Teaching healthier lifestyle skills to turn the tide on diabetes

Diabetes often requires medication and serious lifestyle changes to manage, and making those changes usually takes support and education.

At Puentes de Salud, the “Bridges of Health” clinic in South Philadelphia, patients —and people at-risk for diabetes—work with lay volunteers called ‘promotoras.’

“[They] basically help patients achieve their health goals and teach them about topics like diabetes and obesity and high blood pressure, and in a way that’s more culturally spot on than anything any of us could say,” says Robin Canada, who is the medical director at Puentes and an internal medicine physician at Penn Medicine.

The clinic is largely staffed by doctors and medical students who volunteer their time. The patients are mostly Latinos from nearby neighborhoods.

The Latino diet has lots of tortillas and rice, and Canada says when she tells a patient to “cut the starch” that approach is less effective than when a promotora—whose first language is Spanish—spends time with a patient looking for ways to make meals healthier.

Promotora Rosalinda Hernandez asks people to spend several days recording everything they do and eat—then together, they go over the log.

“Lots of time people will say ‘I don’t know why my sugar level is so high; I don’t eat sugar.’ So, that’s why we say: ‘Tell me what you eat in a typical day.’ They might say ‘I eat bread, I eat cookies, but I don’t drink soda,’ so then that begins the process.

Hernandez leads her classes in Spanish, and spoke with “The Pulse” through an interpreter.

She nudges people to roast chicken instead of frying it or to try one piece instead of two.

“It’s not easy; the hardest thing is for them to actually want to do it for themselves,” Hernandez said.

So she helps people find reasons to stick to healthier habits.

“The self-esteem boost that they get, like ‘I look good, I feel good, I can wear the jeans that 10 years ago I wasn’t able to fit into’,” Hernandez said.

At a recent check-up, physician Robin Canada couldn’t have been happier with her patient Blanca’s progress.

She is five feet tall and used to weighed 224 pounds. Blanca, who wants to use just her first name, is 30 years old and was diagnosed with type 2 diabetes earlier this year.

Twenty nine million people in the United States have diabetes and most of them are living with type 2. The body struggles to convert sugar to energy, and when sugar backs up in the body, that can cause short and long-term health problems. The long-term personal cost of out-of-control diabetes can be heart trouble, kidney damage or amputations. The financial cost of caring for Americans with diabetes is rising.

Nurses, health coaches and other healthcare providers are looking for ways to help people with diabetes find success.

Canada prescribed an anti-diabetes medicine, but what Blanca is doing—and not doing—at home makes a difference. She’s picking healthier foods; she’s exercising and monitoring her blood sugar.

Blanca dropped a couple of pounds but Canada seems most excited by the change in her patient’s A1C—that’s a test that gives doctors a snapshot of blood-sugar levels over the last two or three months. The number suggests how well a patient’s diabetes treatment is working.

During the check-up, Canada pulls up a graphic from the Web to show Blanca a “diabetes thermometer.”

The cartoon image indicates different A1C levels. Elevated levels are represented at the top in hot red and orange colors. “In control” or “non diabetic” A1C levels are shown in cooler green and blue colors.

A few months ago, Blanca’s A1C was 9.2, dangerously elevated and in the orange zone on the thermometer. Now she scores a 6.3 in the green zone.

Canada says, for someone with diabetes, that’s excellent and Blanca’s quick turnaround is pretty unusual. Often it takes months or years for patients to adopt better habits and get diabetes in check.

Dr. Robin Canada speaks with a patient at Puentes de Salud. (Taunya English/WHYY)

Four management strategies 

To explain her success, Blanca pulls out a small spiral notebook with page after page of scribbled notes. Every morning and every night, she pricks her finger to test her blood sugar then records the number in her notebook.

She’s figured out the four pillars of diabetes management. Experts sometimes call them the four M’s. Meal planning. Movement. Medication. Monitoring.

Doctors can prescribe medicine—and that often drives down A1C by one point. The three other diabetes management tools take patient follow-through and healthier lifestyle skills.

Puentes promatora Susana Pimentel meets with patients for those healthy living lessons.

“Somehow, in South Philadelphia, people know who we are,” Pimentel said.

She’s part of the Saint Thomas Aquinas Catholic Community, and at church, people pull her aside to ask about health issues. They want to chat when she’s doing her laundry, so much so that Pimentel says, these days, the Laundromat feels like her office.

“People just stop you and ask you, ‘can you make an appointment for me?”

As a volunteer, she’s unofficially on call a lot, but the people she works with aren’t clients.

“I just call them friends,” Pimentel said.

She also gives out her cell phone number.

“I try to just say: ‘Please don’t call me after 10,’ cuz they do.”

In her neighborhood everybody knows somebody with diabetes. Pimentel says if your grandmother has it, if your cousin has it, some people feel like sooner or later they’ll develop it too.

“We thought it was OK to have it in the family, it’s like: ‘Diabetes OK, yeah, no problem.'”

Diabetes is a problem, nationwide. African Americans, Latino Americans, American Indians and some Asian Americans have a particularly high risk for developing type 2 diabetes. Genetics plays a part, and people who carry fat around the belly and mid-section also have a higher risk.

Providing support and community 

The kind of diabetes education that seems to work best includes both one-on-one support and group classes, said Maggie Powers, president-elect of the Health Care & Education section of the American Diabetes Association.

When someone is diagnosed with diabetes, the needed education and support goes beyond lifestyle counsel to include help with medication adherence and blood sugar monitoring.

“Once you have diabetes, the hallmarks of the food plan are distributing the carbohydrates that you eat throughout the day and having moderate amounts of carbohydrate.”

Carbohydrates are macronutrients that the body uses for fuel. So-called ‘simple carbs,’ such as those in soda and candy, deliver a burst of energy that can spike blood sugar levels.

She suggests a program that is recognized by the American Diabetes Association or credentialed through the American Association of Diabetes Educators. The Medicare program pays for education if it’s provided through a certified or recognized program.

Researchers are beginning to study how well those programs work.

In a recent review of trials, health researchers from the American Association of Diabetes Educators compared the change in A1C for people who completed group, individual or combination education program—then compared their results to people with diabetes who had no formal self-management education.

“The combination group who had a little individual and a little group education, their A1C was reduced by .88 percent,” Powers said.

In the control group—among people who got no education—their A1C went down by .22 percent, according to topline results presented at a professional meeting this summer.

“That’s pretty dramatic because drugs can be approved if it lowers A1C by .4 percent,” Powers said. “So here the impact of a diabetes education program is twice that.”

Powers is a registered dietitian, a certified diabetes educator and sees patients every week at the International Diabetes Center at Park Nicollet, Minneapolis, Minnesota.

“There’s a very important emotional health aspect to diabetes, so in an education program we’re looking at the clinical, the psychosocial, the behavioral needs of an individual,” she said.

Studies of behavioral health programs and their impact on A1C have typically checked-back with patients after six months or a year, researchers say they’d like to know more about the longer term affects of the skills training and counseling.

Education is key 

Nurse care manager Andrew Johnstone says part of diabetes education is convincing people to take the illness seriously and take care of themselves.

“It may sound funny, but I preach hot baths a lot,” Johnstone said.

He leads a four-week Diabetes Academy at the Care Clinic in Philadelphia, a federally qualified health center run by the Public Health Management Corporation.

Students gather for a lunch provided by Whole Foods, they get a free token to come to class. The academy also partnered with the YMCA to give students a place to exercise.

There have been three academy classes so far, and Johnstone says he now understands that his student do best when they stay connected to the diabetes community after they complete the formal class.

Even his star students need reminders. At a recent movie screening, none of the class graduates could say whether wheat bread or white bread had more carbs. Trick question: they both have about the same amount of carbs, but wheat bread is generally a better source of nutrition and has more fiber.

“We do go to these events, and it’s like ‘ahh’ like they didn’t remember that one key point,” Johnstone said. “I think I have to get told things lots of times, and it is hard, it takes waves of learning this.”

When you’ve ignored your chronic illness for years, diabetes class can feel like a harsh spotlight. People suddenly see how a lifetime of choices can take a toll on the body.

“Some people go too hard, they say: I’m not going to have any more sodas, I’m gonna check my blood sugar, I’m gonna exercise, I’m not going to have any carbs or sweets.”

But that kind of enthusiasm is hard to keep up. So, Johnstone also teaches compassion and balance.

“Chinese food and cake is OK, like once a month or something like that. And if you are monitoring your blood sugar, that’s OK,” he said.

He says the Care Clinic is now a place where graduates can keep coming back to learn from others in the diabetes community and to pick up new lessons when they’re ready.

Deborah Brawley learned tatics to manage diabetes at the Care Clinic in Philadelphia.  (Paige Pfleger/WHYY)

Deborah Brawley took the Diabetes Academy twice. For decades before that, she was the one in the family who made big Sunday dinners for her brothers and sisters.

“They love my lasagna,” she said. She enjoys fried fish and McDonalds food.

“What I do now is I bake everything.”

Brawley also goes to the YMCA three days a week, and stays away from starches to help control her diabetes.

“I know it can kill you,” she said. “It doesn’t change who I am, it does change a lot of things I do.”

Disclosure: The Philadelphia Health Management Corporation is a funder of The Pulse.