Diabetes is a serious condition that affects 55,000 Vermonters. With this condition, the body either cannot effectively produce or cannot properly use the hormone insulin. Insulin allows sugar from the food we eat to enter the body’s cells and provide energy. When sugar cannot enter the cells, it accumulates in the blood. This can progressively lead to serious damage in many of the body’s systems, including the kidneys, eyes, and circulatory and nervous systems. In addition to serious physical consequences, the financial burden of Diabetes is significant. On average, medical costs for people diagnosed with Diabetes are double that of people without the disease. However, the good news is that Type 2 Diabetes, which accounts for 90-95% of all Diabetes, is a manageable condition. Medical nutrition therapy (diet), medication management, blood sugar monitoring, and self-management education help people with Diabetes control blood sugar levels and dramatically slow the progression of the disease. The 3.4.50 behaviors of good nutrition and physical activity can improve insulin sensitivity, and quitting smoking supports improved circulation and related health outcomes. Those three behaviors also reduce the effects of cardiovascular disease, which is strongly correlated with Diabetes.

As many as 30% of Vermonters have a condition called pre-Diabetes. They are at high risk for developing Diabetes, and 15%-30% will develop the disease within five years. Fortunately, the 3.4.50 behaviors of good nutrition, increased physical activity, and quitting smoking may be enough for people with pre-Diabetes to delay or even prevent type 2 Diabetes. Participation in an evidence-based diet and lifestyle change program called the Diabetes Prevention Program (DPP) supports these behaviors and can reduce or delay the development of Diabetes by 58%. Additionally, participation in a nationally recognized DPP can significantly reduce hospital admissions and emergency department visits and their associated costs. Unfortunately, as many as 90% of people with pre-Diabetes do not know they have the condition. Supporting the 3.4.50 behaviors combined with increasing awareness and diagnosis of pre-Diabetes is a crucial step in the prevention of Diabetes for Vermonters, particularly as more and more children and young adults are becoming at risk.

The Vermont Department of Health (VDH) works closely with other organizations to offer and evaluate self-management education programming and Diabetes Prevention Programming as well as track Diabetes and pre-Diabetes outcomes across the state. 

Paying attention to Diabetes prevention and the 3.4.50 behaviors is important because Diabetes is the sixth leading cause of death for Vermonters and people with Diabetes incur significantly higher health care costs. More importantly, Diabetes is preventable and/or treatable with medication, blood sugar monitoring and appropriate evidence based lifestyle interventions that focus on prevention and management.

 For those with pre-Diabetes, lifestyle interventions are proven to reduce the risk of progression to Diabetes, and have the potential to return individuals to normal blood sugar levels. The primary goal of lifestyle interventions is to prevent or delay Diabetes and its complications by targeting the two most important modifiable risk factors: the 3.4.50 behaviors of poor nutrition and physical inactivity. Vermont adults diagnosed with pre-Diabetes are more likely to be overweight/obese, have high blood pressure and have high cholesterol when compared to adults who do not have Diabetes, and all of these contribute to increased morbidity and mortality for Vermonters.

 For those with diagnosed Diabetes, it is extremely important to prevent or delay serious complications of the disease, such as skin ulcerations that may lead to amputation, kidney disease, eye disease and blindness, and neuropathy. Managing Diabetes through blood sugar monitoring, effective use of medication, and reducing the 3.4.50 behaviors of poor nutrition, physical inactivity, and smoking can reduce hospital inpatient admissions, emergency department visits, and their associated costs.

Self-Management Education

• The Vermont Blueprint for Health and the Project Managers, Community Health Teams, and Regional Coordinators are trained as HLW-D leaders. They are the key partners responsible for initiating the workshops statewide.
• Support and Services at Home (SASH) is another important partner. SASH participants have a high prevalence of Diabetes. SASH Coordinators, acting as community health workers, benefit from becoming trained as HLW-D leaders.
• Certified Diabetes Educators are also important partners. Many members of the Vermont Association of Diabetes Educators are trained as leaders in the HLW-D and incorporate this program into their Diabetes self-management education programs and services.
  • Community Health Improvement is the Department of Health’s key partner. They administer the Blueprint's self-management programs across the state. The Helping Yourself to Health website makes it easier to find a program close by: http://myhealthyvt.org/.

Diabetes Prevention Programming

• University of Vermont Medical Center- Community Healthy Improvement and the Vermont Blueprint for Health are the key partners administering the program across the state.
• They collaborate with VDH to establish high level strategies to market the program and increase participation statewide.
• Blueprint funded Regional Coordinators in each health service area along with their Community Health Team colleagues are also key partners. They assist primary care practices to refer to community-based prevention and self-management programs like the DPP to accomplish the activities and goals of their patient-centered medical homes. A website hosted by the Blueprint in collaboration with Community Health Improvement and VDH facilitates program information and enrollment statewide: http://myhealthyvt.org/.

VDH works closely with Community Health Improvement, who is responsible for managing all Blueprint supported self-management programs statewide. This collaboration provides data to evaluate outcomes from the Stanford Diabetes Self-Management Program (HLW-D), which support the needs of the department’s Dashboard Scorecard and other grants the Department receives to conduct Diabetes and pre-Diabetes work. Our focus is the HLW-D data, but Vermonters are also attending other Diabetes self-management education programs offered in each health service area. For these, we have very limited statewide data (provided by the CDC via the American Diabetes Association and the American Association of Diabetes Educators).

In addition to increasing the number of Vermonters who complete the Healthier Living Workshops for Diabetes, we are also beginning to improve our focus on clinical outcomes and performance measures, noting declines in poorly controlled Diabetes (as measured by A1Cs greater than 9).

 VDH uses BRFSS (Behavioral Risk Factor Surveillance System) data to determine the number of Vermonters at risk for Diabetes. These self-reported data under represent the prevalence of pre-Diabetes. Most people (90%) affected are not aware of their condition. Marketing and communication to consumers and providers continue to raise awareness of the problem and available programs, and these efforts are designed to increase enrolment for qualifying Vermonters. VDH partners with primary care providers at select practices to implement quality improvement initiatives that utilize electronic medical records to identify patients suitable for program referral. 

 Reducing the modifiable risk factors through evidence based-programs, including the 3.4.50 behaviors of tobacco use, physical inactivity and poor nutrition, can help prevent and manage Diabetes. Evidence based strategies include maintaining a healthy weight, not smoking, managing blood pressure, and eating a healthy diet rich in fruits, vegetables, and fiber and low in fats and sugars. Several programs housed within the Department of Health’s Division of Health Promotion and Chronic Disease Prevention and Division of Alcohol and Drug Abuse Prevention support activities that promote those strategies.

VDH is working with communities, worksites, schools, health systems, and other partners to promote 3.4.50 across the state. Toolkits have been developed for schools, communities, and worksites. Organizations within those sectors can sign on to be a 3.4.50 supporter and develop strategies that support reducing the 3.4.50 behaviors. For more information on toolkits and the 3.4.50 framework, visit http://www.healthvermont.gov/3-4-50.

The Vermont Department of Health is also funded by the CDC to work on prevention activities that reduce Diabetes through a grant called State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity, and Associated Risk Factors and Promote School Health. Our strategy is to work with providers, clinics, schools and community partners to create healthy environments, promote best practices, and support Vermonters to make healthy choices (including reducing the 3.4.50 behaviors) that will prevent or help reduce the likelihood of developing cardiovascular disease.

Programs such as the Diabetes Prevention Program (DPP) and the Healthier Living Workshop for Diabetes (HLW-D) help teach people at risk for or with Diabetes to manage lifestyle and behaviors that will lead to better blood sugar management, weight loss, increased physical activity, and other lifestyle factors that lower the risk for Diabetes, Diabetes complications, and co-morbidities such as cardiovascular disease, and chronic kidney disease. These programs are available across the state to all qualifying Vermonters at no cost.

An important first step is to make an appointment with your primary care provider to have your hemoglobin A1c (an indicator of long term blood sugar control) checked. Your provider can help identify ways to maintain healthy blood sugar levels, or develop a plan that could include lifestyle changes and possibly medications, to help lower your risk factors. Recommendations from health care providers are among the most influential factors in convincing people to be physically active and join a self-management program. Physicians can play an active role in referring patients to appropriate Diabetes prevention programming and self-management workshops and to the myhealthyvt.org website where they can learn more about these options and how they can participate. The Department of Health is focusing on the health and well-being of all Vermonters through partnerships that foster community engagement, quality health systems, and healthy worksites. These partnerships promote physical activity, healthy nutrition, and tobacco prevention and cessation interventions – the most effective ways to prevent or reduce the risk of developing Diabetes. By engaging in these ways, we can help to address the most significant risk factors and ensure better quality of life for those at risk for Diabetes.

Behavioral Risk Factor Surveillance System (BRFSS)

Vermont tracks risk behaviors and chronic disease using a telephone survey of adults called the Behavioral Risk Factor Surveillance Survey (BRFSS). Since 1990, Vermont, along with the 49 other states, Washington D.C. and U.S. territories, has participated in the BRFSS with the Centers for Disease Control and Prevention (http://www.cdc.gov/brfss). The CDC provides the Vermont Department of Health with funding each year to carry out the survey. Several thousand Vermonters are randomly and anonymously selected and called annually, on both landlines and cell phones. An adult (18 or older) is asked a uniform set of questions. The results are weighted to represent the adult population of the state.

Note that beginning in 2011 the CDC implemented changes to the BRFSS weighting methodology in order to more accurately represent the adult population. While this makes calculations more representative of the population, the changes in methodology also limit the ability to compare results from 2011 forward with those from previous years. The Vermont Department of Health recommends that comparisons between BRFSS data from 2011 forward and earlier years be made with caution. Statistical differences may be due to methodological changes, rather than changes in opinion or behavior.

Youth Risk Behavior Survey (YRBS)

The Youth Risk Behavior Survey (YRBS) is a paper survey administered in Vermont middle and high schools every two years since 1993. The survey is sponsored by the Department of Health's Division of Alcohol and Drug Abuse Programs, and the Department of Education's Coordinated School Health Programs and the CDC. The YRBS measures the prevalence of behaviors that contribute to the leading causes of death, disease, and injury among youth. Vermont surveys over 30,000 students at each administration. Weighted data is compiled to generate a representative state sample, and local data is used by schools, supervisory unions, health programs and other local organizations. The YRBS is completed in over 40 other states and there is a national weighted sample for comparison.

Vital Statistics

The Vermont vital statistics system monitors vital events (births, deaths, marriages and civil unions, divorces and dissolutions, etc.). Death certificates are often completed by the funeral directors who obtain all necessary information from the family. However, a physician is required to complete and certify the cause of death in the Electronic Death Registration System (EDRS). Mortality rates are calculated based on the ICD-10 code for the underlying cause of death listed on death records received by Vital Records. Only Vermont residents are included in these calculations. Rates were calculated by comparing the number of deaths in a given time period to the overall population of Vermont in the same time period.

When a measure is adjusted

Age adjustment is used for comparison of regions with varying age breakdowns. In order to remain consistent with the methods of comparison at a national level, some statistics in Vermont are age adjusted. In cases where age adjustment was noted as being part of the statistical analysis, the estimates were adjusted based on the proportional age breakdowns of the U.S. population in 2000.For more detailed information on age adjustment visit http://www.cdc.gov/nchs/data/statnt/statnt20.pdf

Methods

Prevalence and percentages are calculated by using descriptive statistical procedures using software such as SPSS, SAS, and/or SUDAAN. These statistics describe the proportion of individuals with a given trait in the population during a specified period of time.

Discharge rates are calculated using the Vermont Uniform Hospital Discharge data set. We look at all hospital and ED discharge among Vermont residents who utilized services at regional hospitals (including hospitals in bordering states).We compared the number of discharges in a given time period to the Vermont population in the same time period to calculate discharge rates.