XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

▪ Abstract The thesis of this article is that multilevel interventions based on ecological models and targeting individuals, social environments, physical environments, and policies must be implemented to achieve population change in physical activity. A model is proposed that identifies potential environmental and policy influences on four domains of active living: recreation, transport, occupation, and household. Multilevel research and interventions require multiple disciplines to combine concepts and methods to create new transdisciplinary approaches. The contributions being made by a broad range of disciplines are summarized. Research to date supports a conclusion that there are multiple levels of influence on physical activity, and the active living domains are associated with different environmental variables. Continued research is needed to provide detailed findings that can inform improved designs of communities, transportation systems, and recreation facilities. Collaborations with policy resear...

https://www.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.27.021405.102100

An ecological approach to creating active living communities.

Obesity relationships with community design, physical activity, and time spent in cars

CONTEXT. Environmental factors are suggested to play a major role in physical activity (PA) and other obesity-related behaviors, yet there is no national research on the relationship between disparity in access to recreational facilities and additional impact on PA and overweight patterns in US adolescents. 

OBJECTIVE. In a nationally representative cohort, we sought to assess the geographic and social distribution of PA facilities and how disparity in access might underlie population-level PA and overweight patterns. 

DESIGN, SETTING, AND PARTICIPANTS. Residential locations of US adolescents in wave I (1994–1995) of the National Longitudinal Study of Adolescent Health (N = 20745) were geocoded, and a 8.05-km buffer around each residence was drawn (N = 42857 census-block groups [19% of US block groups]). PA facilities, measured by national databases and satellite data, were linked with Geographic Information Systems technology to each respondent. Logistic-regression analyses tested the relationship of PA-related facilities with block-group socioeconomic status (SES) (at the community level) and the subsequent association of facilities with overweight and PA (at the individual level), controlling for population density. 

MAIN OUTCOME MEASURES. Outcome measures were overweight (BMI ≥ 95th percentile of the Centers for Disease Control and Prevention/National Center for Health Statistics growth curves) and achievement of ≥5 bouts per week of moderate-vigorous PA. 

RESULTS. Higher-SES block groups had a significantly greater relative odds of having 1 or more facilities. Low-SES and high-minority block groups were less likely to have facilities. Relative to zero facilities per block group, an increasing number of facilities was associated with decreased overweight and increased relative odds of achieving ≥5 bouts per week of moderate-vigorous PA. 

CONCLUSIONS. Lower-SES and high-minority block groups had reduced access to facilities, which in turn was associated with decreased PA and increased overweight. Inequality in availability of PA facilities may contribute to ethnic and SES disparities in PA and overweight patterns.

/pdf/inequality-in-the-built-environment-underlies-key-health-4ktbglkmwo.pdf

Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity

Introduction:The past decade has seen a dramatic increase in empirical investigation into the relations between built environment and physical activity. To create places that facilitate and encourage walking, practitioners need an understanding of the specific characteristics of the built en

Built environment correlates of walking: a review.

Purpose. To determine the relationship between urban sprawl, health, and health-related behaviors. Design. Cross-sectional analysis using hierarchical modeling to relate characteristics of individuals and places to levels of physical activity, obesity, body mass index (BMI), hypertension, diabetes, and coronary heart disease. Setting. U.S. counties (448) and metropolitan areas (83). Subjects. Adults (n 5 206,992) from pooled 1998, 1999, and 2000 Behavioral Risk Factor Surveillance System (BRFSS). Measures. Sprawl indices, derived with principal components analysis from census and other data, served as independent variables. Self-reported behavior and health status from BRFSS served as dependent variables. Results. After controlling for demographic and behavioral covariates, the county sprawl index had small but significant associations with minutes walked (p 5 .004), obesity (p , .001), BMI (p 5 .005), and hypertension (p 5 .018). Residents of sprawling counties were likely to walk less during leisure time, weigh more, and have greater prevalence of hypertension than residents of compact counties. At the metropolitan level, sprawl was similarly associated with minutes walked (p 5 .04) but not with the other variables. Conclusion. This ecologic study reveals that urban form could be significantly associated with some forms of physical activity and some health outcomes. More research is needed to refine measures of urban form, improve measures of physical activity, and control for other individual and environmental influences on physical activity, obesity, and related health outcomes. (Am J Health Promot 2003;18[1]:47‐57.)

/pdf/relationship-between-urban-sprawl-and-physical-activity-10oykrbw21.pdf

Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity

Introduction
The World Wide Web is being used increasingly as a resource for accessing health-related information In our study, we identified types of health-related Web sites visited most often, determined how often patients shared Web-accessed health information with their doctors, and examined factors that encouraged Internet use for locating health-related information We also compared health-related Internet use among people who did not have any type of chronic disease with people who reported having one or more chronic diseases

PEER REVIEWED: Health-related Information on the Web: Results From the HealthStyles Survey, 2002–2003

Introduction The World Wide Web is being used increasingly as a resource for accessing health-related information. In our study, we identified types of health-related Web sites visited most often, determined how often patients shared Web-accessed health information with their doctors, and examined factors that encouraged Internet use for locating health-related information. We also compared health-related Internet use among people who did not have any type of chronic disease with people who reported having one or more chronic diseases. Methods We merged data from the 2002 and 2003 HealthStyles surveys to generate frequency and descriptive statistics and used multivariate logistic regression to estimate odds ratios. Results Approximately 35% of survey participants reported using the Internet to search for health-related information. Among them, the Web sites visited most often included health information portals, government agencies, and nonprofit organizations. About 53% reported that they "sometimes" shared Internet information with their doctors. The most important features of the Internet that would encourage its use for health information were ease of finding and using the information and clarity of the information provided. Internet use differed by sex and age and was strongly associated with income and education. Respondents who reported having a chronic disease (odds ratio [OR] = 1.30; 95% confidence interval [CI], 1.16-1.45) were more likely to use the Internet to access health-related information, especially among those with depression (OR = 1.47; 95% CI, 1.27-1.71) and high cholesterol (OR = 1.18; 95% CI, 1.02-1.37). In addition, respondents who reported having two or more chronic diseases (OR = 1.35; 95% CI, 1.16-1.56) were more likely to search for online health information than respondents who reported having no chronic disease. Conclusion Public health professionals have a unique opportunity to use the Internet as a tool to complement and supplement the health information that the public receives from health care professionals.

/pdf/health-related-information-on-the-web-results-from-the-52wbzoaa5v.pdf

Health-related Information on the Web: Results From the HealthStyles Survey, 2002-2003

Purpose. Compare walking and bicycling for transportation and recreation with the percentage of the community devoted to parklands. Methods. Behavioral Risk Factor Surveillance System (N = 206,992), Nationwide Personal Transportation Survey (N = 409,025), and Trust for Public Land (N = 55) data were used to estimate recreational walking and bicycling, utilitarian walking and bicycling, and parkland as a percentage of city acreage. Data were linked at the metropolitan statistical area or city level (N = 34). Pearson correlation coefficients were used to assess the associations among recreational and utilitarian walking and bicycling and parkland acreage. Results. Utilitarian walking and bicycling and parkland acreage were significantly correlated (r = .62, p < .0001). No significant relationships were observed for leisure time walking or bicycling. Discussion. Communities with more parks had significantly higher levels of walking and bicycling for transportation. Urban design features associated w...

Relationships among Community Characteristics and Walking and Bicycling for Transportation or Recreation

Genomics is the study of the entire human genome and involves not only studying the actions of single genes but also the interactions of multiple genes with each other and with the environment. This article emphasizes the multifactorial nature of common obesity, which is caused by the interaction of genes, environment, and lifestyle. Individual variation in genes that influence behavior, satiety, and taste suggests that a one-size-fits-all approach to reducing or preventing obesity may be ineffective. Data are not yet available to allow for personalized obesity interventions based on genetic predisposition. However, a genomics approach may provide a useful framework for addressing the obesity epidemic. More research is needed before specific targeted public health interventions that include genomic strategies can be effectively integrated into addressing obesity in public health practice.

/pdf/addressing-the-obesity-epidemic-a-genomics-perspective-4elgtlri7c.pdf

Amy I. Zlot

Papers

Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity

PEER REVIEWED: Health-related Information on the Web: Results From the HealthStyles Survey, 2002–2003

Health-related Information on the Web: Results From the HealthStyles Survey, 2002-2003

Relationships among Community Characteristics and Walking and Bicycling for Transportation or Recreation

Addressing the obesity epidemic: a genomics perspective.