In accordance with HIPAA Federal Law(The Health Insurance Portability and

Accountability Act of 1996), this humansubject has given explicit consent for

use of her identifiers.

Presentation by: Heather L. O’Leary

HEALTHPROMOTION

OF THEUNSUSPECTING

INDIVIDUAL

WHO? Lois, a 71-year-old

Caucasian female,

retired from

administrative

assistant positions

HEALTH HISTORY• Type II Diabetes Mellitus for 16 years• Hypertension for approximately 30 years• Dyslipidemia for approximately 20 years• Coronary artery disease status post PTCA with

stent of LAD March 2007• Degenerative disks with two herniations for

approximately 25 years• Osteoarthritis for approximately 25 years

• Body mass index at lower end of obesity range (valuewithheld per patient request)

• Waist-to-hip ratio indicative of android figure (valuewithheld per patient request), thus increasing risk ofobesity-related diseases and early mortality (Jarvis,2004)

• Hemoglobin A1c 6.4% (high); HDL 35mg/dL (low); LDL70mg/dL (normal); triglycerides 130mg/dL (normal) asof September 3, 2008

• Blood pressure 128/72; resting pulse 78, regular;respirations 14, regular, even, and unlabored;temperature 36.8°C

• Medications include Glucophage 800mg twice daily;Amaryl 1mg daily; Byetta 10mg twice daily; Lipitor 40mgdaily; Toprol XL 50mg daily; Norvasc 5mg daily

HEALTH ASSESSMENT

• Middle-class, suburban dweller entire life;residency solely limited to Lorain, Ohio

• High-school education, with some collegecourses, but no degree/diploma

• Divorced after 16 years of marriagein 1986 with two daughters

• Born at the end of the Great Depression; heard many recounts ofperiod, but does not feel as though ever personally affected

• Practicing Jehovah’s Witness• Full confidence in Western medicine; skeptical of holistic approaches• Maintains network of friends with regular scheduled and unscheduled

outings• Never considered self physically active “because ladies were not . . .

unless housework counts”

Psychosocial and CulturalConcepts

No, because ladies were notexpected to be physically activeunless housework counts.

““

”EXERCISE?

• Ex-smoker, 3 pack-per-day habit, beginning at age 15 until age44 with short periods of cessation secondary to quittingattempts and pregnancies

• Socially consumes alcohol, 2 drinks biweekly• Relates not experiencing much stress after retiring six years

ago, with the exception of occasional financial concerns;recognizes that such concerns are often due to “retail therapy”

• Expresses some distaste for polypharmacy secondary to act ofconsumption itself alone

Psychosocial and CulturalConcepts (continued)

• Acknowledges having some control over health (e.g.improving diet and increasing physical activity) yetstates, “It is also taken care of with medicine.”

• Recent visit of similarly-aged friend in nursing homerevealed new perspective: “I guess I should be verythankful I’ve been so fortunate with my health. Beforeseeing her, I just thought I was old and felt average formy age.”

• Now rates health as “above-average” but recognizes“room for improvement”

Health Beliefs

[My health] is also taken care ofwith medicine.”“VS

• History of diabetes, hypertension, dyslipidemia, andcoronary artery disease

• Familial history of paternal hypertension and multiplecerebrovascular accidents, paternal multiple falls withresultant hip fractures; questionable maternal diabetes withvascular disease, maternal myocardial infarction; sister withovarian cancer, hypertension, coronary artery disease withthree myocardial infarctions; brother with hypertension andmultiple stents secondary to coronary artery disease

• Lack of regular physical activity• Lack of health-conscious diet• Non-adherence to regular measurements of blood glucose

levels• Mild obesity

RISK FACTORS

Sometimes it’s just easier not toknow what my sugar is.

”

DOYOUMONITOR?

“

PLAN OFACTION

…time for change!

#1 Education

#2 Discussion

PART ONE:

Education

Education: PASS ON DESSERTS

Teach implications of less-than-optimal diet andfailure of self-monitoring blood glucose:

#1 Risk for fractures

#2 Diabetic complications, including worsening ofcoronary artery disease (i.e. additionalPTCA/stents/possible bypass) as well ascerebrovascular accident, vascular issues,neuropathy, nephropathy, retinopathy andsubsequent diagnoses

(American Diabetes Association, 2008)

Education:

Correlate implications of history:

Correlate implications with particular emphasis ondiabetic complications with personal and familialhealth histories to show relevancy

BLOOD IS THICKERTHAN WATER

Education: LET’S GET PHYSICAL

Teach implications of physical inactivity:

Provide information regarding physical activityimproving current conditions, and delay and/orprevention of others

(American Heart Association,2008; National Institute of Diabetes and Digestive and Kidney Diseases, 2006)

Education: KEEP ON PRICKIN’

Teach implications of poor blood glucose monitoring:

Provide information regarding blood glucose controland effects upon present diagnoses and possiblecomplications of poor control; show chart explainingidentical Hemoglobin A1c of 8.0% being not indicativeof good glucose control as chart proves can be greatdaily variances during 30-day measurement period,1/3 less than the required 90 days to determine A1cvalue

(Kovatchev, 2007)

(American Diabetes Association, 2008)

Education: KEEP ON PRICKIN’

Teach implications of poor blood glucose monitoring:

Reinforce necessity of daily glucose checks as “HbA1clevels increase steadily as the number of lipidabnormalities increase . . . [with] low HDL [being] themost common high-risk abnormality (59.8%) . . . andwomen [being] much more likely to have multiplelipid abnormalities”

(Brown, Nichols, Hayes, & Bowman, 2004)

Capitalize on “lifestyle changes” aspect to include“glycemic control”

Education: IT’S NEVER TOO LATE

Teach value of physical activity:

Enforce research that hasdetermined “it’s never too late tobecome physically active” and that“even a small amount of activity canresult in better health”

(Agency for Healthcare Research and Quality and theCenters for Disease Control,2002)

Education: PLAY “RATE YOUR PLATE”

Teach value of a well-balanced meal:

Play “Rate Your Plate”, available from the AmericanDiabetes Association on http://diabetes.org/all-about-diabetes/chan_eng/i3/i3p4.htm; results were Lois’plate often consisting entirely of carbohydrates, asopposed to the ¼ recommendation; discussedproportions of ½ non-starch vegetables and ¼ leanprotein

(American Diabetes Association, 2008)

PART TWO:

DISCUSSION

DISCUSSION:

Although the Health Belief Modelis only appropriate for disease-preventing behavior as opposedto health-promoting, Loiscontends that,“nothing quitemotivates me like a threat”

HEALTHBELIEFS

(Pender, Murdaugh, & Parsons, 2006)

DISCUSSION:

Perceived benefits to action are verbalized as“my health won’t deteriorate as quicklywithout the changes”; “maybe I won’t have totake as many pills”; and “since I have such anaddictive personality, maybe I can make this ahabit”

PERCEIVEDBENEFITS

+

DISCUSSION:

Perceived barriers to action are verbalized as“I find exercise boring”; “I have neverenjoyed sports”; and “I don’t want to hurtmyself . . . I can be so clumsy”

PERCEIVEDBARRIERS

-

DISCUSSION:

Emphasized benefits and addressedbarriers; discussed how regularphysical activity can increasecoordination as well as means offinding enjoyable activities and Loisdecided upon walking: one 15-minute session of walking eitheroutdoors or on the treadmill agreedupon for the first week for 3 days,increasing to 4 days the next, and 5days the following; once 5 days ofactivity is achieved weekly, the timespent shall increase by 5 minuteincrements weekly

INCREASINGPHYSICALACTIVITY

DISCUSSION:

• Carbohydrates will bedecreased to ½ or less of theplate for one month, then to¼ the next month

• Blood glucose levels will bechecked daily for one monththen results to be discussedwith her endocrinologist todetermine any furtheradjustments necessary

FOOD &BLOOD GLUCOSEMONITORING

DISCUSSION:

Both the level of readiness and barrierswere evaluated to be relatively low,necessitating high-intensity cues—e.g.her “retail therapy” was dependentupon adherence to physical activityagreement; friends and family wererecruited as support; primary carephysician, cardiologist, andendocrinologist were informed of plan

SUPPORT

RESOURCES

RESOURCES:AMERICANDIABETESASSOCIATIONwww.diabetes.org

• Founded in 1940, the mission is “to prevent and cure the lives of all people affected bydiabetes”

• Vision is “to make an everyday difference in the quality of life for all people withdiabetes”; core values are “integrity, leadership, ownership, inclusion, trust, [and]passion for making a difference”

• ADA “funds research, publishes scientific findings, provides information and otherservices to people with diabetes, their families, health health professionals, and thepublic. [It] is also actively involved in advocating for scientific research and for therights of people with diabetes.”

• The agency reports to the board of directors whose Chair is R. Stewart Perry

• Senior management is overseen by CEO Larry Hausner

• Departments include accounting, administrative and clerical, communications,community initiatives, customer service, finance, fund-raising, government relations andadvocacy, human resources, information systems, legal, marketing, publications, andresearch

RESOURCES:AMERICANDIABETESASSOCIATIONwww.diabetes.org

• Funding is via corporate and private donations

• The National Office and Service Center in Alexandria, VA employs 302 people; otheroffices are dispersed nationwide, with the majority in the eastern half of the UnitedStates

• The vast array of information provides an invaluable resource to Lois; she has located asupport group at St. John Westshore Hospital; she was astounded during thenavigation of the site with the data available (e.g. diet, exercise, and solutions tocommon questions; she feels she is “much more inclined to find answers since I alwaysforget while I’m in the doctor’s office. I also forget to bring the list of questions thatI’ve written down. I don’t want to call and bother anybody, and hopefully I won’tforget by the time I reach the [ADA] website. Or forget the website. I tell ya, it’s you-know-what getting old!” (The ADA was made Lois’ homepage in order address theaforementioned.)

(continued)

(American Diabetes Association, 2008)

RESOURCES: WEIGHTWATCHERSwww.weightwatchers.com

• Founded in early 1960’s by Jean Nidetch by inviting a group of friends to her hometo discuss weight loss strategies; mission now is “to help people lose weight in asustainable way by helping them adapt a healthier lifestyle and a healthier relationshipwith food and activity”

• The agency consults with a “Scientific Advisory Board” but ultimately defersmembers to their own private healthcare provider

• David Kirchhoff is the president and CEO

• Funding is received by donations, sales, and membership fees

• Employees consist of leaders who conduct group meeting, weigh members, andprovide motivation and instruction on the Weight Watchers plan; and receptionistswho personally welcome, assist, encourage, and support members as well as collectand tally all fees and sales, weigh members, and distribute materials; no figure isavailable for number of employees

RESOURCES: WEIGHTWATCHERSwww.weightwatchers.com

• By supporting the recommendations of the American Diabetes Association, theAmerican Heart Association, the National Institute of Diabetes and Digestive andKidney Diseases, and the Agency for Healthcare Research and Quality and theCenters for Disease Control, Weight Watchers aims to “help make healthy eatingdecisions, and encourage [members] to enjoy [themselves] by becoming moreactive.” (Weight Watchers, 2008).

• Lois admittedly attended her first meeting solely due to the interpersonal influence ofher daughter: “If it will help you”; however, she found the meetings to be enjoyableand informative; by feeling “accountable every week to someone other than myself”she is motivated to pay closer attention to her intake and activity

(continued)

EVALUATION:

• Lois has adhered to the plan in its entirety at the third week interval…perhaps under the not-so-accurate-and-not-corrected-when-presumedpretense that it affects the grade of the project.

• She has lost 9 lbs. and her glucose monitors have ranged from 72-148. Shehas noticed a decrease in the blood glucose levels as her activity increases.She has an appointment with her endocrinologist October 30th, 2008 toreview her medications and discuss the frequency of the glucosemonitoring as she states on every occasion that an audience is presentduring her routine, “This [the fingersticks] is only because I love mychildren.”

• Discussion with her primary care physician has led to repeat lipid profilesduring the first week of December with referral to her cardiologist, asnecessary.

FOLLOW-UP

EVALUATION:

• Lois has verbalized feeling “less achy” and an ability to now “power-shop”since she experiences less fatigue during the day “which I had neverrealized that I had before.”

• Lois notes that it is at times difficult to initiate the physical activity, butonce she has started, she consistently “feels so much better that I did, bothphysically and because I am honoring my commitment.” This positiveactivity-related affect increases her perceived self-efficacy, thus enabling herto continue the behavior with higher likelihood. She has also placed atelevision in front of her treadmill to enhance the situational influence ofindoor walking.

• Lois states that reducing her carbohydrate intake to ½ of her plate was“easier than I thought” because prior to her plan, she concedes to “neverreally paying attention to the type of food that I was eating.” She statesthat the ADA website and Weight Watchers meetings seem to complimenteach other in their teachings.

FOLLOW-UP

HEALTHY PEOPLE 2010 OBJECTIVES

Healthy People 2010 Objectives that have been addressed in thisproject are:

• 5 -7 Reduce deaths from cardiovascular disease in persons withdiabetes by implementing lifestyle changes, Lois has the capability todecrease her risk.

• 5-17 Increase the proportion of adults with diabetes who performself-blood-glucose-monitoring at least once daily. Lois has beenadherent to this objective for 3 weeks and verbalizes commitmentto the plan until speaking with her endocrinologist.

• 12-11 Increase the proportion of adults with high blood pressurewho are taking action (for example, losing weight, increasingphysical activity, or reducing sodium intake) to help control theirblood pressure.

HEALTHY PEOPLE 2010 OBJECTIVES

Healthy People 2010 Objectives that have been addressed in thisproject are:

• 22-2 Increase the proportion of adults who engage regularly,preferably daily, in moderate physical activity for at least 30 minutesper day.

• 22-4 Increase the proportion of adults who perform physicalactivities that enhance and maintain muscular strength andendurance. Lois has increased her physical activity to walking 20minutes 5 times weekly and has lost 9 lbs. in 3 weeks.

• 19-2 Reduce the proportion of adults who are obese. Lois statesshe has a better understanding of the term obese as it relates tobody mass index values and has verbalized a goal of a BMI less than30 before January 1, 2009.

ON THE PATH TO BETTER HEALTH

THE END

• Agency for Healthcare Research and Quality and the Centers for Disease Control (2002). Physical activity and older Americans.Retrieved October 7, 2008 from http://www.ahrq.gov/ppip/activity.htm.

• American Diabetes Association. (2008). The American Diabetes Association. Retrieved October 5, 2008 fromhttp://www.diabetes.org/aboutus.jsp?WTLPromo=HEADER_aboutus.

• American Diabetes Association. (2008). Complications of diabetes in the United States. Retrieved October 5, 2008 fromhttp://www.diabetes.org/diabetes-statistics/complications.jsp.

• American Diabetes Association. (2004). Dyslipidemia management in adults. Diabetes Care. Retrieved October 5, 2008 fromhttp://professional.diabetes.org/Multimedia_Display.aspx?TYP=8&CID=53336.

• American Heart Association. (2008). Older Americans and physical activity. Retrieved October 5, 2008 from<http://www.americanheart.org/presenter.Jhtml?identifier=811>.

• Brown, J. B., Nichols, G. A., Hayes, R. P., & Bowman, L. (2004). Poorer glycemic control is associated with dyslipidemia in type 2diabetes. Retrieved October 5, 2008 from http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=44264.

• Jarvis, C. (2004). Physical examination and health assessment (5th ed.). St. Louis:Elsevier.

• Kovatchev, B. (2007). Continuous glucose monitoring reduces risks for hypoglycemia and hyperglycemia and glucose variability indiabetics. [Webcast]. Retrieved October 6, 2008 from<http://professional.diabetes.org:80/flashplayer/player.asp?idspk=322…inicial=../content/ADA2007/sync/CT-OR01/&Speed=Modem&current_slide=1>.

• National Institute of Diabetes and Digestive and Kidney Diseases. (2006). Tips to help you get active. Weight-control InformationNetwork. Retrieved October 6, 2008 from http://win.niddk.nih.gov/publications/tips.htm.

• Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). New Jersey: Pearson.

• U. S. Department of Health and Human Services. (2008). Healthy people 2010. Retrieved October 8, 2008 fromhttp://www.healthypeople.gov/document/html/objectives.

• Weight Watchers. (2008). History and philosophy. About us. Retrieved October 9, 2008 fromhttp://www.weightwatchers.com/about/his/history.aspx.

REFERENCES