Guidelines for Preventing Diabetes: When to Get Checkups and What to Expect The keys to diabetes prevention and management are the same as those for …
Live Well, Live Long: Steps to Better Health
Health Promotion and Disease Prevention for Older Adults
Diabetes Prevention and Management: Small Steps With Big Rewards
Chapter 2 Supporting People With Diabetes and Those at Risk
Table of Contents
Introduction
Guidelines for Preventing Diabetes: When to Get Checkups and What to
Expect
Screening for Diabetes
Guidelines for Diabetes Care: When to Get Checkups and What to Expect
Ongoing, Patient-Centered Care
Diabetes Self-Management Training
Comprehensive Treatment of Diabetes
Managing the ABCs of Diabetes
Blood Glucose Monitoring
A1C
Self-Monitoring of Blood Glucose
Blood Pressure Monitoring
Cholesterol Monitoring
Preventing Long-Term Diabetes Problems
Weight Loss and Diabetes
Identifying and Treating Long-Term Diabetes Problems
Nutrition for People With Diabetes
Physical Activity for People With Diabetes
Recommended Guidelines for Physical Activity for Older
Adults
with Diabetes
Special Considerations for Being Physically Active With
Diabetes
Preparing for a Diabetes Care Checkup: A Checklist
Health Insurance Coverage
What Does Medicare Cover?
Medicare Benefits
Medicare-Covered Preventive Services for All Enrollees
Other Financial Assistance for Diabetes Care and Supplies
References
Glossary
Introduction
The keys to diabetes prevention and management are the same as those for
generally healthy habits Adequate amounts of physical activity, proper
nutrition, good mental health, knowing how to take medications, getting
regular checkups, and being aware of ones health status — these concepts
are all basic to good health In this section, you will find an outline of
the principles of diabetes prevention, proper diabetes care, and good self-
care Many of the principles apply to people with prediabetes and to older
people who are overweight, and therefore at risk for diabetes
There is no magic bullet to prevent or manage diabetes, no diabetic diet
or diabetic exercise prescription Although the American
Diabetes
Association publishes separate guidelines for nutrition and physical
activity in people with diabetes, the guidelines are essentially the same
as those for the general population, with a few extra precautions thrown
in The difficulty is that many of us do not follow the standard
recommendation of engaging in 30 minutes of physical activity on most days
of the week Also, many of us do not consume the recommended amounts of
nutrients and calories for our weight, age, and activity level The reasons
for this are complex, but not impossible to unravel
One of the keys to unraveling the mystery of why we do not take this
simple advice is that making lifestyle changes requires a supportive
environment Another key to unraveling this mystery is that many of us set
about changing our lifestyle by taking huge steps Starting tomorrow, I
will go on a diet and never eat the foods I love again Starting
tomorrow, I will go walking for an hour every day When these life-
changing efforts fail, we decide to give up on making any changes
whatsoever When we look back on changes that we have made successfully in
our lives, sometimes some may have been by quitting cold turkey But more
often, we
have achieved larger goals by taking small steps to get there
Sometimes we may need help getting started in making healthy changes
Diabetes self-management training is highly effective in lowering and
managing blood glucose sugar levels in people with diabetes Certified
diabetes educators and community-based professionals who have been trained
in diabetes self-management can help people with diabetes set realistic,
individualized goals They also provide the person with support for
learning new skills related to managing medications and determining when to
contact a healthcare professional Dietitians and other health
professionals can provide people who are overweight with support for losing
small to moderate amounts of weight to improve their health
This section presents key messages on nutrition, physical activity, and
diabetes self-management, as well as the principles for proper diabetes
care — in other words, what older adults with diabetes should expect from
their healthcare and community-support services
Although you may not have a healthcare background, you may want to
familiarize yourself with these principles to better advocate for elders
with diabetes in your
community Becoming familiar with the guiding
principles for diabetes care and the limitations of Medicare and other
health insurance plans can help you to better address the gaps in services
These principles also provide the basis for key messages to deliver during
individual counseling sessions or group presentations on diabetes and
health
Guidelines for Preventing Diabetes: When to Get Checkups and What to Expect
It is important to promote physical activity and nutrition as part of
preventing diabetes For more information on using physical activity to
prevent diabetes, see the physical activity guidelines in the diabetes care
section For more information on nutrition, see the Live Long, Live Well
nutrition module
For people diagnosed with prediabetes sometimes called impaired glucose
tolerance or impaired fasting glucose, there may be specific measures they
need to take to increase insulin sensitivity and lower blood glucose, blood
pressure, cholesterol, and weight People who are diagnosed with metabolic
syndrome a condition that places people at increased risk for heart
disease and stroke may also be at risk for diabetes or prediabetes
Eating healthy smaller portions, less
fat and increasing physical
activity have both been proven effective in preventing or delaying
diabetes[1] and increasing insulin sensitivity, even when no weight is
lost[2] Medications can also be helpful A modest amount of weight loss 5
to 7 percent, or 10 to 14 pounds for someone who weighs 200 pounds has
been associated with a 71 percent lowering of risk in older adults with
prediabetes
Screening for Diabetes
The information below is based on the Standards of Medical Care published
in the January 2005 Clinical Practice Recommendations[3] of the American
Diabetes Association and the Guiding Principles for Diabetes Care: For
Health Care Providers published by the National Diabetes Education
Program[4] The information listed here only applies to older adults — see
the reference materials cited above for recommendations regarding all age
groups
What does screening for diabetes mean?
The purpose of screening is to improve health outcomes by identifying
people at high risk for diabetes as well as those who are undiagnosed,
and treat them appropriately Separate tests are required after a
positive screening test to confirm the diagnosis of
diabetes
Who should get screened?
Men and women ages 45 and above who are overweight, which is measured
as a body-mass index BMI of 25 or higher Note that Asian Americans
are considered overweight if they have a BMI of 23 or higher
How do older adults get screened for diabetes?
If you encounter an older adults who are concerned that about their
risk for diabetes, refer them to the American Diabetes Associations
Am I At Risk? questionnaire Encourage them to see a healthcare
provider to do a blood test The blood test will measure blood glucose
sugar levels If blood glucose levels are high, a second test will
be required to confirm a diagnosis of diabetes
Tips for professionals about screening:
Blood glucose screening should only be conducted as part of a
healthcare office visit Screenings done at a health fair or local
business where follow-up care is not readily available are not
effective and may screen people that are not likely to develop
diabetes, while missing people who are at high risk
When screening is done outside of a healthcare setting, it is
possible
that the results of the test may never be discussed with the persons
primary care provider In addition, people may have the misleading
impression that they have received a full physical examination or that
they are okay, when in fact they have not received a complete
assessment of their health
Also note that administering the paper-and-pencil Am I at Risk? test
wwwndepnihgov/ is more cost effective in most community settings
than blood glucose screening The self-test builds individual
awareness about diabetes and is not likely to be misinterpreted as a
full physical examination by the person taking it
Guidelines for Diabetes Care: When to Get Checkups and What to Expect
The information presented below is a summary of guidelines developed by the
American Diabetes Association and the National Diabetes Education Program
for diabetes care
Ongoing, Patient-Centered Care
People with diabetes need to be part of a healthcare delivery system that
provides high-quality, patient-centered care on an ongoing basis This
approach ensures that timely changes in their treatment are made to achieve
optimal control of
the disease
Key components of care for people with diabetes:
Ongoing care in a patient-centered, supportive, and positive
environment without barriers to obtaining care
A healthcare provider responsible for ongoing care and skilled in
its delivery, with access to other physician specialists and
healthcare professionals
Mechanisms in place to ensure that the special needs of certain
high-risk groups, including ethnic populations and older adults,
are addressed
Support for people with diabetes from their family, friends, and
coworkers
Financial resources for ongoing education, durable equipment,
supplies, medications, and insulin
Mechanisms to prevent discrimination against employment, licensing,
and obtaining insurance[5]
Diabetes Self-Management Training
People with diabetes and their family members need accurate information and
education for diabetes self-care Adequate diabetes education should
accomplish the following:
Address the individuals medical and emotional needs
Enable people with diabetes to participate actively in their
treatment and in
prevention of complications
Be ongoing, beginning with the essential elements of self-care as
well as instruction on following the prescribed medical regimen
Over time, the instruction should become a dialogue that defines
and addresses the ongoing needs of the individual and his or her
family[6]
Hospitals, clinics, nursing homes, and other healthcare organizations can
create system-wide support for people with diabetes and the professionals
who care for them by providing the following:
Self-management support
Decision support
Delivery system design
Clinical information systems[7]
Self-management support
Providers emphasize patients active and central role in
managing their illness
Standardized patient assessments include self-management
knowledge, skills, confidence, supports, and barriers
Effective behavior change interventions and ongoing support
with peers or professionals are provided
The care team assures collaborative care planning and
assistance with problem solving
Decision
support
Evidence based guidelines are embedded into daily clinical
practice
Specialist expertise is integrated into primary care
Provider education modalities proven to change practice
behavior are utilized
Patients are informed of guidelines pertinent to their care
Delivery system design
Team roles are defined and tasks delegated
Planned visits are used to provide care
The primary care team assures continuity
Regular follow-up is ensured
Clinical information systems
There is a registry with clinically useful and timely
information
Care reminders and feedback for providers and patients are
built into the information system
Relevant patient subgroups can be identified for proactive
care
The information system facilitates individual patient care
planning
Comprehensive Treatment of Diabetes
The exact methods of treatment of diabetes — diet, exercise, oral diabetes
medications, and insulin injections — should be tailored to
individual
needs People with diabetes should participate in the decision-making
process with options, goals, and targets clearly stated Treatment goals
should address the ABCs of diabetes[8]
Managing the ABCs of Diabetes
A1C, blood pressure, and cholesterol, the ABCs of diabetes, should
be kept as near to normal as is safely possible The target values
should be based on an overall assessment of the persons health
Diabetes treatment includes lowering the risk of long-term diabetes-
related problems by controlling the diabetes ABCs:
A for the A1C test , which measures average blood glucose
The goal for most people with diabetes is below 7 percent
B is for blood pressure The blood pressure goal for most
people with diabetes is less than 130/80 mm Hg
C is for cholesterol The LDL cholesterol goal for most
people with diabetes is below 100 mg/dL
These figures are considered target values for the general
population, and are meant to be tailored to individual needs by a
healthcare provider Among frail older adults, in particular, these
rules
do not always apply To find out more, see How Is Diabetes
Different for Older Adults Than Younger Adults? in Chapter 1 If
target values are set too high, the person with diabetes may become
discouraged Professionals working with older adults should encourage
people with diabetes to let their healthcare provider know if the
target values appear un-reachable - lower goals over a shorter
timeframe may be more effective in these cases
Scientific evidence shows that controlling the ABCs of diabetes can
significantly lower individuals risk for:
Eye disease retinopathy
Kidney disease nephropathy
Nerve damage neuropathy
Damage to blood vessels in the legs peripheral arterial
disease
Heart disease and stroke
Hardening of the arteries
Blood Glucose Monitoring
Diabetes is often called a silent disease because it can cause serious
complications without having serious symptoms The absence of symptoms of
high blood glucose is an unreliable guide for judging glucose control since
symptoms do not occur until blood glucose reaches high levels[9]
A1C and
blood glucose should be measured on a routine basis using current,
reliable methods Both A1C and self-monitoring of blood glucose SMBG
should be thought of as a check rather than a test An individual
checks to see what his numbers are and makes decisions based on the
numbers This terminology eliminates the passing-failing-cheating
mentality
Encourage people to write down their A1C and SMBG results
A1C
A1C is the principal method for monitoring diabetes status and is done
by taking a small blood sample in a healthcare setting Some people
believe that they can cheat on this test by fasting before they go
to see the doctor This is not the case — the A1C provides a picture
of blood glucose levels over the last two to three months and does not
change much on a day-to-day basis
Some people also believe that the A1C is a test — if they fail it,
then they will be put on insulin Insulin is not a punishment for bad
behavior, and it is not recommended that healthcare providers use
insulin injections as a threat to get their patients in shape If
someone has diabetes for 10 years or more, it is likely that they will
need to use insulin at some point
The goal for most people with diabetes is an A1C below 7 The American
Geriatrics Society guidelines
wwwasagingorg/cdc/module7/phase1/phase1_6acfmAmerican_Geriatrics_S
ociety recommend an A1C below 8 for frail older adults, persons with
life expectancy of less than 5 years, and others in whom the risks of
intensive control of blood glucose appear to outweigh the benefits
The National Diabetes Education Program
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf recommends that
A1C be checked twice each year If the person is not meeting their
goals, the A1C should be checked every three months
Self-Monitoring of Blood Glucose
Routine self-monitoring of blood glucose sometimes called SMBG is a
successful approach in self-management of diabetes because it provides
a picture of the immediate blood glucose level Self-monitoring of
blood glucose is usually done with a fingerstick, test strip, and
blood glucose meter
Individual circumstances will define how often self-monitoring is
used, the specific approach, and the methods of recording
and
reporting results Blood glucose is usually checked before meals,
after meals, and sometimes at bedtime People who take insulin usually
need to check their glucose more often A certified diabetes educator
or dietitian can be helpful in providing individualized instruction
Blood glucose goals will depend on the type of meter used and if it
measures whole blood or plasma values For most people, blood glucose
levels should be:[10]
|Whole Blood Values |Plasma Values |
|Before |80-120 |Before |90-130 |
|meals | |Meals | |
|1-2 hours |Below 170 |1-2 hours |Below 180 |
| | |after meals | |
|after | | | |
|meals | | | |
People with diabetes need access to self-management tools, including
blood glucose meters and strips See
wwwfdagov/diabetes/glucosehtml16 for information about the
different kinds of blood glucose meters available Some people have
trouble paying for them — see the section Financial Assistance for
Diabetes Care and Supplies for information on how to obtain
assistance Medicare and Medicaid do cover these supplies for eligible
enrollees, but the information may be helpful to older adults who do
not qualify for Medicare or Medicaid for example, those who are
younger than age 65, above the income restrictions for Medicaid, or
members of certain immigrant groups
People who have blood glucose that is higher or lower than ideal see
the goals described above for two to three days should contact a
healthcare provider
Many older adults with diabetes fear that physical activity will
aggravate their diabetes and other conditions, and cause high or low
blood glucose While physical activity may require some adjustment to
eating or medication schedules, the benefits clearly outweigh the
risks Older adults who know how to spot the signs of low or high
blood glucose and what steps to take if they experience it will feel
more confident about the benefits of physical activity
Things that make blood glucose too high:
Eating more than usual
Eating foods high in glucose sugar
Exercising less than usual
Stress
Sickness
Taking certain medicines
Not taking diabetes medicines
Things that make blood glucose too low:
Eating less than usual
Exercising more than usual
Taking more insulin than needed
Taking too much diabetes medication
Delaying or skipping a meal
Blood Pressure Monitoring
Most people with diabetes have high blood pressure The risk of developing
high blood pressure with diabetes varies with age, overweight obesity,
and ethnicity Lifestyle changes, such as increasing physical activity,
lowering sodium intake in food, increasing consumption of fruits,
vegetables, and low-fat dairy products, avoiding excessive alcohol
consumption, and weight loss have been shown to be effective in reducing
blood pressure in people who do not have diabetes
Target blood pressure goals for older adults with diabetes are less than
130/80 mm Hg if they can be safely achieved Blood pressure should be
measured at every routine diabetes visit Encourage
people to write down
their blood pressure results
Before beginning treatment, people with diabetes who also have high blood
pressure should have their blood pressure reexamined on a separate day
within the month to confirm the diagnosis However, in cases where blood
pressure is greater than or equal to 160 mm Hg systolic or 100 mm Hg
diastolic, prescription drug therapy should be started immediately For
older adults, systolic blood pressure should be lowered incrementally, no
more than 20 mm Hg[11] at a time
Many people with diabetes will require three or more drugs to reach target
goals for blood pressure This may place many people at risk for medication-
related problems wwwasagingorg/cdc/module3/phase2/phase2_5cfm Older
adults taking prescription medication to lower their blood pressure should
have labwork done to test for medication-related problems with kidney
function within 1-2 weeks of starting the drugs and then at least once a
year afterwards Kidney function should be re-tested if there is an
increase in the dose of medication All older adults can benefit from a
yearly medication review with a pharmacist For more information on
medication-related problems related to
high blood pressure, see the Under-
or Overdosage and the Adverse Drug Reactions sections of ASAs Optimal
Medication Use module
Cholesterol Monitoring
People with diabetes are more likely to have problems with cholesterol and
other blood fats called lipids Management of lipids in people with
diabetes has been shown to lower the risk of heart disease and stroke,
particularly in those people who have experienced a heart attack or
stroke
People with diabetes should ask their healthcare provider if they need to
have their lipids checked Older adults with diabetes and LDL cholesterol:
Under 100 mg/dL
Should be rechecked at least every 2 years
100 to 129 mg/dL
Should receive medical nutrition therapy MNT and increase
physical activity wwwasagingorg/cdc/module6/homecfm; lipids
should be checked annually, and response to therapy should be
monitored If LDL cholesterol does not go down to 100 or lower
within 6 months, then cholesterol-lowering drugs should be
prescribed if safe
130 mg/dL or greater
Cholesterol-lowering drugs are required in addition to lifestyle
changes; lipids should be
checked at least annually, and response
to therapy should be monitored[12]
Target goals for lipids for people with diabetes are:
LDL cholesterol: Less than 100 mg/dL
Triglycerides: Less than 150 mg/dL
HDL cholesterol: More than 40 mg/dL
Encourage people to write down their cholesterol and lipid results, and to
share these results with their healthcare provider
Lipids are measured through a blood sample taken after 8 - 12 hours of not
eating for example, before breakfast Aggressive management of lipids and
aspirin use when not contraindicated are reasonable interventions in most
cases For older adults, overall health status and control of blood glucose
and blood pressure should be considered first[13] before beginning
management of lipids
Preventing Long-Term Diabetes-Related Problems
Comprehensive care can significantly lower risk for long-term diabetes-
related problems such as blindness, end-stage renal disease, and leg
amputations
The primary goals to keep in mind in preventing long-term problems among
older adults are supporting the individual to
Control blood glucose and perform self-monitoring of blood glucose
as
prescribed by a healthcare provider
Control the risk of heart disease and stroke:
o Control blood pressure and perform self-monitoring of blood
pressure as prescribed by a healthcare provider
o Control cholesterol
o Quit smoking for smokers
Reach and stay at a healthy weight
Receive regular diabetes care to measure and manage the above
every two to three months
Receive pneumonia and influenza vaccines as appropriate
Make sure eyeglasses or contact lens prescription is up to date and
that the person can see clearly Report changes in vision to a
healthcare provider
Practice other healthy self-care behaviors daily:
o Eat a variety of foods that are high in fiber and low in fat
and salt
o Select appropriate portion sizes
o Be active every day
o Take medications as prescribed
o Look at feet and wash and dry them well each day Tell a
podiatrist or healthcare provider about changes in feet
o Check mouth daily for gum or tooth problems
o Make routine
visits to healthcare providers for foot, dental,
and eye care[14]
Weight Loss and Diabetes
Modest weight loss 5 to 7 percent, or between 10 - 14 pounds for a person
who weighs 200 pounds through regular physical activity and a low-fat, low-
calorie diet can prevent or delay the onset of diabetes This may also
improve blood pressure and cholesterol levels Preventing or delaying the
onset of diabetes also is likely to prevent or delay the onset of diabetes
complications Provide a supportive, caring attitude and focus on the
health benefits of weight loss, not size or pounds
To experience further health benefits and to lower the chances of
developing heart disease or stroke, the American College of Sports Medicine
ACSM and the American Diabetes Association recommend that people with
diabetes lose a moderate amount of weight about 10-15 percent of body
weight, or between 20 and 30 pounds for someone who weighs 200 pounds At
the same time, the ACSM recognizes that people with type 2 diabetes are
often not able to be physically active at a level that is required for
significant weight loss, and warns professionals to guard against
expectations of quick or easy weight
loss in people beginning a physical
activity program
People can better maintain a healthy weight if they participate in a
structured program on a weekly or monthly basis Keeping a record of foods
consumed throughout the day is also helpful
Identifying and Treating Long-Term Diabetes Problems
People with diabetes should have regular exams to help find and treat
diabetes problems All diabetes problems have effective treatments Routine
checking for long-term complications can help detect problems at a time
when they can be treated and managed successfully The physical examination
and laboratory tests that identify early complications include the
following:[15]
|Examination/Laboratory Test |How Often Should It Be Conducted?|
|At each diabetes visit: |Every three months Every six |
|Blood pressure |months if normal |
|Weight check | |
|Foot check | |
|Lipid profile cholesterol check|Yearly Every two years if |
| |normal |
|Dilated eye examination |Yearly
Every two to three years |
| |if normal |
|Physical examination for |Yearly |
|detecting nerve damage | |
|Comprehensive foot exam to |Yearly |
|identify high-risk feet by | |
|checking circulation, loss of | |
|feeling, sores, or changes in | |
|shape | |
|Laboratory tests to detect kidney|Yearly |
|disease serum creatinine, | |
|urinalysis for protein, | |
|microalbumin, | |
|albumin-to-creatinine ratio | |
|A1C |Every three months Every six |
| |months if normal |
|Dental exams to prevent gum |Every six months |
|disease and loss of teeth |
|
|Flu influenza vaccine |Yearly |
|Pneumonia pneumococcal vaccine |Older adults ages 50 - 64 with |
| |diabetes or other risk factors |
| |eg, for people who live in |
| |long term care facilities should|
| |receive a one-time, single dose |
| |of pneumococcal vaccine All |
| |adults ages 65 and older should |
| |receive a one-time, single dose |
| |of pneumococcal vaccine[16] A |
| |one-time revaccination may be |
| |needed for people aged greater |
| |than 65 years old if they |
| |received the pneumococcal vaccine|
| |more than 5 years ago, and they |
| |were younger than 65 years old at|
| |the time[17], [18] |
Nutrition
for People With Diabetes
Although studies on the effects of fruits and vegetables are inconclusive
on diabetes,[19] diets that are high in fruits, vegetables, and whole
grains, and low in saturated and trans- fats, have been shown to be
effective in preventing diabetes[20] Also, eating more fruits and
vegetables are good for the body because they help replace calories that
would otherwise come from less nutritious foods They contain vitamins,
including anti-oxidants that help with disease prevention, and natural
fiber that has proven health benefits They also contain water, which
helps older adults increase their daily fluid intake
Some eating plans discussed periodically in the media, such as the
carbohydrate exchange system, very low calorie diets, and carbohydrate
counting may be helpful to some to control their blood glucose, but they
are not recommended for all people with diabetes[21] For example,
exchange systems and carbohydrate counting can be difficult for people to
understand and implement, especially if their health literacy level is low
see Chapter 3 section on Language and Literacy[22], [23] In fact,
simple meal plans emphasizing healthy food choices such as
eat less fat,
and limit carbohydrates can work as well as the traditional diabetes
exchange system for meal planning[24] The best eating plans are designed
jointly by the person with diabetes and a registered dietitian, and are
based on the persons health, other medications, activity level, and
treatment goals[25] Discussions of food values and portions should center
around foods that are familiar and regularly consumed, especially in
communities that have distinct cultural traditions relating to food
The following presents the nutrition guidelines from the American Diabetes
Association The American Diabetes Association publishes Clinical Practice
Recommendations every January They are available online at
wwwdiabetesorg/for-health-professionals-and-scientists/cprjsp
These include information regarding nutrition principles for people with
diabetes They state that Medical Nutrition Therapy MNT is an integral
component of diabetes management and Diabetes Self-Management Education
They further state that Because of the complexity of nutrition issues, it
is recommended that a registered dietitian, knowledgeable and skilled in
implementing nutrition therapy into diabetes management
and education is
the team member who provides MNT
Medicare covers MNT In order to qualify, Medicare recipients must obtain a
prescription from their physician for MNT services, which include the
following:
A review of current eating habits
Nutrition counseling on what foods to eat
Counseling on how to manage lifestyle factors that affect food
choices
Follow-up visits to check on progress in managing food choices
Medicare covers:
A total of 3 hours of one-on-one or group MNT services during the
first year must have prescription from the physician
An additional 2 hours of follow-up services each year after the
first year of services must have yearly prescriptions from the
physician
Additional hours of services prescribed by physician if condition,
treatment, or diagnosis changes
You can find a nutrition professional in your area by contacting the
American Dietetic Association at 800 366-1655 They provide a national
referral service directing people to local dietitians across the country
You can also visit the associations website at wwweatrightorg and select
Find a Nutrition Professional
from the home page
The goals of MNT include the following:
Attaining and maintaining recommended metabolic outcomes, including
glucose and A1C levels, LDL cholesterol, HDL cholesterol,
triglyceride levels, blood pressure and body weight
Preventing and treating the chronic complications and comorbities
of diabetes
Modifying nutrient intake and lifestyle as appropriate for the
prevention and treatment of obesity, high cholesterol
dyslipidemia, heart disease and stroke cardiovascular disease,
high blood pressure hypertension, and kidney disease
nephropathy
Improving health through healthy food choices and physical activity
Addressing individual nutritional needs, taking into consideration
personal and cultural preferences and lifestyle, while respecting
the individuals wishes and willingness to change[26]
The gold standard for MNT is nutrition care that follows the following
format: assessment, goal setting, intervention and evaluation This format
is derived from practice guidelines and commonly taught as part of the
training of dietetics professionals For a more complete
description of how
to apply nutrition practice guidelines to diabetes care specifically, see
the 2004 article by Patti Geil and Carolyn Leontos Nutrition Practice
Guideline Care Improves Diabetes Outcomes in Diabetes Spectrum, 172: 83-
86
The American Diabetes Association recognizes that in individuals with
prediabetes, reduced energy intake and modest weight loss improve insulin
resistance and blood glucose sugar levels in the short term The
guidelines of the American Diabetes Association are good for the general
public, but are intended for people with diabetes
Physical Activity for People With Diabetes
For older adults who are at risk for diabetes or have diabetes, physical
activity is crucial in improving insulin sensitivity, preventing or
delaying the onset of diabetes, and lowering the risk of short-term and
long-term diabetes-related problems Many people, including some older
adults, believe that changes in physical activity and eating habits will
make no difference past a certain age The Diabetes Prevention Program
study clearly demonstrated that this is not true - older adults can benefit
from such changes more than younger age groups However, professionals
and
elders, especially those with diabetes, must take certain precautions to
minimize the risks of injury and diabetes-related problems while countering
myths about aging and capacity for physical activity
Physical activity is one of the principal therapies to acutely lower blood
glucose in type 2 diabetes, for the following reasons:
Physical activity enhances the effects of insulin on the body
During physical activity, the liver produces less glucose and the
muscles increase their need for glucose and draw more from the
blood[27]
Regular physical activity can have many benefits for people with type 2
diabetes:
Greater glucose control and lower insulin resistance
Lower blood pressure
Heart health benefits lower heart rate, greater pumping
efficiency, better ability to pull oxygen from the blood to the
cells
Long-term weight loss and maintenance[28]
For people with prediabetes, physical activity is crucial in improving
insulin sensitivity and preventing or delaying the onset of diabetes
Physical activity combined with weight loss can lower ones chances of
developing heart disease
In the general
population, research suggests that physical activity can
also improve mood, lower stress levels, improve self-esteem, and improve
the ability to cope with lifes stressful events More research is needed
to know if the same is true for people with type 2 diabetes
Recommended Guidelines for Physical Activity for Older Adults With
Diabetes
Most older adults who have diabetes can safely be physically active to
improve their health and fitness and control their blood glucose
Heavy, intense workouts are not necessary - mild or moderate physical
activity effectively lowers blood glucose, both during and following
the activity Because the effect of physical activity on insulin
action in people with type 2 diabetes is usually lost within three
days, the American College of Sports Medicine ACSM[29] and the
American Diabetes Association[30] recommend regular activity performed
at a low-to-moderate intensity to lessen insulin resistance in people
with type 2 diabetes
Older adults are included in the current recommendation of moderate-
intensity physical activity for 30 minutes a day, five days or more
a week[31] Moderate intensity should make the person feel like he
or she is working somewhat hard Some also use the talk test; a
person working at a moderate intensity should be able to carry on a
conversation without being too out of breath
Elders who are not currently active should start slowly with 10 minute
bouts or less if necessary of low-intensity activity, and gradually
work up to three 10-minute bouts of moderate-intensity activity per
day Physical activity should be a routine part of daily life and does
not require participating in a formal physical activity program
Older persons should be told that everything counts — walking,
recreational sports, group classes, any kind of dancing, climbing
stairs, exercise videos, playing with grandchildren or pets, gardening
raking, mowing, pruning, digging, washing the car, vacuuming or
other activities around the house if done at moderate intensity
While endurance activities at a moderate intensity are crucial for
blood glucose control and heart health, older adults also need to
include strength, stretching and balance in their
physical activity
program
Special Considerations for Older Adults Being Physically Active with
Diabetes
All older adults with diabetes should consult their healthcare
provider before starting a physical activity program A stress test
electrocardiogram is recommended for everyone with type 2 diabetes
ages 35 and above 4 In addition to evaluating glycemic control, the
healthcare provider should assess physical limitations with respect to
stiff joints common in people with diabetes, prescribed medications,
and diabetes-related long term problems In nearly all cases, however,
professionals can stress that activity is fun, enhances your good
moods and energy levels, and is safer than not being active even if
precautions need to be taken or no weight is lost
Diabetes educators and other healthcare professionals should:
Assure that the person with diabetes has been assessed for
diabetes related complications that may require altering the
physical activities he or she can engage in[32], such as:
|Diabetes-Related |Physical Activity Precaution
|
|Health Problem | |
|Problems affecting |Healthcare provider should conduct a |
|heart health or |stress test electrocardiogram to |
|cardiac function |determine safety of engaging in |
| |aerobic-type physical activity |
|Eye problems |Avoid the use of weights or sudden |
| |jerking motions - these activities may |
| |put harmful pressure on the eyes |
| |Activities that cause blood pressure to |
| |increase dramatically, such as head-down|
| |or jarring activities or those with arms|
| |overhead, should be avoided |
|Loss of feeling in |Do more non-weight-bearing activities, |
|the foot insensate |such as swimming or cycling, to minimize|
|foot or foot wounds|the risk of foot ulcers and infections |
|or ulcers |Proper footwear for all weight-bearing |
| |activities of daily living is important |
| |to minimize blisters, sores, and |
| |infection Feet should be
examined daily|
| |by the person with diabetes and at each |
| |diabetes care visit |
|Kidney problems |In many cases, kidney problems require |
| |people to do less physical activity and |
| |monitor blood pressure more closely |
| |People with diabetes-related kidney |
| |problems should avoid activities that |
| |cause the blood pressure to rise to |
| |180-200 mm Hg systolic blood pressure |
| |such as weightlifting, high-intensity |
| |aerobics or strength exercises |
| |Higher intensity physical activity can |
| |place pressure on the kidneys However,|
| |lower intensity physical activitiy is |
| |beneficial for most people with |
| |diabetes-related kidney problems, even |
| |in later stages of kidney disease |
| |Exercise testing supervised by a |
| |healthcare
professional can help to |
| |determine safe intensity limits |
|Physical limitations|A common condition in older people and |
|with respect to |especially those with diabetes, it may |
|stiff joints |limit some of the types of physical |
| |activity that people feel comfortable |
| |doing |
Teach older adults with diabetes to self-monitor their blood
glucose before and after activity to learn the effect of physical
activity on blood glucose levels, and to avoid hypoglycemic
reactions
Discuss how insulin or oral medication will affect the elder with
diabetes when they are physically active
Discuss how to time diabetes medications or alter the amount taken
before and after physical activity
Encourage older adults with diabetes to set aside at least 30
minutes all at once or broken into 2-3 shorter sessions on 5 days
or more a week for physical activity[33]
See the following handouts found in Chapter 6 for additional information
on diabetes and physical activity for older
adults:
Tips for Working with Older Adults on Diabetes and Physical
Activity
Supporting People with Diabetes to Become More Physically Active
Tips for Physical Activity for People With Diabetes
If I Have Low Blood Glucose, Can I Exercise?
Exercise for Life A Physical Activity Program for Prevention and
Management of Diabetes
wwwasagingorg/cdc/module6/phase4/images/PAprogramfordiabetespdf
Preparing for a Diabetes Care Checkup: A Checklist
Communication with the physician or other health care professional is an
important tool for quality health care Working with the doctor to stay
well is as important as getting treatment when someone is sick Each
individual is an important member of his or her own health care team The
more an individual knows about diabetes, the better they will be able to
take better care of themselves
Communication can be more complicated with some older people, especially if
they have a language deficiency or have low literacy skills In these
cases, a family member will often accompany them to the doctor In some
instances, the family member may be a child whom the older person is caring
for
Although translators are to be provided by law, many doctors
offices are not equipped to properly translate medical terminology to the
patient
It is helpful for elders and their families to prepare for doctor
appointments If dressed appropriately, precious time will not be wasted
during the visit Many doctors have only 10 minutes to spend with each
patient If clothing is easy to remove, valuable appointment time will not
be wasted Clothing with buttons, especially small buttons is not
advisable Individuals who have diabetes should have their feet checked at
every regularly scheduled doctors visit Removing shoes and socks before
the doctor comes into the examining room will help to ensure the foot
examination takes place It is a good idea to leave dangling jewelry at
home It will just get in the way
Some individuals find writing down the questions they want to ask
beneficial If they make two copies they can give one to the doctor and
keep one for their own use When appropriate, provide copies of the
Preparing for a Diabetes Care Checkup: A Checklist to family members or
caregivers, in addition to the elder with diabetes If your organization
regularly provides services to people
who bring family members to
appointments, be sure to specify that the family member should not be a
minor at the time the appointment is made and whenever reminders are sent
Allowing space to write the answers to questions is a useful strategy If
the elder appears to have difficulty completing forms, staff should be
available to provide assistance Elders and their families or caregivers
should also be given contact information for your organization in the event
that they have questions after the visit Recommend picking no more than
three questions per visit and ask the one that is most essential first
Asking about seeing a dietitian may be the first question if what to eat is
a major concern
These questions are available as a handout
Some questions to ask are:
What is the most important thing I can do to take care of my
diabetes?
What should I eat? Should I see a dietitian?
Will I always need to take medication?
What time of day should I take these pills?
Does it matter if I take my pills before or after I eat?
Will I ever have to take insulin?
How should I take care of my feet?
How often should I
get my eyes checked?
What type of exercise is best for me?
Do I need to check my blood glucose sugar at home?
What time of day should I check my blood glucose?
What about my cholesterol?
What about my blood pressure?
What do those numbers mean?
Will I get kidney disease?
Will my children and grandchildren get diabetes?
Health Insurance Coverage
This section is a partial reprint of the NIH publication Financial Help
for Diabetes Care [34]
Health insurance coverage, or lack of coverage, is often a barrier for
elders living on a fixed income to obtain appropriate diabetes care
According to the American Diabetes Association, people who have diabetes
spend an average of 13,243 a year on health care expenses
Many people who have diabetes need help paying some of the bills Its a
good idea to start by looking for an insurance plan that covers as many
diabetes-related expenses as possible A variety of governmental and
nongovernmental programs exist to help, depending on whether you qualify
All older adults regardless of exact age who want assistance in obtaining
or understanding health insurance benefits
should contact the
Administration on Agings AoA Eldercare Locator at 1-800-677-1116 AoA
staff will connect callers with the health insurance counseling program in
their state, or the nearest area agency on aging
What Does Medicare Cover?
Medicare is a government program providing health care services for people
who are 65 years and older People who are disabled or have become disabled
also can apply for Medicare, and limited coverage is available for people
of all ages with kidney failure To learn if youre eligible, check with
your local Social Security office or call the Medicare Hotline listed
below Medicare now includes coverage for glucose monitors, test strips,
and lancets as well as medical nutrition therapy services for people with
diabetes or kidney disease when referred by a doctor Diabetes self-
management training, therapeutic shoes, glaucoma screening, and flu and
pneumonia shots are also covered
People with Medicare are facing increasingly steep increases in Medicare
Part B premiums Beginning in January 2005, the Medicare Part B premium
increased 174 percent to 7820 a month 93840 annually About 156,000
older and disabled Americans, with incomes between 120 to 135
percent of
the poverty level, and assets below 4,000 for an individual and 6,000 for
a couple in most states, will lose their Medicare premium support if the
Qualifying Individual-1 QI-1 program is terminated The QI-1 program is
one of three Medicare Savings Programs that helps low-income people with
Medicare lower their out-of-pocket health care expenses[35] The other two
programs are the Qualified Medicare Beneficiary program, where Medicaid
pays the Medicare Part B premium for people at 100 percent of the poverty
level, and the Qualifying Individual-2 QI-2 program, where people at 135
percent of the poverty level qualify for reduced Medicare Part B
premiums[36]
Diabetes-related Medicare coverage is available only to those who can
afford Medicare Part B premiums Also, some elders, such as Hispanic/Latino
Americans or immigrant elders, may not be enrolled in Medicare because they
think it is welfare Healthcare providers should probe to make sure they
are enrolled in Medicare Part A and Part B Elders at times, especially
those with low literacy skills or English language ability will, when
asked, say they are covered by Medicare without understanding the
difference between Part
A and B
The Medicare Rights Center wwwmedicarerightsorg offers training and
resources for professionals and consumers on Medicare benefits, with
special attention paid to low-income beneficiaries Contact this
organization for information on how the changes in Medicare affect low-
income elders
For more information about diabetes-related Medicare benefits, call the
National Diabetes Education Program at 1-800-438-5383 and request copies of
The Power to Control Diabetes Is in Your Hands and Expanded Medicare
Coverage of Diabetes Services, or read them online at wwwndepnihgov
click on Control under About Diabetes and Pre-Diabetes You can also
read the booklet Medicare Coverage of Diabetes Supplies Services PDF
online or request a copy from:
Centers for Medicare Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850
Phone: 1-800-MEDICARE 633-4227
Internet: wwwmedicaregov
The handout on Preventive Health Services Covered by Medicare Part B is a
summary of the services provided by Medicare for people with diabetes
adapted from the Medicare Rights Center MI Counselor tool, downloaded
December 2004, updated to reflect changes in Medicare
effective January
2005 For individual counseling on Medicare benefits, the American Society
on Aging has a Medicare Advisor program which focuses primarily on
prescription drug benefits but also provides information and training on
other areas of Medicare coverage To become an ASA Medicare Advisor or to
find one in your area, go to wwwasagingorg/medicare
Medicare Benefits
Professional training resources for general Medicare benefits can be found
on the Center for Medicare Rights website wwwmedicarerightsorg The
Center has developed a do-it-yourself training and reference manual with
ready-to-use presentation materials, including presentation scripts for
each module, downloadable presentation slides, consumer handouts, a
reference guide, a glossary of key Medicare terms, yearly updates, and a
subscription to Medicare Watch, and a bi-weekly Medicare e-mail newsletter
The cost is 150 The Center has also developed useful consumer handouts,
titled the Medicare Can Help series, that address the Medicare
application process for home care services, terminal illness care, skilled
care in a nursing home, durable medical equipment, and mental health care
The American Society on Aging
provides support for professionals who want
to know more about the new Medicare prescription drug benefits and how to
identify people at risk for medication-related problems For more
information, visit wwwasagingorg/medicare
Medicare-Covered Preventive Services for All Enrollees
The preventive care benefits listed in the handouts below are for all
Medicare Part B enrollees, not just those who have diabetes Medicare has
not traditionally covered preventive care, such as routine physical
examinations Doctors may not realize that Medicare now covers these
services, so it is important for elders to ask their doctor about them
Under the Medicare Modernization Act of 2003, there is now a one-time
Welcome to Medicare visit that stresses preventive services The
Partnership for Prevention has developed a one-page document for healthcare
providers to better understand what is covered
As long as you meet basic eligibility standards, you have the right to
receive these services no matter which Medicare health plan you are
enrolled in your HMO or PPO may charge you a co-pay for these services
Be sure to follow the Medicare guidelines for receiving these services in
order to ensure that
Medicare will cover them since some are covered only
once every few years and others are only covered if you meet specific
criteria
Medicare covers Medical Nutrition Therapy MNT for selected conditions
such as diabetes and kidney disease In order to qualify as a covered
service, MNT must be ordered by a physician
See the following handouts for more information:
Preventive Health Services Covered by Medicare Part B
Diabetes Services and Supplies Covered by Medicare Part B
Handout
Preventive Health Services Covered by Medicare Part B
|Service |Medicare Covers |How Often? |
|Diabetes |100 of the |You are eligible for up to two |
|screening |Medicare-approved |diabetes screenings each year if you|
| |amount no Part B | |
| |deductible |Have hypertension |
| | |Have dyslipidemia a metabolism |
| | |disorder |
| | |Have a prior blood test showing low |
| |
|glucose sugar tolerance |
| | |Meet at least two of the following: |
| | |You are overweight |
| | |You have a family history of diabetes|
| | | |
| | |You have a history of diabetes during|
| | |pregnancy gestational diabetes or |
| | |have had a baby over nine pounds |
| | |You are 65 years of age or older |
|Glaucoma |80 of the |Yearly examinations are covered for |
|screening |Medicare-approved |those at high risk for glaucoma: |
| |amount after Part |People with high blood pressure |
| |B deductible |People with a family history of |
| | |glaucoma |
| | |African Americans ages 50 and older |
|Blood testing |100 of the |Medicare now covers blood tests every|
|for heart |Medicare-approved |five
years to screen for cholesterol,|
|disease and |amount no Part B |lipid and triglyceride levels |
|stroke |deductible | |
|Flu shot |100 of the |Annually |
| |Medicare-approved | |
| |amount no Part B | |
| |deductible | |
|Pneumonia |100 of the |Older adults ages 50 - 64 with |
|vaccine |Medicare-approved |diabetes or other risk factors eg,|
| |amount no Part B |for people who live in long term care|
| |deductible |facilities should receive a |
| | |one-time, single dose of pneumococcal|
| | |vaccine All adults ages 65 and older|
| | |should receive a one-time, single |
| | |dose of pneumococcal vaccine[37] A |
| | |one-time revaccination may be needed |
| | |for people aged
greater than 65 years|
| | |old if they received the pneumococcal|
| | |vaccine more than 5 years ago, and |
| | |they were younger than 65 years old |
| | |at the time[38], [39] |
|One routine |80 of the |A one-time routine, Welcome to |
|physical exam |Medicare-approved |Medicare physical examination during|
|includes an |amount after Part |the first six months after you enroll|
|EKG, |B deductible |in Medicare Part B Some Medicare |
|measurement of| |private plans HMO, PPO, PFFS may |
|height, | |cover routine physicals |
|weight, and | | |
|blood | | |
|pressure, | | |
|education and | | |
|counseling | | |
Handout
Diabetes Services and Supplies Covered by Medicare Part
B
|Service |Details |Medicare Covers |You Pay |
|Certain diabetic |In limited |80 of the |20 of the |
|supplies: |quantities |Medicare-approved |Medicare-appro|
|Glucose monitors,|You can get these |amount after you |ved amount |
| |benefits even if you |meet your annual |after the |
|Blood glucose |dont use insulin |Medicare Part B |annual Part B |
|test strips, | |deductible |deductible |
|Lancet devices | | | |
|and lancets, and | | | |
| | | | |
|Glucose control | | | |
|solutions | | | |
|Insulin when |If you use an insulin|80 of the |20 of the |
|used with an |pump, the insulin and|Medicare-approved |Medicare-appro|
|insulin pump |the pump may be |amount after you |ved amount |
| |covered as durable |meet your annual |after
the |
| |medical equipment |Medicare Part B |annual Part B |
| |Contact your Durable |deductible |deductible |
| |Medical Equipment | | |
| |Regional Carrier for | | |
| |additional | | |
| |information | | |
|Therapeutic shoes|The doctor who treats|80 of the |20 of the |
|for people with |your diabetes must |Medicare-approved |Medicare-appro|
|severe diabetic |certify your need for|amount after you |ved amount |
|foot disease |therapeutic shoes |meet your annual |after the |
| |Medicare helps pay |Medicare Part B |annual Part B |
| |for one pair of |deductible |deductible |
| |therapeutic shoes and| | |
| |inserts per calendar | | |
| |year The fitting of | | |
| |the shoes or inserts | |
|
| |is covered in the | | |
| |Medicare payment for | | |
| |the shoes | | |
You may have to pay up to 15 percent of the Medicare-approved amount in
addition to the 20 percent coinsurance, if you see a provider who does not
accept Medicare assignment For Durable Medical Equipment DME, your
expenses may be even higher if you use a supplier who does not accept
assignment To keep your costs down be sure to use providers who accept
assignment Call 800 633-4227 to request a list of participating
providers or doctors who accept Medicare assignment
|Service |Details |Medicare Covers |You Pay |
|Diabetes |First year: up to 10|80 of the |20 of the |
|self-manageme|hours of |Medicare-approved |Medicare-approved|
|nt training |self-management |amount after you meet |amount after the |
|and education|training |your annual Medicare |annual Part B |
| |Every year |Part B deductible |deductible |
|
|thereafter: two | | |
| |hours | | |
|Medical |You need a doctors |80 of the |20 of the |
|nutritional |referral |Medicare-approved |Medicare-approved|
|therapy |First year: Medicare|amount after you meet |amount after the |
| |will generally cover|your annual Medicare |annual Part B |
| |three hours of |Part B deductible |deductible |
| |medical nutritional |Remember that you need| |
| |therapy |a doctors referral | |
| |Every year |for Medicare to cover | |
| |thereafter: Two |this service | |
| |hours Medicare will| | |
| |cover more hours if | | |
| |your doctor says you| | |
| |need them | | |
|Glaucoma |Once every 12 months|80 of the
|20 of the |
|screenings |and must be done or |Medicare-approved |Medicare-approved|
| |supervised by an eye|amount after you meet |amount after the |
| |doctor legally |your annual Medicare |annual Part B |
| |allowed to perform |Part B deductible |deductible |
| |this service in your| | |
| |state | | |
|Foot care for|Once every six |80 of the |20 of the |
|diabetics |months, as long as |Medicare-approved |Medicare-approved|
|with |you have not seen a |amount after you meet |amount after the |
|peripheral |foot-care specialist|your annual Medicare |annual Part B |
|neuropathy |for another reason |Part B deductible |deductible |
| |between visits | | |
|Dilated eye |As prescribed by |80 of the |20 of the |
|exam for |physician |Medicare-approved |Medicare-approved|
|diabetes-rela| |amount after you meet |amount after the |
|ted eye |
|your annual Medicare |annual Part B |
|problems | |Part B deductible |deductible |
|Items not |Insulin unless used|NOTHING |100 |
|covered |with an insulin pump| | |
| |– see above, | | |
| |insulin pens, | | |
| |syringes, needles, | | |
| |alcohol swabs, | | |
| |gauze, and eye exams| | |
| |for glasses Note | | |
| |that many of these | | |
| |may be covered | | |
| |through Medicare | | |
| |Part D and Medicare | | |
| |Advantage plans | | |
You may have to pay up to 15 percent of the
Medicare-approved amount in
addition to the 20 percent coinsurance, if you see a provider who does not
accept Medicare assignment For durable medical equipment, your expenses
may be even higher if you use a supplier who does not accept assignment To
keep your costs down be sure to use providers who accept assignment Call
800 633-4227 to request a list of participating providers or doctors
who accept Medicare assignment
In order to have these services covered by Medicare, you must get them
from Medicare-approved providers The shoes and inserts must be prescribed
by a podiatrist or other qualified doctor and provided by a podiatrist,
orthotist, prosthetist, or pedorthist And you must get nutritional therapy
from a registered dietitian or other qualified nutrition professional
Other Financial Assistance for Diabetes Care and Supplies
The information in this section may be beneficial to give to older adults
and their family members or caregivers Due to the high costs of managing
diabetes, all elders can benefit from this information, although low-income
elders and immigrant elders who may not be familiar with the benefits
available will benefit
especially
Medicaid
Medicaid is a state health assistance program for people based on financial
need Your income must be below a certain level to qualify for Medicaid
funds To apply, talk with a social worker or contact your local department
of human services Check the government pages of your phone book
Health Insurance
Because health insurance is meant to cover unexpected future illnesses,
diabetes that has already been diagnosed presents a problem It is
considered a preexisting condition, so finding coverage may be difficult
Many insurance companies have a specific waiting period during which they
do not cover diabetes-related expenses for new enrollees, although they
will cover other medical expenses that arise during this time
Recent state and federal laws, however, may help Many states now require
insurance companies to cover diabetes supplies and education The Health
Insurance Portability and Accountability Act HIPAA, passed by Congress in
1996, limits insurance companies from denying coverage because of a
preexisting condition To find out more about these laws, contact your
state insurance regulatory office This office can also help you find an
insurance company
that offers individual coverage
Managed Care
Most HMOs keep costs down by limiting the choice of doctors to those who
belong to the network, restricting access to specialists, reducing hospital
stays, and emphasizing preventive care In most managed care plans,
especially Medicare HMOs, you select a primary care physician who will be
responsible for directing your care and referring you to specialists when
he or she feels it is necessary Some plans also cover extra benefits such
as prescription drugs
For more information on managed care organizations, particularly the
quality of care they offer to patients, contact the National Committee for
Quality Assurance at 888 275-7585 or visit its website at wwwncqaorg
Medicare also has many publications to educate people about managed care
For more information, visit wwwmedicaregov or call 800 MEDICARE 633-
4227
Health Insurance After Leaving a Job
If you lose your health coverage when you leave your job, you may be able
to buy group coverage for up to 18 months under a federal law called the
Consolidated Omnibus Budget Reconciliation Act COBRA Buying group
coverage is often cheaper than buying individual coverage If you have
a
disability, you can extend COBRA coverage for up to 29 months COBRA may
also cover young people who were insured under a parents policy but have
reached the age limit and are trying to obtain their own insurance
For more information, call the Department of Labor at 866 487-2365 or
visit wwwdolgov/dol/topic/health-plans/cobrahtm
If you dont qualify for coverage or if your COBRA coverage has expired,
you can still seek other options:
1 Some states require employers to offer conversion policies, in
which you stay with your insurance company but buy individual
coverage
2 Some professional or alumni organizations offer group coverage for
members
3 Your state may be one of 29 with a high-risk pool for people unable
to get coverage
4 Some insurance companies also offer stopgap policies designed for
people who are between jobs
Contact your state insurance regulatory office for more information on
these and other options Information on consumer health plans is also
available at the US Department of Labors website at
wwwdolgov/dol/topic/health-plans/consumerinfhealthhtm
The Bureau of Primary Health Care, a service of the
Health Resources and
Services Administration, offers healthcare to people regardless of their
insurance status or ability to pay To find local health centers, call
800 400-2742 and ask for a directory, or visit the bureaus website at
wwwbphchrsagov
The Department of Veterans Affairs VA runs hospitals and clinics that
serve veterans who have service-related health problems or who simply need
financial aid If youre a veteran and would like to find out more about VA
health care, call 1-800-827-1000 or visit their website at wwwvagov
Many local governments have public health departments that can help people
who need medical care Your local county or city governments health and
human services office can provide further information
Hospital Care
If youre uninsured and need hospital care, you may be able to get help In
1946, Congress passed the Hospital Survey and Construction Act, which was
sponsored by
Senators Lister Hill and Harold Burton and is now known as the Hill-Burton
Act
Although the program originally provided hospitals with federal grants for
modernization, today it provides free or reduced-charge medical services to
low-income people The program is administered by the
Department of Health
and Human Services For more information, call 800 638-0742 or visit
wwwhrsagov/osp/dfcr on the Internet
Dialysis and Transplantation
Kidney failure is a common complication of diabetes In 1972, Congress
passed legislation making people of any age with permanent kidney failure
eligible for Medicare To qualify for Medicare on the basis of kidney
failure, you must need regular dialysis or have had a kidney transplant,
and you must have worked under Social Security, the Railroad Retirement
Board, or as a government employee or be the child or spouse of someone
who has, or you must already be receiving Social Security or Railroad
Retirement benefits Every American needing dialysis for chronic kidney
failure is eligible for dialysis assistance For more information, call the
Centers for Medicare Medicaid Services at 800 MEDICARE 633-4227 to
request the booklet Medicare Coverage of Kidney Dialysis and Kidney
Transplant Services This booklet is also available on the Internet at
wwwmedicaregov under Publications
For information on financing an organ transplant, contact the following
organization:
United Network for Organ Sharing UNOS
PO Box 2484
Richmond, VA
23218
888 894-6361
Website: wwwunosorg
Prescription Drugs and Medical Supplies
If you cant pay for your medicines and supplies without help, you should
tell your healthcare provider Your doctor may be able to direct you to
local programs or even provide free samples
You or your doctor can order a free filament to check feet for nerve
damage The filament with instructions for use is available by calling
the Bureau of Primary Health Cares Lower Extremity Amputation Prevention
Program LEAP at 888 ASK-HRSA 275-4772 or by visiting
wwwbphchrsagov/leap on the Internet
The Medicare program offers a searchable database of prescription drug
assistance programs at wwwmedicaregov/Prescription/Homeasp This website
gives information on public and private programs offering discounted or
free medication You can also learn about Medicare health plans with
prescription coverage
In addition, drug companies that sell insulin or diabetes medications
usually have patient assistance programs Such programs are available only
through a physician The Pharmaceutical Research and Manufacturers of
America and its member companies sponsor an interactive website with
information on drug assistance
programs at wwwhelpingpatientsorg
Also, since programs targeted at the homeless sometimes provide aid, try
contacting a local shelter for more information on how to obtain free
medications and medical supplies Check your phone book under Human
Service Organizations or Social Service
Organizations for the number of the nearest shelter
For individual counseling on Medicare benefits, the American Society on
Aging has a Medicare Advisor program that focuses primarily on prescription
drug benefits but also provides information and training on other areas of
Medicare coverage To become an ASA Medicare Advisor or to find one in your
area, visit wwwasagingorg/medicare
Prosthetic Care
If youve had an amputation, paying for your rehabilitation expenses may be
a concern The following organizations provide financial assistance for
people who need prosthetic care:
Amputee Coalition of America
900 East Hill Avenue, Suite 285
Knoxville, TN 37915-2568
Phone: 888 AMP-KNOW 267-5669
Website: wwwamputee-coalitionorg
Easter Seals
230 West Monroe Street, Suite 1800
Chicago, IL 60606
Phone: 800 221-6827
Fax: 312 726-1494
Website:
wwweastersealscom
Prosthetics for Diabetics Foundation
323 Reed Way
Monroe, GA 30655
Phone: 770 267-0019
Fax: 770 395-7487
Website: wwwexpagecom/page/pfdfoundation
Technological Assistance
Assistive technology, which can help people with disabilities function more
effectively at home, at work, and in the community, can include computers,
adaptive equipment, wheelchairs, bathroom modifications, and medical or
corrective services The following organizations provide information,
awareness, and training in the use of technology to aid people with
disabilities:
Alliance for Technology Access
1304 Southpoint Boulevard, Suite 240
Petaluma, CA 94954
Phone: 707 778-3011
E-mail: ATAinfo@ATAccessorg
Website: wwwataccessorg
UCP United Cerebral Palsy
1660 L Street NW, Suite 700
Washington, DC 20036
Phone: 800 872-5827
Fax: 202 776-0414
Email: webmaster@ucporg
Website: wwwucporg/ucp_channelsubcfm/1/14/86
Local Resources
Finally, for help in financing some of the many expenses related to
diabetes, you may also want to seek out available local resources, such as
the
following charitable groups:
Lions Clubs International, which can help with vision care
Rotary Clubs, which provide humanitarian and educational assistance
Elks Clubs, which provide charitable activities that benefit youth
and veterans
Kiwanis Clubs, which conduct fundraising events and projects to
help the community
religious organizations
In many areas, nonprofit or special interest groups such as those listed
above can sometimes provide financial assistance or help with fundraising
In addition, some local governments may have special trusts set up to help
people in need You can find out more about such groups at your local
library or your local city or county governments health and human services
office
References
Adapted from Better Diabetes Care — How to Make Systems Changes for
Improved Care Available on the World Wide Web:
http://betterdiabetescarenihgov
American College of Sports Medicine Position Stand Albright, A, Franz,
M, et al 2000 Exercise and Type 2 Diabetes Medicine and Science in
Sports and Exercise 327:1346
American Diabetes Association 2005 Standards of Medical Care Diabetes
Care 28S1:
S4-S36
American Diabetes Association Position Statement 2004 Physical
Activity/Exercise and Diabetes Diabetes Care 271:S58-S62
Bebe, D 2004 Low-Income Americans to Lose Benefit That Pays Medicare
Premium Unless Congress Acts Quickly Press release Medicare Rights
Center Available at Medicare Rights on the World Wide Web:
wwwmedicarerightsorg/pressrelease2004_29html
Biesalski, HK 2004 Diabetes preventive components in the Mediterranean
diet European Journal of Nutrition 4326
California Healthcare Foundation/American Geriatrics Society Panel on
Improving Care for Elders with Diabetes 2003 Guidelines for Improving
the Care of the Older Person with Diabetes Mellitus Journal of the
American Geriatrics Society 51:S265-S280
Centers for Disease Control and Prevention CDC April 4, 1997
Prevention of Pneumococcal Disease: Recommendations of the Advisory
Committee on Immunization Practices ACIP MMWR Recommendations and
Reports 46RR-08:1-24
CDC, The Advisory Committee on Immunization Practices 2004 Summary of
Recommendations: Recommended Adult Immunization Schedule, United States,
October 2004 - September 2005 Available at CDC on the World Wide
Web:
wwwcdcgov/nip/recs/adult-schedulepdf
Centers for Disease Control and Prevention Physical Activity for
Everyone: Recommendations: Are there special recommendations for older
adults? Available on the World Wide Web:
wwwcdcgov/nccdphp/dnpa/physical/recommendations/older_adultshtm
Delaware Health and Social Services, Division of Services for Aging and
Adults With Physical Disabilities 2004 Frequently Asked Questions: What
Is Qualified Medicare Beneficiency? Available at DSAAPD on the World Wide
Web: wwwdhssdelawaregov/dhss/dsaapd/faq_qmbhtml
Diabetes Prevention Program Research Group 2002 Reduction in the
Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin New
England Journal of Medicine 3466:393-402
Dziura, J, et al 2004 Physical Activity Reduces Type 2 Diabetes Risk
in Aging Independent of Body Weight Change Journal of Physical Activity
and Health 1:19-28
Geil, PB, Holzmeister, LH 1999 101 Nutrition Tips for People with
Diabetes Alexandria, VA: American Diabetes Association, p 11
Hyson, D 2002 The Health Benefits of Fruits and Vegetables: A Scientific
Overview for Health Professionals Literature review from 1999 - 2002
Wilmington, DE: Produce for Better
Health Foundation
Kendall, P, Jansen, G 1990 Educating patients with diabetes:
comparison of nutrient-based and exchange group methods Journal of the
American Dietetic Association 90:238 -243
National Diabetes Education Program 2004 Guiding Principles for Diabetes
Care: For Health Care Providers NIH Publication No 99-4343 Available at
NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
National Diabetes Education Program In press as of June 2005 The Power
to Control Diabetes Is in Your Hands, revised toolkit
National Institutes of Health 2004 Financial Help for Diabetes Care NIH
Publication No 04-4638 Available on the World Wide Web:
http://diabetesniddknihgov/dm/pubs/financialhelp/
West, KM 1973 Diet therapy of diabetes: an analysis of failure
Annals of Internal Medicine 79:425-434
Ziemer, DC, et al 2003 A simple meal plan emphasizing healthy
food choices is as effective as an exchange-based meal plan for urban
African Americans with type 2 diabetes Diabetes Care 266:1719-1724
Glossary - Chapter 2
A1C
The A1C also called HbA1C, Hemoglobin A1C, or glycosylated
hemoglobin is a test that measures the amount of glucose
attached to
the hemoglobin molecule in your blood cells The A1C test is a simple
lab test that reflects your average blood glucose levels over the past
3 months It is the best way to know how well your blood glucose is
controlled overall It does not measure how your blood glucose changes
over the course of the day This test used to be called hemoglobin
pronounced he-mo-glo-bin A-1-C or H-b-A-1-C You should have this
test at least twice a year The goal for most people with diabetes is
below 7
———————–
[1] Diabetes Prevention Program Research Group 2002 Reduction in the
Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin New
England Journal of Medicine 3466:393-402
[2] Dziura, J, et al 2004 Physical Activity Reduces Type 2 Diabetes
Risk in Aging Independent of Body Weight Change Journal of Physical
Activity and Health 1:19-28
[3] American Diabetes Association 2005 Standards of Medical Care
Diabetes Care 28S1: S4-S36
[4] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide
Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[5] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[6] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[7] Adapted from Better Diabetes Care — How to Make Systems Changes for
Improved Care Available on the World Wide Web:
http://betterdiabetescarenihgov
[8] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[9] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[10] National Diabetes Education Program In press as of June 2005 The
Power to Control Diabetes Is
in Your Hands, revised toolkit
[11] California Healthcare Foundation/American Geriatrics Society Panel on
Improving Care for Elders with Diabetes 2003 Guidelines for Improving
the Care of the Older Person with Diabetes Mellitus Journal of the
American Geriatrics Society 51:S265-S280
[12] Ibid
[13] California Healthcare Foundation/American Geriatrics Society Panel on
Improving Care for Elders with Diabetes 2003 Guidelines for Improving
the Care of the Older Person with Diabetes Mellitus Journal of the
American Geriatrics Society 51:S265-S280
[14] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[15] National Diabetes Education Program 2004 Guiding Principles for
Diabetes Care: For Health Care Providers NIH Publication No 99-4343
Available at NIH on the World Wide Web:
wwwndepnihgov/diabetes/pubs/GuidPrin_HC_Engpdf
[16] Pneumococcal polysaccharide vaccination Medical indications: chronic
disorders of the pulmonary system excluding asthma; cardiovascular
diseases; diabetes mellitus; chronic liver diseases,
including liver
disease as a result of alcohol abuse eg, cirrhosis; chronic renal
failure or nephritic syndrome; functional or anatomic asplenia eg,
sickle cell disease or splenectomy; immunosuppressive conditions eg,
congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple
myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow
transplantation; chemotherapy with alkylating agents, antimetabolites, or
long-term systemic corticosteroids; or cochlear implants Geographic/other
indications: Alaska Natives and certain American Indian populations Other
indications: residents of nursing homes and other long-term-care facilities
see MMWR 1997;46[No RR-8] and MMWR 2003;52:739-40
[17] Revaccination with pneumococcal polysaccharide vaccine One-time
revaccination after 5 years for persons with chronic renal failure or
nephrotic syndrome; functional or anatomic asplenia eg, sickle cell
disease or splenectomy; immunosuppressive conditions eg, congenital
immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma,
Hodgkins disease, generalized malignancy, or organ or bone marrow
transplantation; or chemotherapy with alkylating agents,
antimetabolites,
or long-term systemic corticosteroids For persons aged 65 years, one-time
revaccination if they were vaccinated 5 years previously and were aged 65
years at the time of primary vaccination CDC April 4, 1997 Prevention
of Pneumococcal Disease: Recommendations of the Advisory Committee on
Immunization Practices ACIP MMWR Recommendations and Reports 46RR-
08:1-24
[18] CDC, The Advisory Committee on Immunization Practices 2004 Summary
of Recommendations: Recommended Adult Immunization Schedule, United
States, October 2004 - September 2005 Available at CDC on the World Wide
Web: wwwcdcgov/nip/recs/adult-schedulepdf
[19] Hyson, D 2002 The Health Benefits of Fruits and Vegetables: A
Scientific Overview for Health Professionals Literature review from 1999 -
2002 Wilmington, DE: Produce for Better Health Foundation
[20] Biesalski, HK 2004 Diabetes preventive components in the
Mediterranean diet European Journal of Nutrition 4326
[21] Geil, PB, Holzmeister, LH 1999 101 Nutrition Tips for People
with Diabetes Alexandria, VA: American Diabetes Association, p 11
[22] Kendall, P, Jansen, G 1990 Educating patients with diabetes:
comparison of nutrient-based and exchange group
methods Journal of the
American Dietetic Association 90:238 -243
[23] West, KM 1973 Diet therapy of diabetes: an analysis of failure
Annals of Internal Medicine 79:425-434
[24] Ziemer, DC, et al 2003 A simple meal plan emphasizing healthy
food choices is as effective as an exchange-based meal plan for urban
African Americans with type 2 diabetes Diabetes Care 266:1719-1724
[25] Geil, PB, Holzmeister, LH 1999 101 Nutrition Tips for People
with Diabetes Alexandria, VA: American Diabetes Association, p 11
[26] American Diabetes Association 2005 Standards of Medical Care in
Diabetes Diabetes Care 28S1:S4-S36
[27] American College of Sports Medicine Position Stand Albright, A,
Franz, M, et al 2000 Exercise and Type 2 Diabetes Medicine and
Science in Sports and Exercise 327:1346
[28] American College of Sports Medicine Position Stand Albright, A,
Franz, M, et al 2000 Exercise and Type 2 Diabetes Medicine and
Science in Sports and Exercise 327:1346
[29] American College of Sports Medicine Position Stand Albright, A,
Franz, M, et al 2000 Exercise and Type 2 Diabetes Medicine and
Science in Sports and Exercise 327:1345-1360
[30] American Diabetes Association Position Statement 2004
Physical
Activity/Exercise and Diabetes Diabetes Care 271:S58-S62
[31] Centers for Disease Control and Prevention Physical Activity for
Everyone: Recommendations: Are there special recommendations for older
adults? Available on the World Wide Web:
wwwcdcgov/nccdphp/dnpa/physical/recommendations/older_adultshtm
[32] American Diabetes Association Position Statement 2004 Physical
Activity/Exercise and Diabetes Diabetes Care 271:S58-S62
[33] Centers for Disease Control and Prevention Physical Activity for
Everyone: Recommendations: Are there special recommendations for older
adults? Available on the World Wide Web:
wwwcdcgov/nccdphp/dnpa/physical/recommendations/older_adultshtm
[34] National Institutes of Health 2004 Financial Help for Diabetes
Care NIH Publication No 04-4638 Available on the World Wide Web:
http://diabetesniddknihgov/dm/pubs/financialhelp/
[35] Bebe, D 2004 Low-Income Americans to Lose Benefit That Pays
Medicare Premium Unless Congress Acts Quickly Press release Medicare
Rights Center Available at Medicare Rights on the World Wide Web:
wwwmedicarerightsorg/pressrelease2004_29html
[36] Delaware Health and Social Services, Division of Services for Aging
and Adults With
Physical Disabilities 2004 Frequently Asked Questions:
What Is Qualified Medicare Beneficiency? Available at DSAAPD on the World
Wide Web: wwwdhssdelawaregov/dhss/dsaapd/faq_qmbhtml
[37] Pneumococcal polysaccharide vaccination Medical indications: chronic
disorders of the pulmonary system excluding asthma; cardiovascular
diseases; diabetes mellitus; chronic liver diseases, including liver
disease as a result of alcohol abuse eg, cirrhosis; chronic renal
failure or nephritic syndrome; functional or anatomic asplenia eg,
sickle cell disease or splenectomy; immunosuppressive conditions eg,
congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple
myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow
transplantation; chemotherapy with alkylating agents, antimetabolites, or
long-term systemic corticosteroids; or cochlear implants Geographic/other
indications: Alaska Natives and certain American Indian populations Other
indications: residents of nursing homes and other long-term-care facilities
see MMWR 1997;46[No RR-8] and MMWR 2003;52:739-40
[38] Revaccination with pneumococcal polysaccharide vaccine One-time
revaccination after 5 years for persons
with chronic renal failure or
nephrotic syndrome; functional or anatomic asplenia eg, sickle cell
disease or splenectomy; immunosuppressive conditions eg, congenital
immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma,
Hodgkins disease, generalized malignancy, or organ or bone marrow
transplantation; or chemotherapy with alkylating agents, antimetabolites,
or long-term systemic corticosteroids For persons aged 65 years, one-time
revaccination if they were vaccinated 5 years previously and were aged 65
years at the time of primary vaccination CDC April 4, 1997 Prevention
of Pneumococcal Disease: Recommendations of the Advisory Committee on
Immunization Practices ACIP MMWR Recommendations and Reports 46RR-
08:1-24
[39] CDC, The Advisory Committee on Immunization Practices 2004 Summary
of Recommendations: Recommended Adult Immunization Schedule, United States,
October 2004 - September 2005 Available at CDC on the World Wide Web:
wwwcdcgov/nip/recs/adult-schedulepdf
Source:asaging.org
