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Decreasing Diabetes in Lake

County, Michigan
Community Change Project
Group 1
Charles Dietrich
Nurs 340

Amber Kulppi
Holly Owen
Lori Rosendale

Lake County, Michigan has an increased
rate of diabetes due to many factors.
The following is a proposal as to how to
decrease this risk.

Problem Statement

Community Health Diagnosis




26.9% Poverty Rate

Lack of access to fresh food Dist. 10 77.7%

12.7% Unemployment

Lack of activity 26%

White pop. 87.3%; Black 9.2%; Hispanic 2.4% Access to health care providers 18.8%
Obesity Lake Co-43.1%; MI 35.6%
High School Diploma 80.8%
Bachelors Degree 8.2%

-persons per provider in Lake County-5,785

-persons per provider in Michigan- 1,271

District Health Department #10 (2013).

Community Health Diagnosis

The community of Lake County is at an increased risk for diabetes related

to reduced activity rates, obesity, diets high in saturated fats, sugars and
processed foods, lack of access to fresh fruits and vegetables, poverty and
lack of insurance and access to health care providers.
Causative Factors

Access to fresh fruits and
Safe areas for children to
play; adults to exercise.
education starting early in
the school system

If the interventions are successful; we should see a

decline in new onset Type II Diabetes. Obesity
rates will fall, consumption of fresh foods will
increase and children and adults with have access
to safe areas to exercise and play.

District #10
Lake County


Diabetes is a concern that is growing in prevalence in todays

Many factors contribute to Type 2 diabetes in adults and
Some risk factors associated with Type 2 diabetes:
Being overweight- this is a primary risk factor as the increase in
fatty tissue stored in the body causes an increase in insulin
Fat Distribution- increased fat in the abdominal area increases risk.
Inactivity- less activity equals increased risk.
Family History- if a parent or sibling has type 2 diabetes, there is an
increased risk.
Race- Blacks, Hispanics, American Indians and Asian Americans
have an increased risk.
Age- increased risk as you age, but it is becoming increasingly
more prevalent in children, adolescents and younger adults.

Lake County












No healthcare



No healthcare
due to cost





Median Income
Jobless Rate


District Health Department #10


Lake County


free/reduced lunch



Diabetes related
mortality rates



Lack of Activity









District Health Department

#10 (2013)

The Health Belief

Hochbaum and Rosenstock

The Health Belief Model

Created by Hochbaum and Rosenstock, the

health belief model specifies four key
1. The severity of the potential
illness or physical challenge.
2. The level of conceivable
3. The benefits of taking
preventive action.
4. What stands in the way of
taking action toward the goal
of health promotion.
Hochbaum and Rosenstock
believed that these factors were
what shaped individual, family and
community health-based behaviors
(Harkness & DeMarco, 2012).

The Health Belief Model

The following information illustrates the severity of the potential
illness or physical challenge:
Lake County
Living below poverty level



High school graduates



Access to health care (No




Access to health care (No

provider due to cost)





Diagnosed Diabetes






Lack of proper nutrition



Diabetes related deaths (per

100,000 population)

District Health Department #10 (2014). Health profile chart book 2013: Lake County.
Retrieved from:

Planning and

Increasing Access to Care was used to find income based

and free health care clinics in Lake County Michigan.
There are a very limited number of income based health
care clinics, and there are no free health care clinics
There are several pharmacies that offer A1c testing
throughout the nation. But, upon searching, none were
found in Lake County.
Attempting to find information on Diabetes education and
screening in Lake County is very difficult.
The Lake Countys health department offers no diabetes
screening or education from what was found (District
Health Department #10, 2014).

Taking Action: Health Belief


If it could be known what income based clinics are available

in Lake County, perhaps more individuals would get
physicals, and diabetes could be better under control.
Education can also be performed in this setting as well.
If there could be a decrease in the number of diabetes
related deaths, and obesity, along with an increase in good
nutrition this would illustrate the benefits of taking
preventative action.
A decrease in obesity would ultimately decrease the
amount of diagnosed Diabetes Mellitus Type 2 as well.

Challenges: The Health Belief


What stands in the way of taking action

toward the goal of health promotion?
(Harkness & DeMarco, 2012).
Transportation for many individuals may stand a
According to, 75% of the population
in Lake County drive their own car as a means of
transportation. That leaves a large amount of
individuals (25%) that use either public transport,
rely on others for rides, walk or bicycle.
This creates a challenge to get people to the
income based health clinic for a physical and
health education.

Yates Dial-A-Ride

Yates Dial-A-Ride is a demand response system

that offers transportation to 16 townships within
the Lake County area (MDOT, 2014).
It is only a dollar for a one way ride.
Yates Dial-A-Ride offers transportation to area
human service agencies, senior centers, and
offers transportation for individuals with
Yates Dial-A-Ride can be contacted at
(231) 745-7311
It would bring them more business, so it works out for both



Choose a goal
The use of transportation by the
diabetic community in Lake County.

SMART Goal Continued

Measurable: You must choose the appropriate measurement for

defining the publics outcome of public transportation.
Quantity: The number, rate, amount, margin, percentage, of the product
or service that is expected to be accomplished when the transportation is
used. The first year goals will be to see an increase in service by 5%. A 5%
increase in Lake County diabetics to their hospital. Lake County has about a
13% diabetic population (University of Wisconsin Population Health
Quality: The characteristics of the task performed. Usage of transit will see
an increase. Surveys from the public can be gathered as they use the
Time: The period, duration, or term involving the task or responsibility. The
surveys will be evaluated at the end of each month. At the end of each
month evaluations will be done to look at making the transit more efficient.
Cost: The budget and financial allocations designed for the task or
responsibility. The budget will be evaluated at the end of a fiscal year to
evaluate for additional usage or cut backs.

SMART Goal Continued

Achievable: Can this task/responsibility be

accomplished or completed by the public?
Ask the following questions:
Does the public have knowledge of services offered? There
are just over 11,000 people that live in Lake County of which
16.9% are under 18 years of age. Increased knowledge would
be an increase in the use of public transportation by 5%.
Are there barriers for the public to understand what
transportation methods are offered and/or how to obtain
them? Review barriers. There are 17% of the Lake County
population that cannot afford to visit their healthcare
provider. (University of Wisconsin Population Health
Institute,2014). The public transportation will offer a low cost
service to a health care facility for anyone in need.

SMART Goal (Achievable)

Is the publics accessibility to transportation attainable?
Increase route stops in the county by 5% in the first
Does the public have the necessary resources?
Additional stops will be assessed after each month.
Added vehicles and drivers will be assessed after fiscal
year. Approximately 79% of the workers in Lake County
drive alone to work (University of Wisconsin Population
Health Institute,2014).
Is the task realistic enough to attain success within the
agreed upon time frame? Public input from surveys and
call ins will be evaluated after each month and then
after one year. Call backs to the public about service will
increase by 3% at each month.

SMART Goal Continued

Does the publics knowledge directly contribute to
the mission/goals of the department and Lake
County. Yes, if the public has a millage vote to
fund public transportation.

SMART Goal Cont.

There should be a clear time frame, deadline, or
other time-based expectations when the action,
activity or behavior will take place. Efficiencies in
public transportation should be evaluated after
each month. Any capital investment changes in
the public transit will be evaluated after the fiscal


Flyers could be posted at local grocery stores,

gas stations, pharmacies, and areas of high
foot traffic.
The flyers would urge individuals to get a
check up at a low price, and advertise the
services of the Yates Dial-A-Ride.
The hope would be that people will become
educated on the need to be healthy, as well as
the low out of pocket cost.
The local radio station, 98.3 WRLR, could also
advertise the campaign on air.

Advertising for low income and free clinics
in Lake County and nearby areas.
Flyers posted in local establishments as well
as senior living centers and recreation
Listing the name, location and phone
numbers of nearby low income/free clinics.
Listings provided to area medical centers
and doctors offices for referral of patients
who cannot afford services.


The following clinics are funded by federal government and

individuals can receive care even if they do not have
insurance. The clinics have income based programs
Baldwin Family Health Care

Hope House Free Medical Clinic- Big Rapids


Stehouwer Free Clinic-Cadillac


NW MI Health Services, Inc-Bear Lake

This clinic is exclusively to serve migrant and seasonal farmworkers and family
It is closed October-March

Evidenced Based

Evidence Based Practice (EBP)

Researchers through the Yale University Human

Investigations Committee (2012), conducted a study in the
Fair Haven neighborhood of New Haven, CT.
The study was conducted to find if there would be a greater
adherence to preventative care in free, student run clinics
affiliated with the local University.
The free clinics were made available to uninsured, low income

EBP continued
Testing of fasting lipid panel increased
considerably from 53% of eligible patients
pre-intervention to 72% post-intervention.
Similarly, testing of fasting blood glucose
screening rose from 59% of eligible patients
pre-intervention to 82% post-intervention.

EBP Continued

Non-diabetes related testing was also found

to have increased adherence rates for the
eligible population:
HIV testing rates rose 3% to 19%.
Cholesterol screening rates increased from 19.5% to 38.1%.

Pap-smear examinations were found to be a

constant at 59% test rate in the eligible

EBP conclusion
The information gathered by the study
concludes that clinics that are made
available to low income and uninsured
individuals do in fact increase the amount of
diabetes testing.
By making the low cost clinics in the Lake
County area well known, and a low cost
transportation system well known, there
should then be an increase in diabetes
screening and education.

Diabetes Education
Medications and Nutrition

Education: Medications
A pill that is considered the first line of defense drug
used in conjunction with a change in eating and
physical activity. Because of gastrointestinal adverse
reactions it is recommended to start the drug at a
low dose of 500 mg daily, increasing by 500 mg
every 1 to 2 weeks, up to an ideal and maximum
dose of 2000 mg daily in divided doses. Greater than
2000mg has no benefit.
1.Potential weight loss
2.Less frequent finger sticks compared to insulin
3.Improves insulin sensitivity.
4.Taking oral pill without injections. This is painless
and may increase adherence.
5.Less instruction time
6.Only the IR form has been approved for children.

Other medications

Thiazolidinediones(actos,avandia):These medicines lower insulin

resistance in muscle and fat.
Sulfonylureas(glucotrol):increase the amount of insulin produced
by the pancreas, and insulin lowers blood sugar.

Some individuals may need medicines to lower their blood pressure

and cholesterol to reduce the risk for complications.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin

II receptor blockers (ARBs) may be used to lower blood pressure.
Statins may be used if a healthy diet and physical activity do not
lower cholesterol.

Education: Medication



The simplest insulin regimen consists of a single

injection of long acting insulin at bedtime.
Short acting insulin(Novolog) may be a
beneficial treatment before meals.
Some with T2DM can be managed successfully
with a single injection of long-acting insulin
(Levemir) in conjunction with an oral agent
(Metformin). Lantus can be used for ages >6
years old.

Education: Nutrition
Calories come from carbohydrates, proteins and fats.

1g fat = 9 calories
1g protein = 4 calories
1g carbohydrate = 4 calories

Carbs are Sugar!

Glycemic Index: According to the ADA, the glycemic index is a ranking of

carb containing foods based on their effect on blood sugar (Aug, 2014).
Foods with a high glycemic index increase blood sugar more than a mid
or low glycemic index food.
Fat and fiber tend to lower a glycemic index of a food (ADA, 2014).

Education: Food and

Low Glycemic Index foods:

Stone ground whole wheat

Sweet potatoes, corn, beans, peas, legumes
Pasta, barley, whole grains, carrots,
Non starchy fruits

High Index Foods:

If eating a high index food, the ADA recommends pairing it
with a low index food to balance it out!
White bread, Russet Potatoes, Puffed rice cereal
Melons, pineapple
Processed foods

Diabetic Superfoods
1. Beans
2. Dark Green Leafy Veggies
3. Citrus Fruit
4. Sweet Potatoes
5. Berries
6. Tomatoes
7. Fish High in Omega 3s
8. Whole Grains
9. Nuts
10.Yogurt and Fat Free Milk

Foods to Avoid!
1. Processed and refined sugars
2. Candy
3. Cake
4. Sweetened sodas
5. High fat foods


Short Term
1. There will be an immediate increase in the
number of uninsured individuals receiving
diabetes screening and education.
2. Yates Dial-A-Ride will help the 25% of individuals
without personal transportation.
3. Education of these services through flyers and
public broadcast will be immediate.

Evaluation Continued
Long Term
1. Region 10, Lake County Health
Department will show a decline in
diagnosed diabetes.
2. Region 10 will show a decline in health
care costs related to diabetes.
3. Region 10 will display an increased
adherence to diabetes screening and
education in the uninsured population.

Increased awareness through flyers in
public places, and knowledge of public
transportation will increase the amount of
uninsured individuals that use these
In the long-term there will be an increased
amount of individuals that will adhere to
diabetes screening and education.
There will be an eventual decline in the
diabetes rates in Lake County.


American Diabetes Association (2009). Medical management of hyperglycemia in type 2 diabetes: A


algorithm for the initiation and adjustment of therapy. Diabetes Care, 32: 193203.

American Diabetes Association, (2014). Glycemic Index and Diabetes. Retrieved




American Diabetes Association, (2014). What can I eat? Retrieved from

Butela, N.M., Murk, W., Horwitz, L.I, Graber, L.K, Bridger, L. (2012). What is the quality of preventive care
provided in a student-run free clinic? Journal of Healthcare for the Poor and Underserved, 23(1), 414424.

Copeland, K. C., Silverstein, J., Moore, K. R., Prazar, G. E., Raymer, T., Shiffman, R. N., & ... Flinn, S. K. (2013).
Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents.
Pediatrics, 131(2), 364-382. doi:10.1542/peds.2012-3494

References Continued

District Health Department #10 (2013). DHD #10 community statistics. Retrieved


Free Medical Search. (2014). Lake county clinics. Retrieved from:

Harkness, G.A., DeMarco, R.F. (2012). Community and public health nursing: Evidence for practice (5th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.

Michigan Department of Transportation. (2014). Yates township transportation system. Retrieved from:,1607,7-151-9625_21607-164380--,00.html.

Onboard Informatics. (2012). City data: Lake County, Michigan. Retrieved from:

University of Wisconsin Population Health Institute. (2014). Building a culture of health county by county. In County

Rankings and Roadmaps. Retrieved October 27, 2014, from