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Interim Report:
Proposed Recommendations for Action

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

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Strategy and Policy Recommendations

Many state and local agencies and organizations, including the diabetes control programs supported in large part by CDC, are engaged in the prevention and control of diabetes. However, significantly large gaps exist in the tools, capacities, and resources of these organizations. To fill these gaps, this section presents recommended strategies and policies of highest priority for action in the next 3-5 years. Recommendations encompass two major areas: Communication and Education and Services and Programs. Included in the area of communication and education are recommendations for increasing awareness of diabetes among women, the disease’s impact on women’s health, effective prevention strategies, and the importance of early diagnosis and management. Strategies and policies target women in each of the life stages, as well as their families, health care providers, and other professionals who may serve them. Recommendations in the area of services and programs aim to improve the effectiveness of services at the local, state, and national levels to prevent and manage diabetes among women. They encompass strategies and policies for schools, work sites, health care systems, and other community organizations and settings.

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All Women

Several key strategy and policy recommendations pertain to women of all ages, regardless of their life stage. Some of these recommendations also appear later in this report, in the context of a specific life stage.

Strengthen advocacy on behalf of women with or at risk for diabetes, either by constituting a new organization focused exclusively on the issues related to diabetes and women’s health, or by forming a consortium of existing organizations with missions that encompass diabetes, chronic disease, and quality of life for women.
Increase awareness among the general public of the seriousness and preventability of diabetes in women. Using social marketing approaches, educational programs should be designed to appropriately consider age, language, literacy level, culture, race, ethnicity, motivation, and other relevant factors including access to personal, family, and community resources.
Expand community-based health promotion education, activities, and incentives for all ages in a wide variety of settings such as: schools, workplaces, senior centers, churches, civic organizations, and the like. Of particular importance are messages promoting physical activity, healthy eating, and smoking cessation. Materials and activities should be available at all times of the year, but especially materials on diabetes during National Diabetes Awareness Month in November. Representatives of community organizations should be involved in all aspects of the program, from early planning through implementation and evaluation.
Integrate diabetes messages and prevention activities within the larger context of chronic disease prevention and health promotion. Health organizations should strive to cooperate, strategize, and plan public health initiatives with organizations in other sectors, such as education, parks and recreation, city planning, and businesses.
Enhance community development policies and practices including “smart growth” initiatives and empowerment zones) that promote safe environments for physical activity such as: recreational facilities and activities, parks, sidewalks, mass transit, well-lit neighborhoods.
Increase availability of and access to healthy food choices for all sectors of the population. This recommendation is particularly important for urban and economically disadvantaged populations.
Support policies and programs in schools and workplaces that respect the health-related needs of their female students and employees, particularly women with or at risk for diabetes, and facilitate prevention and self-management of the disease.
Fortifying community programs with
- guidelines on education strategies at different levels of funding, including tips for developing multisectoral coalitions, implementing strategies, ways to use available resources most efficiently, discussion of resource allocation issues to aid decision making, and suggestions for accessing extant resources,
- measures for evaluating diabetes activities,
- dissemination of “best practices” and lessons learned from community programs and in workplace and school settings (for example, physical activity programs, health coverage, healthy cafeteria foods, and support groups),
- enhanced funding opportunities,
- simplified processes for securing financial support from federal, state, and local agencies, and
- technical assistance (such as workshops and mentoring) to help state and local policy makers prepare and submit successful proposals to potential government and private funding sources.
Assure access to trained health care providers who offer quality services to prevent and manage diabetes among women of all ages. Care should be tailored to the woman’s specific life stage, race, ethnicity, culture, religion, family and financial situation, motivation, and needs.
Expand public and private health insurance packages to provide adequate coverage for preventive care, including health promotion, health and nutritional education, physical activity, self-management, and screening for complications among women diagnosed with diabetes.

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The Adolescent Years (ages 10-17 years)

The primary emphasis of public health action in the adolescent years is to improve the health and preventive practices among all youth, and more particularly among girls already diagnosed with diabetes. To accomplish this goal, several major challenges must be overcome. These challenges include: lack of diabetes education and prevention materials appropriate for adolescent females; inadequate numbers of trained physicians who specialize in caring for this age group; lack of physical education programs in schools; lack of awareness of the need for weight control, healthy diets, and physical activity among adolescents; and a plethora of fast food and other unhealthy eating options.

Opportunities for prevention and hope for the future are influenced by recent school policy changes and better models for physical education and health education curriculum. Successes for other diseases and health problems that might benefit diabetes prevention efforts (such as no smoking and Drug Abuse Resistance Education [DARE] campaigns) include: more effective media messages to raise awareness and promote healthy lifestyles; advances in electronic and computer technology as a teaching tool; and the receptivity of adolescents to computer technology.

Communication and Education
For Professionals

Examine and improve the health professional school curriculum as it relates to preventing diabetes complications among adolescents.
Strengthen continuing education and training for physicians, nurses, and other health care providers on adolescent weight control, glucose management, eating disorders, and other diabetes prevention and management issues relevant to female adolescents with or at high risk of diabetes.
Explore establishing a subspecialty of physicians on diabetes care for female adolescents.
Target dentists to help prevent periodontal disease in adolescents, particularly girls, with type 1 diabetes.

For Adolescent Females and Their Families

family-oriented education materials covering such topics as nutrition, physical activity, and a family’s risk of diabetes and other chronic diseases.
Begin to introduce concepts of reproductive health to adolescents and their families, particularly the relationship between poor contraception and congenital anomalies.
Structure educational messages to encourage female adolescents with diabetes to engage in regular physical activity and make healthy food choices in the face of the vast fast food market.
Use teen media outlets, entertainers, and community “champions” (including teen performers with diabetes) to deliver key messages to adolescent females. Search for positive images and role models for girls that, for example, emphasize being “strong” rather than “thin.”
Target gestational diabetes and broader family health messages to pregnant adolescents, urging the teens to, for example, get their glucose level checked.
Educate recipients of public assistance (such as food stamps and Women, Infants and Children [WIC] program services) on preparing healthy and appetizing meals within a limited budget for families with an adolescent with diabetes.

Services and Programs
In Communities

Create positive, rewarding forums that promote healthy eating and physical activity among adolescent females. Partner with established groups such as Girl Scouts and Girl Power, and use locations where adolescents typically congregate. Consider such programs as “teen summits” (similar to the Black Entertainment Television’s Teen Summit program), visits to local cable channel stations, and televised “town hall meetings” on health issues. Involve young girls in the planning and delivery of these programs whenever possible.
Establish appealing and acceptable alternatives to competitive sports for those adolescent females who would otherwise not engage in any physical activity.
Expand support groups (at YWCAs, churches, and other grassroots organizations’ sites) for adolescent girls with diabetes and their families.

In Schools

Integrate health into the school science curriculum and supplement with activities that directly influence adolescents, such as videos and guest speakers with thought-provoking messages that have been shown to change behavior.
Conduct awareness campaigns to influence parental behavior to prevent and manage diabetes among children. Heighten sensitivity to the challenges of disease management specific to adolescents.
Urge community and state boards of health and education to allocate more funding for physical activity programs in public schools offered before, during, and after school.
Develop school policies that limit soda and candy vending machine availability in schools (or support vending machines for healthy snacks and drinks), and promote healthy food choices in cafeterias.
Advocate for national support of on-site school nurses to aid youth diagnosed with diabetes and other health problems.
Educate school system administrators and teachers about diabetes and its management so that a “diabetes friendly” environment can be established and medical emergencies avoided or handled appropriately.

In Work Sites

Educate employers of adolescents, such as retailers, grocery stores, fast food restaurants, and other restaurants, about the risks for diabetes among adolescents and the need for adequate breaks, healthy food choices, and health insurance.

In Health Care Systems

Promote early diagnosis and self-management of diabetes, particularly type 2 diabetes, among health care providers.
Encourage guidelines that trigger interventions for adolescents at risk of developing type 2 diabetes. Risk factors include low waist-to-hip ratio and an apple-shaped body type.
Define a healthy weight loss regimen for overweight adolescents, focusing on the influences of family and school.
Encourage health insurance companies to cover health and nutrition education for adolescents (for example, management of obesity and eating disorders).
Develop population-specific messages, materials, and programs for health insurance or pharmaceutical companies to use for diabetes education and self-management among adolescents.
Collaborate with diabetes prevention and control programs in state health departments to develop prevention efforts among adolescents.

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The Reproductive Years (ages 18-44 years)

One of the major barriers to self-care facing women in their reproductive years is balancing the demands of marriage and other relationships, work, child care, household chores and hobbies. The result is limited time for physical activity, healthy eating patterns, and attending to the woman’s own health care needs. In addition, physical activity is further restricted during pregnancy and early postpartum. Mothers may not lose the weight gained during pregnancy and thus put themselves at greater risk of obesity and of developing diabetes in later pregnancies or later in life. Cultural differences influencing these behaviors are also important to understand. Conflicting health messages from a multitude of sources addressing chronic disease prevention is another barrier to self-care.

Strategies for countering these barriers include tailoring messages to reproductive-aged women, capitalizing on the intergenerational aspects of gestational diabetes, and including men and families as supportive partners. Prenatal and other reproductive health services represent important vehicles for identifying and instituting preventive care for women at high risk for diabetes.

Communication and Education
For Professionals

Establish a clearinghouse of programs and materials for women of reproductive age, and disseminate best practices and lessons learned from community programs (such as the National Kidney Foundation’s Healthy Hair Beauty Salon Project in Michigan) and workplace, clinic, and other settings (for example, exercise programs, health coverage, healthy cafeteria foods, and support groups).
For health care providers, expand education in diabetes prevention and management, emphasizing such specialties as family planning, obstetrics, gynecology, general practice, family practice, midwifery, and social services (for example, providers in WIC or the Expanded Food and Nutrition Education Program [EFNEP]).
Encourage makers of drugs and instruments for diabetes management (such as insulin, oral agents, acarbose, and glucose meters) to include a public message in the package encouraging good diabetes control.
Urge pharmacies to provide information for patients.

For Women and Their Families

Include lifestyle counseling and education strategies for women with and without diabetes in preconception, prenatal, and postpartum care (including women with or at risk of gestational diabetes). Address contraception and pregnancy planning.
Emphasize to women, health care providers, and health insurers the importance of appropriate follow-up diagnostic and preventive care after delivery for women with gestational diabetes and other risk factors for type 2 diabetes.
Increase diabetes awareness programs and materials in workplaces and other settings, such as drug stores, health clinics, the media, community recreational centers, school newsletters, and church bulletins.
Review educational materials produced by organizations serving women of reproductive age (such as March of Dimes; Healthy Mothers, Healthy Babies Coalition; and Maternal and Child Health Bureau) to ensure inclusion of appropriate, current, and consistent information regarding diabetes and related risks (for example, obesity, poor diet, and physical inactivity). Materials should also be culturally and linguistically appropriate.
Educate women with diabetes and prior gestational diabetes about the risk to their offspring for developing diabetes. Establish a follow-up program to test these children.

Services and Programs
In Communities

Provide opportunities to support and sustain lifestyle changes among women of reproductive age, including
- assessment and counseling within the framework of existing programs and services, and linking to other available resources,
- peer and other social support programs geared toward women for exercise, healthy eating, and diabetes self-management, and
- assessment of family and community barriers specific to this age group, such as lack of access to affordable child care.
Evaluate existing community programs to maximize opportunities for prevention activities, improved quality, and increased access to health care among women in their reproductive years.
Adapt existing resources to the needs of reproductive-aged women, and ensure appropriate support services such as child care to enable time for physical activity.

In Schools

Use school sites as a way to reach women in their reproductive years, such as students, mothers of students, and female teachers, with prevention and management messages.
Influence policies of colleges and universities to require a minimum number of hours of physical education and to include healthy food options in cafeteria food plans.
Encourage colleges and universities to promote exercise, dance, and other physical activities for females.

In Work Sites

Promote partnerships between health care providers and workplaces, and encourage employers and employees to discuss needed diabetes benefits in the health package offered.
Promote workplace policies that positively affect the health of women of reproductive age, such as flextime for exercise on lunch hours, shower facilities, health club memberships, and support for insulin breaks.
Promote purchasing cooperatives among small businesses to enable progressive health insurance packages.

In Health Care Systems

Develop a chronic disease prevention policy for reproductive-aged women, and enhance cooperation among state and community chronic disease programs to support common prevention strategies (for example, exercise, nutrition, and smoking cessation).
Ensure that all women who have had or are at risk for gestational diabetes are identified, treated, and followed up regularly over time in traditional and nontraditional settings (for example, WIC, mobile outreach services, family planning clinics, Indian Health Service clinics, and community health centers).
Assure postpartum follow-up to assess risk factors, conduct diagnostic testing for diabetes with other routine tests, and recommend preventive strategies. Use existing programs such as WIC and the State Children’s Health Insurance Program to reach at-risk women to promote preventive activities, and provide tools that health care providers can incorporate into routine care. Expand activities like “Project Fresh” in WIC programs to encourage fresh fruit and vegetable consumption.
Promote expansion of routine physical examinations of reproductive-aged women to include assessments of physical activity, diet, hip and waist measurements, and body mass index in addition to standard weight and blood pressure measurements. Glucose screening should also be performed if the woman is significantly overweight and has one or more risk factors for diabetes.
Review existing standards of care for women of childbearing age to determine if the guidelines are comprehensive and whether they have been implemented (for example, those sponsored by the American College of Obstetrics and Gynecology, the American Diabetes Association, the U.S. Preventive Health Services Task Force, and WIC). In addition, the standards and guidelines should be updated as appropriate.
Modify current policies regarding weight gain during pregnancy to promote appropriate, rather than excessive, weight gain regardless of age or ethnicity.
Promote comprehensive health care coverage that includes diabetes prevention and management for women of reproductive age.

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The Middle Years (ages 45-64 years)

During this life stage, some of the major barriers to preventing diabetes and its complications are similar to those in the reproductive years. Prevention takes a backseat to treatment, particularly for acute health issues. A transition in health care providers occurs, from gynecologists to family practitioners, internists, or specialists. Women may have even less time to focus on their own needs as they begin to care for their children and also for their own parents.

However, this role as the primary decision maker, sandwiched between two generations, affords a rare opportunity. The woman’s sphere of influence is broader and deeper than at any other time in her life; she has the chance to be a role model for female relatives and friends. Middle age is also the time when women are most active in civic and religious organizations, offering an ideal site for delivery of prevention messages, interventions, and support.

Communication and Education
For Professionals

Increase training opportunities for health care professionals to learn how to effectively prevent and manage diabetes in middle-aged women. Consider such mechanisms as continuing education units, web-based training, CD-ROMs, and partnerships with pharmaceutical companies.
Develop and disseminate a list of successful programs (“best practices”) that promote the incorporation of physical activity and healthy eating into the daily routines of women who are employed, raising children, or both.
Encourage providers to explore the use of both traditional and alternative medicine for preventing and treating diabetes among women in their middle years.

For Women and Their Families

Emphasize physical activities and healthy eating habits appropriate for the middle years, and focus on incorporating them into the daily routines of work and family. Stress that prevention of weight gain, not just weight loss, can prevent diabetes onset.
Promote self-management among middle-aged women with diabetes, and provide support and education for self-care.
Develop champions for diabetes among middle-aged women, and use them to deliver messages about the positive benefits of physical activity and healthy eating.

Services and Programs
In Communities

Encourage policy makers to focus on priorities for women in their middle years:
- chronic disease in general, and diabetes in particular,
- modifiable risk factors, such as age-appropriate physical activity within daily life, diet, and smoking,
- support needs,
- focus on family and quality of life, and
- preparation for menopause and retirement.
Establish community support groups similar to Alcoholics Anonymous (AA) and Weight Watchers designed primarily for middle-aged women with diabetes.
Use pharmacies and other nontraditional sites (such as beauty salons) to reach middle-aged women diagnosed with or at risk of diabetes.

In Work Sites

Promote work site policies that encourage and support physical activity and healthy eating. Highlight diabetes prevention and education.
Consider using work sites for training and support groups on caregiving.
Establish “health days” or release days for employees on which they can schedule diagnostic testing for diabetes and other routine medical tests on-site or off-site.

In Health Care Systems

Develop “best practices” for prevention and treatment of diabetes among women in their middle years.
Work with health insurers and policy makers to expand reimbursement policies to include prevention services for women throughout their life span.
Integrate diagnostic testing for diabetes with routine tests for other chronic diseases, such as mammograms, Pap smears, and colonoscopies).

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The Older Years (ages 65 and older)

Health insurance barriers are compounded in the older years, with the transition from employer-based coverage to Medicare and other private or public health insurance carriers. The elderly also frequently experience isolation, depression, and lack of social support from their families and communities. Prescription drug coverage is an issue, as is the fragmentation of health care services. Financial resources may be limited, particularly for those relying on Social Security and fixed incomes. In addition, the number of elderly persons from racial and ethnic minority populations who have limited English proficiency is increasing dramatically, with no comparable increase in the availability of culturally and linguistically appropriate health care services.

Opportunities for prevention lie in the frequency of health care visits among the elderly for diabetes and comorbidities. Although the actual face-to-face time with health care providers is limited, that time can be optimally used for meaningful education and motivational messages. Community, civic, and religious organizations can also play key roles in promoting behaviors that improve health and quality of life.

Communication and Education
For Professionals

Encourage health care providers to become aware of and inform their elderly patients about relevant community services.
Train nurses, other clinic staff, and lay educators on key messages for older women with or at risk of diabetes (for example, about the need for foot screening).
Incorporate training on cultural competence into the curriculum of all health care professions, particularly for providers who interact with older women.
Train housing managers, community health workers, and senior center workers on how to recognize signs of depression and how to respond appropriately to those signs.

For Women and Their Families

Promote self-management and education through advocacy and training for the elderly and their health care providers and through expanded availability of quality programs.
Design a media campaign targeted to elderly women, with a diabetes champion (a celebrity or community leader) as spokesperson.
Use mainstream media that will reach older women, such as the popular magazines Good Housekeeping, Ladies’ Home Journal, and Readers Digest and the American Association of Retired Persons (AARP) newsletters.
Educate seniors on lifestyle changes that prevent and treat diabetes, including physical activity, healthy eating, and relieving depression. Emphasize all the diseases that typically have onset in later life and their relationships (for example, between heart disease and diabetes).

Services and Programs
In Communities

Build community coalitions that involve the elderly and address their unique needs.
Identify key places and organizations to reach the elderly (such as libraries, grocery stores, senior centers, Lions Clubs, churches, Area Agencies on Aging and other non-traditional, non-health care organizations) and involve them in program planning and implementation.
Expand intergenerational programs and activities.
Partner with local and state commissions on aging to provide transportation for the elderly (such as “Call a Bus”), while also expanding programs that serve the elderly in their homes and congregate living sites to avoid transportation and other motivational issues.

In Health Care Systems

Ensure affordable, accessible, and appropriate care for older women by expanding preventive services, increasing public awareness of diabetes and its burden, and facilitating greater community involvement.
Increase the priority of federal, state, and local funding for
- diabetes training for elderly patients and their health care providers,
- prescription drugs and health insurance coverage, and
- grassroots and community programs.

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