporating proper breathing muscles into slow rhythmical water exercise, one can achieve progress toward stress management and restful nights. (Comprehensive Aquatic Therapy, Dr. Bruce Becker, 2009.)

Aquatic Therapy may be delivered in a variety of settings, including but not limited to, skilled nursing facilities, hospitals, assisted living facilities, adult day programs, hospice, continuing care retirement centers, senior centers, outpatient clinics, and the community.

Aquatic Therapy Programs are popular with group wellness classes especially with arthritis, multiple sclerosis, Parkinson's disease, Plantar Fasciitis, Back Pain, Fibromyalgia, Metabolic Syndrome, Heart Disease, Breast Cancer, Hodgkin's Lymphoma, and Diabetes Type 1, 2 or 3.

In the Journal of Geriatric Physical Therapy Vol. 26; 1:03 it was determined that Aquatic Exercise was more effective than land based exercise using the Berg Balance Test between pretest and post test. Likewise in the Rheumatology International, 24 January 2008, by Deniz Evcik, Department of Rehabilitation Ankara Turkey, that Aquatic Exercise was a superior modaltiy for treating persons with Fibromyalgia syndrome in a randomized controlled open study.

In the Australian Jouranl of Science and Medicine in Sport, March 1990, sufficient heart rates were encountered during deep water running satisfies the principles of specificity of training for running activities, and that an eight week water running programme was successful in improving aerobic and anaerobic fitness.

A study in Clinical Rehabilitation by Dong Koog Noh, examined the effect of aquatic therapy on postural balance and muscle strength in stroke survivors- a randomized controlled pilot trial that concluded that postural balance and kknee flexor strength were improved based on the Halliwick and Ai chi methods of in stroke survivors.

A systemic collection of effective studies on Therapeutic Aquatic Exercise in the treatment of low back pain is given by Waller B. Lambeck in Clin Rehabilitation 2009, Jan; 23(1):3-14. There was sufficient evidence to sugggest that therapeutic aquatic exercise is potentially beneficial to patients suffering from chronic low back pain and pregnancy related back pain: 1) McIlveen, B in Physiotherapy, 1998:84: 17-26, A study of the outcome of hydrotherapy for subjects with low back pain or leg pain. Schrepfer, R. A comparison of changes in the visual analogue scale in the Journal of Aquatic Physical Therapy,2000; 8: 25-28. Saggini, R. Eur Medicophys 2004; 40:311-16 with two microgravitational protocols to treat chronic low back pain associated with discal lesions, RCT. Friedrich, M. Long term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain in Spine 2005; 30: 995-1000. Marks R., Chronic Osteoarthritis and adherence to exercise: a review of the literature. Journal of Aging Physical Activity 2005; 13: 434-60.

The American Physical Therapy Association has a collection of evidenced based studies that point to the solidity of the body of research that indicates that going back to the times of Hippocrates, Aquatics are good for the ailments of the population.

We know that 50 million Americans go to a pool and swim every year. 4,000 drown each year. The American Red Cross has an amazing network of experts who are waiting to train Water Safety Instructors, Lifeguards. The National Swimming Pool Foundation is training hundreds of thousands of Pool Operators to make sure that the water is safe. All across the Country the Aquatic Exercise Association, the Aquatic Therapy Association are having conventions to increase the proficiency of programs to help with the objectives in this document for 2020. The American Physical Therapy Association, the American Occupational Therapy Association and the American Speech, Hearing, Language and Pathology Association are ready to assist with this initiative.

Advising overweight, sedentary people to go out and walk 10,000 steps a day without qualification is a risky strategy without the inclusion of buoyancy, hydrodynamic, thermal sensitivity to help to get America moving safely and with vigor.

Proposed Data Source(s): Propose valid, reliable, nationally representative data and data systems for this objective.

Anonymous on 11/21/2009 4:33:00 PM

Proposed Objective Text: Provide counter ads to fast food advertisements on TV

Rationale: None or few ads on TV encourage people to eat well

Proposed Data Source(s): Count the number of healthy-eating ads on TV
Encourage funding sources to purchase healthy-eating ads on TV
follow the pattern used by stop smoking ads on TV

Anonymous on 11/21/2009 2:37:00 PM

Proposed Objective Text: Increase the incidence and duration of breastfeeding.

Rationale: Breastfeeding reduces the risk of Type 1 and Type 2 Diabetes for the infant.
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Structured Abstract. May 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/brfouttp.htm
Dose-response relationships were seen; in fully adjusted models, women who reported a lifetime history of more than 12 months of lactation were less likely to have diabetes.
Schwarz, Eleanor Bimla MD, MS; Ray, Roberta M. MS; Stuebe, Alison M. MD, MSc; Allison, Matthew A. MD, MPH; Ness, Roberta B. MD, MPH; Freiberg, Matthew S. MD, MSc; Cauley, Jane A. DrPH. “Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease”Obstetrics & Gynecology: May 2009 - Volume 113 - Issue 5 - pp 974-982.

Proposed Data Source(s): CDC National Immunization Survey
http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm

Anonymous on 11/18/2009 4:08:00 PM

Proposed Objective Text: Increase the proportion of persons screened for prediabetes.

Rationale: Prediabetes is called out under the new topics, DHP2020-16, but we first need to improve identifying/screening those at risk before we can get them engaged in lifestyle behaviors. Lack of screening/identification of predibetes has been a barrier in a pilot intervention WA is conducting in YMCA's using the Diabetes PRevention Program (DPP).

Proposed Data Source(s): Journal of General Internal Medicine 2009

Anonymous on 11/16/2009 12:00:00 PM

Proposed Objective Text: Increase the proportion of pregnant women who receive screening for gestational diabetes.

Rationale: Gestational diabetes is one of the most common complications of pregnancy. Women with undiagnosed gestational diabetes have a higher incidence of complications (maternal, fetal, & neonatal).

Proposed Data Source(s): The California Diabetes & Pregnancy Program
http://www.cdph.ca.gov/programs/cdapp/Pages/default.aspx

Cathy Clark RN on 11/4/2009 1:57:00 PM

Proposed Objective Text: Increase awareness of a night shift employees risk for diabetes.

Rationale: Research confirms the risk factors associated with diabetes and working “off” shift hours. An impaired circadian rhythm can be the causative factor in abnormal insulin and cortisol levels. These abnormal levels can contribute to diabetes, cardiovascular disease, gastrointestinal disorders, breast and prostate cancer and impaired cognition. There are interventions that can help improve this condition. Alerting the employee and their family to the risk factors will encourage medical screenings. Educating on appropriate food choices available on nights, along with “work friendly” exercises can help improve the medical conditions. Community awareness of the risk factors associated with driving while exhausted can improve our current driving stats of accidents associated with fatigue-related car accidents. Educated family and friends can offer psychosocial support to the employee by contributing to their well being, i.e. act as a human alarm clock and/ or driver of the night shift worker to clinics for well health screenings. “Work specific” education can be offered to employees during working hours when cognition is at its peak.

Proposed Data Source(s): http://www.harvardscience.harvard.edu/culture-society/articles/researchers-find-potential-cause-heart-risks-shift-workers

Anonymous on 11/4/2009 1:54:00 PM

Proposed Objective Text: Increase awareness of a night shift employees risk for diabetes.

Proposed Data Source(s): http://www.harvardscience.harvard.edu/culture-society/articles/researchers-find-potential-cause-heart-risks-shift-workers

Betty C. jung on 11/3/2009 9:46:00 AM

Proposed Objective Text: Increase the proportion of post-partum screening among women who had gestational diabetes

Rationale: Current statistics show that very few women return for post-partum screening. It is essential that women who had gestational diabetes be appropriately diagnosed as having gestational diabetes and rule out the possibility of type 2 diabetes. Such screening will provide early opportunities to properly educate women who had gestational diabetes about lifestyle modifications that can prevent subsequent gestational diabetes and development of type 2 diabetes. Such screening will also identify those women who may have type 2 diabetes that was not diagnosed prior to being pregnant and facilitate timely treatment of this disease to prevent complications

Proposed Data Source(s): http://www.bettycjung.net/Inprint/GDM2008.pdf; numerous recommendations from professional diabetes organizations

Betty C. jung on 11/3/2009 9:37:00 AM

Proposed Objective Text: Increase the proportion of pregnant women who are screened for gestational diabetes

Rationale: Early diagnosis would result in timely treatment of women who are at risk for not only birth complications but for the development of type 2 diabetes.

Proposed Data Source(s): http://www.bettycjung.net/Inprint/GDM2008.pdf; numerous peer-reviewed literature reporting on the HAPO study

Anonymous on 11/2/2009 5:44:00 PM

Proposed Objective Text: Establish funding for lay educators who have had success in controlling diabetes

Rationale: ADA and JDRF are only focused on research

Proposed Data Source(s): They get all of the funding. Tye 2 does not need more research but more resources in the right hand.

Anonymous on 10/30/2009 5:07:00 PM

Proposed Objective Text: Decrease the proportion of adults with diabetes who are current smokers.

Rationale: Smoking increases the already elevated risk for heart attack, stroke, kidney failure, and lower extremity amputation in people with diabetes.

Proposed Data Source(s): Behavioral Risk Factor Surveillance System