Interim Report:
Proposed Recommendations for Action

A National Public Health Initiative on Diabetes and Women's Health

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Disease Tracking and Research Recommendations

This section highlights priorities for disease tracking and research to further knowledge about the impact of diabetes on women’s health. Recommendations are divided into five categories: disease tracking, epidemiologic research, socioenvironmental and behavioral research, translational research, and biomedical research.

Disease Tracking covers the ongoing and systematic collection, analysis, interpretation, and dissemination of data to understand the nature and extent of diabetes and its complications among women, including changes over time in incidence, prevalence, and risk factors.

Epidemiologic research questions address population-based studies to better identify and understand the distribution of diabetes and its risk factors among women.

Socioenvironmental and behavioral research questions explore the identification and analysis of social, behavioral, economic, and political factors influencing diabetes and its complications among women.

Translational research questions address studies that aim to convert findings from other types of research into practical programs, policies, techniques, and materials for real-world settings.

Biomedical research questions involve basic science and clinical research aimed at characterizing the mechanisms and risk factors that influence diabetes and its complications among women. This document emphasizes prevention and public health, but advances in relevant clinical and basic science research could enhance the effectiveness of public health programs and policies.

Recommendations for disease tracking and research questions that pertain to all women are presented first, followed by additional research topics that are pertinent to each life stage.

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All Women

Disease Tracking
To enhance disease tracking of diabetes among women and its impact on their health, the following actions are recommended:

• Define and monitor the geographic distribution of diabetes among females.
• Expand population-based disease tracking to monitor and understand intragroup variations in disease distribution and the factors (such as cultural, racial, ethnic, geographic, demographic, socioeconomic, and genetic) that influence risks for diabetes and complications.
• Establish routine disease tracking of the quality of care for women of childbearing age (for example, the Pregnancy Risk Assessment Monitoring System [PRAMS] for women who have had a recent live birth) and women in later years.
• Routinely collect and analyze disease tracking data by life stage.
• Design disease tracking systems to track and assess where and from whom women are receiving health care.

Epidemiologic Research Questions

• What valid indicators can be used to measure intragroup variations (such as cultural, demographic, socioeconomic, and genetic factors) in disease distribution that influence the risk for diabetes and its complications?
• How do changes in diet, physical activity, psychosocial stress, and work conditions affect the onset of diabetes, particularly for immigrant and disadvantaged populations?

Socioenvironmental and Behavioral Research Questions

• What are some of the psychosocial factors and measures that facilitate (or hinder) successful completion of interventions designed to promote diabetes self-management?
• What are women’s perceptions of health care providers’ recommendations?
  • To what extent are the recommendations of health care being followed after patients leave the office?
  • Do health care professionals clearly explain recommendations and instructions for care so that patients can comprehend them?
  • What barriers do women face in trying to follow the recommendations?
• What are the care-seeking behaviors of the uninsured and the working poor?
• How does physical activity change over the life span, and how does this influence the risk for diabetes?
• What is the effect of depression on the lives of women living with diabetes, including their ability to self-manage, obtain adequate health care, and control their risk for diabetes complications?
• How can interventions with immigrant populations encourage physical activity and positive dietary patterns after they move to urban or other new settings?
• What are the best practices for diabetes self-management, use of computerized learning programs, and support groups?
• What is the effect of family structure, income, education, and community factors on diabetes risk, prevention, and care?
• What is the role of social isolation in accelerating risk factors that lead to diabetes and its complications, and at which life stages is it most critical?
• What influence do culturally relevant or health-relevant aspects of religious practice have on health?

Translational Research Questions
In Health Communications and Program Design

• What are the knowledge level, attitudes, and perceptions of diabetes risk among health care providers, patients, and the general population, and how do these vary by age, race, ethnicity, and culture?
• What are the community’s perceptions of appropriate risk reduction strategies (including programs, resources, and priorities), and to what extent does community-wide “buy-in” exist for application of these strategies?
• How do the history and traditional beliefs of a racial, ethnic, or cultural groups affect health messages and intervention design and delivery about diabetes and its risk factors?
• How can healthy uninsured and underinsured persons be reached, and what messages do they need to hear about diabetes prevention?
• How can women who do not believe in allopathic medicine be reached?
• How can the media be used effectively to reach and mobilize various communities and populations?
  • What makes a media message persuasive enough to change behavior?
  • Do these elements differ by racial, ethnic, cultural, educational, and religious groups?
• What diabetes education literature is available for women of different ages or life stages, in different languages, and for low-literacy populations?
  • What is the quality of that literature?
  • Does it cover all aspects of diabetes?
  • What adaptations to existing diabetes prevention program materials and methods are needed to be effective for pregnant, postpartum, and nonpregnant women?
• How do women with diabetes rank health issues with regard to primary, secondary, and tertiary care?
  • Do they have different concerns at different life stages or levels of care?
  • What would encourage them to respond differently to these levels?
  • How, where, and from whom do women prefer to receive health information for primary, secondary, and tertiary levels of prevention?
• How can other organizations and programs be convinced to incorporate diabetes messages?
• What are effective ways to encourage women to participate in preventive behaviors?
• What strategies will effectively maintain or increase physical activity and healthy eating at critical times in a woman’s life, such as transition to adolescence, pregnancy, or postpartum?
• What are the characteristics of diabetes-related prevention and intervention services that contribute to effective recruitment, retention, and achievement of stated aims for women at different life stages?
• What is the most effective way to identify leadership and empower specific groups of women to promote disease prevention and management?
• How can traditional public health organizations and programs best partner with those outside of public health to benefit women with diabetes?

In Health Service Delivery

• How do women define an effective source of diabetes services, and what do women with diabetes look for and want in health services?
• What models of effective diabetes-related preventive care services exist or can be tested?
• What diabetes education classes or medical nutrition therapy classes are available and paid for by health insurance plans?
• What tests and information are various types of health care providers including in their standard examinations and counseling sessions (particularly in settings that serve large numbers of minority patients? Are mutually agreed upon goals established?
• Do health care providers follow accepted guidelines for prevention and management of diabetes?
  • Are there differences in care for different population groups?
  • Are there differences between types of health care providers?
• What strategies can best be used to deliver prevention messages and interventions to patients who present in emergency rooms, and are there opportunities to reach women through other health care professions or venues (such as pharmacies)?
• What are the effects on diabetes care of moving from one health care professional to another as treatment and age demands (for example, from pediatricians to gynecologists or from general practitioners to ophthalmologists), and what are effective strategies for maintaining continuity of care?
• What is the relationship between diagnosis, treatment, and postpartum follow-up of gestational diabetes and the risk for subsequent gestational diabetes, polycystic ovary syndrome, and type 2 diabetes?
• What strategies best improve communication between health care professionals and women of different cultures, races, ethnicities, ages, and so on?
• Do uninsured and underinsured women, including the working poor, access diabetes care?
  • If so, how?
  • What is the best way to provide services to these women?
• How can employers and health insurers be motivated to include essential elements in their diabetes benefit packages?
• What standardized diagnostic testing protocol (for example, time of day and meals prior to testing) will allow valid comparisons within and between various demographic groups?
• How can the team approach to diabetes care be implemented?

In Health Economics

• What is the lifetime cost of health care (including clinical system cost, patient cost, support systems cost, supplies, and equipment) for a woman diagnosed with diabetes at various life stages?
• What are the direct and indirect costs of undiagnosed and untreated diabetes during pregnancy for the mother and her baby?
• What are the costs associated with long-term diabetes prevention programs, such as regular physical activity and healthful eating?
• What are the societal costs of diabetes among women in terms of lost productivity, lost time at work, disability, social assistance, and premature death?
• What are the most cost-effective interventions, both traditional and nontraditional?
• How do changes in cost or health insurance coverage affect outcomes?

Biomedical Research Questions

• What is the natural history of the development of diabetes in women?
• What are the most critical periods (fetal, perinatal, childhood, adolescence) for an intervention to have maximum affect on long-term outcomes?
• How can we advocate that biomedical research involve more women? How can we extrapolate biomedical research findings from men to women?

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The Adolescent Years (ages 10–17 years)

Many of the research questions listed in the previous section pertain to adolescents. This section highlights additional questions unique to the life stage that encompasses females aged 10-17 years.

Epidemiologic Research Questions

• Does the level of physical activity change during the adolescent years?
  • If so, how and why?
  • How does this affect the risk for diabetes?
• How nutritious are school lunches, and what types of snacks and drinks are offered in school vending machines?
• What is the content and quality of physical education classes and curricula?
• What percentage of adolescents participate in organized sports or other physical activity, and with what health benefits?

Socioenvironmental and Behavioral Research Questions

• What are the effects of peer pressure and other psychosocial factors on eating habits and participation in physical activity during adolescence, and how do they vary by culture, race, ethnicity, or income?
• What is the role of school systems in encouraging environments that enhance diabetes prevention opportunities (for example, increasing diabetes awareness and encouraging physical activity and healthy eating)? Are dietary standards and physical education standards followed?
• What impact have new school, health care, and other social policies over the past decade had on the incidence of diabetes among adolescent females?
• Are female adolescents who work outside the home at more or less risk of developing obesity or diabetes? If so, why?

Translational Research Questions
In Health Communications and Program Design

• Who will adolescent females talk to about personal and sensitive health issues?
• What is the impact of advertising on adolescent females’ food choices and eating habits and on their participation in physical activity?
• What are adolescent females’ perceptions and knowledge about healthy eating and physical activity, and what are the consequences of these perceptions and knowledge?
• Where do adolescent females get diabetes information that they consider important and credible, and what are effective ways to communicate this information to them?
• How can food practices be altered, such as fast food choices, school vending machine selections, and foods served at sporting events and movies?
  

In Health Service Delivery

• What is the pediatrician’s role in preventing, diagnosing, referring, treating, and following adolescent females with gestational diabetes and polycystic ovary syndrome?
• How well do health care providers distinguish type 1 diabetes and type 2 diabetes developed during adolescence?
• What is the role of school nurses in preventing, identifying, treating, and referring students with diabetes?
• What is the extent of health care professionals’ knowledge of the risk factors, diagnosis, and treatment of type 2 diabetes in children?

In Health Economics

• What are the costs of type 2 diabetes prevention in youth?

Biomedical Research Questions

• What is the most effective use of insulin versus oral agents among adolescents?
  

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The Reproductive Years (ages 18–44 years)

Specific research questions for the life stage covering ages 18–44 years are itemized below.

Socioenvironmental and Behavioral Research Questions

• What are the family and community support systems for reproductive-aged women with diabetes, and how can their development be encouraged?
• What are the determinants of women’s behavioral of patterns and attitudes regarding physical activity during the reproductive years? How can it be made more socially acceptable to include physical activity and healthy eating as normal parts of everyday life during the reproductive years?
• What is the impact of depression and eating disorders on the lives of reproductive-aged women with diabetes, including their ability to self-manage, obtain adequate health care, and control their risk for diabetes complications?

Translational Research Questions
In Health Communications and Program Design

• What are the beliefs of health care providers and patients about gestational diabetes, its seriousness, and its consequences, and what is the impact of these beliefs on content and quality of care?
• How can the future risk for developing diabetes be communicated to women diagnosed with gestational diabetes?

In Health Service Delivery

• What is the pattern of health care use for reproductive-aged women with diabetes, and how does this pattern vary with socioeconomic status?
• What are the best methods for diagnosing and treating women who may not use reproductive health services?
• Are current standards of prenatal and postpartum diagnosis and follow-up care being followed?
  • At what proportions and with what quality?
  • Which groups of women are most likely to receive inadequate follow-up care?
• What is the extent of postpartum follow-up of women with gestational diabetes and women at high risk of developing diabetes?
• How can existing opportunities or new opportunities be used to identify high-risk women for early intervention and prevention activities (for example, clinics for family planning, prenatal care, postpartum care, or WIC)?
• What is the pediatrician’s role in following up with women who have been diagnosed with gestational diabetes?
• What models exist for effective delivery of health care for reproductive-aged women in terms of diabetes prevention and management?

Biomedical Research Questions

• Among women of reproductive age, to what extent is depression an indicator or potential risk factor for developing diabetes, eating disorders, or other conditions?
• What effects do changes in weight, diet, and physical activity during and after pregnancy have on the risk of developing gestational diabetes and type 2 diabetes?
• Can early behavioral intervention reduce the risk of gestational diabetes?
• Can effective control of gestational diabetes reduce the woman’s risk of subsequent type 2 diabetes?
• What is the interaction between contraception choice and the risk of developing diabetes?
  

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The Middle Years (ages 45-64 years)

Additional recommendations for research regarding women in the middle years (ages 45-64 years) are listed below.

Socioenvironmental and Behavioral Research Questions

• What types of health care professionals and health care services do women in middle age seek?
• What is the role of spirituality and natural medicine in maintaining and improving health among middle-aged women with diabetes?
• To what extent does the caretaker role for elderly parents, children, and families interfere with a woman’s ability to provide self-care or seek health care services for herself?

Translational Research Questions
In Health Communications and Program Design

• How, where, and from whom do women in middle age prefer to receive health information for primary, secondary, and tertiary levels of care?
• What diabetes education literature and interventions are available for women in their middle years, and how effective are they for different literacy levels, languages, cultures, religions, races, and ethnicities?
• What interventions for diabetes in the middle years will best affect long-term outcomes and improved quality of life?
• How should the delivery of prevention services to middle-aged women with diabetes be designed?

In Health Economics

• What affects do diabetes self-management policies have on small and large businesses?

Biomedical Research Questions

• How can middle-aged women with diabetes and comorbidities be supported and their conditions managed?
  

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The Older Years (ages 65 and older)

Research questions pertinent to women aged 65 years and older are as follows:

Socioenvironmental and Behavioral Research Questions

• Are there differences in methods used to alter behaviors related to diet and physical activity later in life than at other life stages?
• How are aging networks and other community coalitions being used to reach the elderly with diabetes education, and how effective are they?
• How can peer volunteers and other strategies be best used to support families?
• Are there grassroots organizations, such as churches and beauty shops, which provide ongoing support groups for older women with diabetes?
  • How can additional grassroots organizations be encouraged to get involved?
  • What are other sources of support in the community for older women with diabetes?
• To what extent does caring for a frail, elderly spouse interfere with a woman’s ability to provide self-care or seek health care services for herself?

Translational Research Questions
In Health Communications and Program Design

• What are the most effective methods for educating the elderly about medical nutrition therapy, detection, comorbidities, and the importance of regular physical activity?
• Are easy-to-read, understandable publications available to help elderly women comprehend how a new diet and physical activity regimen will help control their diabetes?

In Health Service Delivery

• How can patients’ time with a health care worker be maximized to better support the patient in incorporating diabetes management into their lifestyle?
• What are health care providers’ perceptions of caring for elderly women with diabetes, and how do these perceptions influence the quality of care and services provided?
• What are the use, compliance, participation, and outcome rates of available health care programs and services for older women?
• How can health care provisions such as prescription drug coverage be ensured for the Medicare population that is underinsured?
• How can the quality of care for the elderly be improved through affordable health insurance, better access to health care, or education for health care providers?

Biomedical Research Questions

• What is the connection between depression, physical activity, healthy eating, interpersonal relationships, and diabetes in the older years?
• To what extent does multiple prescription drug use in the elderly years interfere with diabetes self-management?
• How is physical activity limited by arthritis, the risk of falls, general frailty, and osteoporosis?

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