Public Health Practice and Diabetes—What More Can Be Done to Halt the Epidemic?

Public Health Practice and Diabetes—What More Can Be Done to Halt the Epidemic?

Albright Ann
US Endocrinology - Volume 4 - Issue II
Published: April 2009
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As diabetes prevalence and incidence continue to grow at unprecedented rates,1 addressing diabetes as a public health problem is more important than ever before. Treating diabetes as a public problem means understanding and appreciating that it affects not only individuals but also families, communities, and society. In order to halt or substantially slow the diabetes epidemic, we need to take action in each of these arenas. The Ecological Model of Health Behavior (see Figure 1) provides a framework for understanding the multiple levels of influence on health behavior.2 The further you move from the individual to societal interventions, the more complex and multifactorial the approaches become, the longer it can take to achieve change, and the more difficult it is to evaluate, but the impact is more far-reaching.

While much of the work in improving diabetes outcomes has focused on clinical care, there is growing recognition that improving diabetes prevention and control also requires public health approaches that are complementary to what can be achieved in clinical care.3,4 Glasgow et al.5 defined a public health approach to diabetes as “a broad, multidisciplinary perspective that is concerned with improving outcomes in all people who have (or are at risk for) diabetes, with attention to equity and the most efficient use of resources in ways that enhance patient and community quality of life.” For people with diabetes, medical concerns are not the only factors that need to be managed: lifestyle, family, psychosocial, cultural, and economic matters also warrant attention. For people at high risk for developing type 2 diabetes (often referred to as pre-diabetes), the non-medical factors are even more important. Reducing the diabetes epidemic will require that the healthcare delivery ‘system’ and the public health network interconnect (see Figure 2). The healthcare delivery system takes the lead in diagnosis and disease care, while the public health network picks up the baton in health protection, promotion, prevention, and preparation. There is a wide area in which the healthcare delivery system and the public health network should work hand-in-hand.

Improving Personal and Population-based Health Services
Monitoring the nation’s health through surveillance data is a major public health function. In addition to monitoring prevalence (number of cases at a given point in time) and incidence (number of new cases in a given period of time) of diabetes, surveillance data provide important information on preventive care practices. Using the National Health and Nutrition Examination Survey (NHANES) (1988–1994 and 1999–2002) and the Behavioral Risk Factor Surveillance Survey (1995 and 2002) information for those 18–75 years of age who had reported a diagnosis of diabetes, data were obtained on diabetes processes and outcome measures of care. Although care remains short of current recommendations, annual lipid testing, dilated eye and foot examinations, self-monitoring of blood glucose level, and adoption of aspirin use and pneumococcal and influenza vaccinations have significantly improved. Large improvements in lipid control and some improvements in glycemic control have also occurred, but blood pressure control has not improved.6 Another study using NHANES data from 1971 to 2000 examined cardiovascular disease risk factors, including cholesterol, blood pressure, and smoking, among people with diabetes.7 The prevalence of high cholesterol, high blood pressure, and smoking declined by 17, 27, and 15%, respectively, during the three decades. Reduction in mean total cholesterol tended to be greater among men than women and in older (60–74 years of age) than younger (20–59 years of age) adults. Improvements in mean blood pressure tended to stop after 1988–1994. Reduction in smoking prevalence was mainly in earlier decades (1970s and 1980s) among men and in the 1990s among women.

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