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Marginal levels signal warning about lifestyle choices
One of the advantages of screening for diabetes is the opportunity to increase awareness about the chronic disease. The Alexandria, VA-based American Diabetes Association (ADA) estimates that 16 million Americans have diabetes, but about 5 million of them don’t know it.
"There are so many people who walk around with diabetes and have damage done to their bodies because they don’t realize they have the disease. Often they have no signs and symptoms, or what signs and symptoms they do have develop so gradually that they are unaware," says Cindy Farricker, MS, RD, CD, a registered dietitian at the Diabetes Care Center at the University of Washington Medical Center (UWMC) in Seattle.
The goal of public screenings conducted by UWMC is to not only uncover people with high glucose levels, such as 300 mg/dl, who need to see their physician and learn how to control their diabetes, but identify people who are at risk for type II diabetes and who could potentially develop it within the next year or two, explains Dori Khakpour, RD, CD, CDE, nutrition and education coordinator at the Diabetes Care Center.
"The positive aspect of glucose screening is to identify patients who are asymptomatic and have lower elevations in their blood sugars that will allow simpler diabetes management regimes and will have better outcomes. It’s a lot easier to treat a blood sugar of 129 mg/dl than someone with a fasting glucose test of 400 mg/dl," says Amparo Gonzalez, RN, CDE, director of the Specialty Center for Diabetes Care at Saint Joseph’s Hospital of Atlanta.
These diabetes educators are fully aware that the ADA no longer endorses community screenings due to the lack of scientific evidence proving them effective. One of the problems with community screenings cited in the organization’s 2001 clinical practice recommendations for diabetes screening is that there is not appropriate follow-up testing and care for those with high glucose levels. Additionally, says the ADA, there’s no way to ensure repeat testing for those who screen negative but have glucose levels high enough to indicate that they could be at risk for diabetes.
The educators also acknowledge that there are drawbacks to diabetes screening. The downside of glucose screening is that people get a false sense of security because they were tested and their blood sugar was good after fasting, says Farricker.
Other drawbacks are that there’s limited time to conduct patient teaching and it’s difficult to ensure that patients pursued the appropriate medical follow-up, says Janet Hale, RN, manager of the Health Information Center of University of Missouri Health Care in Columbia.
In spite of the drawbacks and the concerns voiced by the ADA, many health care institutions have programs in place for glucose screening that they find effective. To help make them successful, they have set in place steps for education and as much follow-up as possible. What they all have in common is they ensure patients understand that screenings are not for the purpose of diagnosing diabetes but to determine if those screened are at risk. If they have an elevated glucose level, they would be referred for further testing, says Hale. (For more information on follow-up see article on p. 100.)
Create a plan
At the Health Information Center, which is located in a mall setting, a glucose screening is available once a month on a walk-in basis. A newspaper ad encourages people who are over the age of 40, overweight, or have a family history of diabetes to have a glucose test periodically. It explains that the test is best done two hours after eating a well-balanced meal.
The center averages 40-50 people a month for this screening, and most are over the age of 50. On average, two or three new people are identified with high blood sugar each month. "We get two kinds of people, those with a diagnosis of diabetes who want to compare our glucose readings with their own and those individuals who may be at risk for diabetes and want to be screened," says Hale.
A consent form people fill out before the screening asks several questions, such as their family history pertaining to diabetes, to see if they are at high risk for developing the chronic disease. The form is used to initiate education specific to each person being screened during the time it takes for the machine to determine his or her glucose level.
For example, if they have a family history of diabetes, they would be told the importance of being tested on a regular basis even if their glucose is within a normal range so that they might catch the onset of diabetes early. According to ADA guidelines, high-risk individuals should be evaluated at three-year intervals beginning at age 45.
Hale doesn’t try to cram too much information into the short amount of time there is for teaching. "If you try to teach people more than three things, they won’t remember them anyway. If I can drive three points home, I have been successful," says Hale.
While Provena Mercy Center in Aurora, IL, no longer conducts community screenings for diabetes, it does provide free glucose screenings by appointment twice a month from 8:30 a.m. to noon. "I do a risk assessment over the phone when setting up appointments for screening, but even if they are not at risk for diabetes, I let them schedule an appointment because this is a service to the community," says Rita Smith, MSN, RN, coordinator of clinical education at the health care facility.
The ADA identifies high risk factors as a family history of diabetes, obesity, habitual physical inactivity, members of certain race/ethnic groups such as African-Americans and Hispanic-Americans, and people with signs of insulin resistance or conditions associated with insulin resistance.
Smith always asks participants if they have questions because often they come to be screened after someone they know is diagnosed with diabetes. This provides a chance to dispel any myths they may have about diabetes. She also discusses the two types of diabetes (Types I and II) and symptoms by providing a pamphlet to reinforce the teaching. She also provides tips on prevention of diabetes. For example, if the person being screened is overweight, she suggests that they try to stay at a normal weight, get adequate exercise, and eat a balanced diet to help prevent diabetes.
At the Specialty Center for Diabetes Care at Saint Joseph’s Hospital, people can walk in for a free glucose screening. Center staff, however, also conduct screenings at corporations, churches, and other community venues when asked. When people test positive for diabetes, Gonzalez takes them to a private area near the screening site and provides five to 10 minutes of basic education. She also gives them a booklet with the basics of diabetes.
It’s impossible to adequately educate people at that moment because many are in a state of disbelief. The goal is to get them to understand their need for follow-up and further education, says Gonzalez. Diabetes education takes at least 10-12 hours, she explains.
When doing community screenings, it is important to make sure people have enough education to prompt them to follow up with their physician if their blood glucose is elevated, says Khakpour. Because the Diabetes Care Center has a multitude of information sheets on specific and general diabetes topics, people can get answers to most of their questions, she says. n
For more information about glucose screenings, contact:
• American Diabetes Association, 1701 N. Beauregard St., Alexandria, VA 22311. Telephone: (800) 342-2383.
• Cindy Farricker, MS, RD, CD, Registered Dietitian, and Dori Khakpour, RD, CD, CDE, Nutrition and Education Coordinator, Diabetes Care Center, UWMC Box 356176, 1959 Pacific St., Seattle, WA 98105. Telephone: (206) 598-4882. Fax: (206) 598-4976.
• Amparo Gonzalez, RN, CDE, Director, Specialty Center for Diabetes Care, Saint Joseph’s Hospital of Atlanta, 5667 Peachtree Dunwoody Road N.E., Suite 100 Atlanta, GA 30342. Telephone: (404) 851-5906. Fax: (404) 851-5899. E-mail: firstname.lastname@example.org.
• Janet Hale, RN, Manager, Health Information Center, University of Missouri Health Care, Columbia Mall, 2300 Bernadette Drive, Columbia, MO 65203. Telephone: (573) 882-4743. E-mail: halej@health. missouri.edu.
• Rita Smith, MSN, RN, Clinical Education Coordinator, Provena Mercy Center, 1325 N. Highland Ave., Aurora, IL 60506. Telephone: (630) 801-2675. Fax: (630) 801-3137. E-mail: RitaASmith@ProvenaHealth.com.