PaTH to Health: Diabetes

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“A Patient-Centered PaTH to Addressing Diabetes: Impact of health policies on health outcomes and disparities”

Greetings from the PaTH to Health: Diabetes Research Team! As Principal Investigator on this project, I’d like to welcome you to our latest issue of our biannual research study newsletters. Inside you’ll find progress updates on our research study, introductions from some of the key players that help make this research possible, and resources as well as community event information for you and your loved ones. Happy reading!

Jennifer L. Kraschnewski, MD, MPH

Executive Director, Penn State PRO Wellness Associate Professor of Medicine, Pediatrics and Public Health Sciences Penn State College of Medicine

HIGH FIVES We would like to give a HIGH FIVE to our patient partners for completing the Community Partner Research Ethics Training course in August 2016. Our study was the first at Penn State College of Medicine to utilize this training and certification program adapted from the University of Pittsburgh. This training will enhance patient-centeredness in research by having our patient partners educated in human participants research and the ethical guidelines that embody best practices. Congratulations, patient partners, for making history by becoming the first Patient Co-Investigators on a research study at our institution! Another HIGH FIVE goes to our patient partners for completing our data extraction training, “De-coding the PaTH of EHR data: How it’s collected, how it’s protected” in fall 2016. A final HIVE FIVE to our stakeholders, patient partners, and investigative team for attending our annual in-person meeting and quarterly stakeholder calls. Your commitment is greatly appreciated!

UPCOMING TRAININGS Project stakeholders will have the opportunity to attend a voluntary Just-InTime mini training session on the data extraction process via the PaTH network in winter 2017. The training will help optimize engagement in discussions and work surrounding the research phase of our secondary data analysis study. Stay tuned for details regarding the new learning management system, Litmos, that will provide the training.

Research Study Overview & Update

Our research study, “A Patient-Centered PaTH to Addressing Diabetes: Impact of health policies on health outcomes and disparities” is funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI is an independent, nonprofit organization that envisions a research world that addresses the questions and concerns most relevant to patients, while including them, their caregivers, clinicians and other stakeholders in the research process. We are thrilled to be working alongside our patient partners and stakeholders throughout each phase of the project. We have added new talent to the project team since the last newsletter edition, updating our roster to include 4 primary care providers, 5 patient partners, and 10 stakeholders who will be engaged in research activities, strengthening our project through their perspective and experience.

Primary Care Providers

Patient Partners

As literature shows, overweight and obesity are a big issue in the U.S. In fact, it’s the number one health concern. Addressing obesity through lifestyle interventions (i.e. healthy eating and increased physical activity) decreases the risk of developing type 2 diabetes, a disease which affects over 29 million people (9.3% of the U.S. population). Diabetes is associated with serious complications, including heart disease, blindness, renal failure and lower extremity amputation. Although complications are preventable with proper medical and lifestyle management, including weight loss, nearly half of patients with diabetes do not have adequate glycemic control. Recent policy changes and health insurance expansion have resulted in coverage for obesity counseling by Centers for Medicare and Medicaid to improve weight loss for adults either with or at high risk of type 2 diabetes. Beneficiaries whom are obesity are eligible for up to 20 face-to-face visits for weight counseling in the primary care setting. However, whether or not this new benefit has actually helped patients lose weight and better control their diabetes is unknown. In the PaTH to Health: Diabetes study, we are looking at Electronic Health Record (EHR) and claims data across three states to see if obesity counseling has improved weight and diabetes outcomes. For patients with or at risk of developing type 2 diabetes, are they receiving obesity counseling? If so, is it leading to weight loss and better blood sugar control? We hope to answer these questions by analyzing data. We’ll be utilizing the PaTH network, which is an integrated research collaboration between Maryland, Pennsylvania, and Utah, to pull EHR data on over 2 million patients with or at risk of type 2 diabetes. This project began in early 2016 and will continue until 2021. In fall 2016, we obtained Institutional Review Board approval (IRB) across the universities collaborating in the research: Penn State College of Medicine, University of Pittsburgh, Temple University, Geisinger Health System, Johns Hopkins University, and University of Utah. Our first data extraction has been completed and the data is being “cleaned” in order to analyze. Additionally, we are in the process of collecting Patient-Reported Outcomes (PRO’s) from each partnering institution, including physical activity levels, fruit and vegetable consumption, social support, and other variables of interest that will help us better understand diabetes and associated risks. 2 | WINTER/SPRING 2017 EDITION

Stakeholders Each individual will engage in key research activities, strengthening our project through their perspective and experience.

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SPOTLIGHT: Team Member Brianna Hoglen, BS

Meet Brianna Hoglen! Brianna is currently a project coordinator for Penn State PRO Wellness at Penn State College of Medicine. Brianna organizes meetings, maintains communication between patient co-investigators and study staff, and coordinates project documentation and deliverables for Path to Health: Diabetes. She meets with project management to ensure milestones are met along with team action items. Additionally, she communicates with patient partners and stakeholders about upcoming meetings, events, or other opportunities

to become involved in the project, to ensure their engagement over the course of the study. In addition to this role, Brianna also works on a variety of projects within PRO Wellness, including obesity prevention work with the Boy Scouts of America, serves as a reviewer for LiveHealthyPA website with the PA Department of Health, and assists the community health improvement team for Better Together Lebanon County. Brianna has a passion for public health in the areas of nutrition, obesity, and preventative medicine.

„Brianna holds a Bachelor of Science in Psychology/Neuroscience from Pennsylvania State University and is currently a full

time student in the Master of Public Health program at Penn State Hershey College of Medicine. In her free time, Brianna enjoys working out, painting, and traveling with friends and family.

Dr. Turer received her medical degree from Johns Hopkins School of Medicine, and completed combined

Internal Medicine/Pediatrics residency training, a Fellowship in Health Services Research in Primary Care, and a Masters in Clinical Research at Duke University Medical Center. She joined the faculty at UT Southwestern in 2010. Her research focuses on primary-care weight management in children and adults. Her goal is to identify specific ways that primarycare providers can improve the weight status and health of patients with overweight and obesity. Her publications address complications of and treatments for pediatric and adult overweight and obesity. Dr. Turer is well-versed in challenges faced by practicing clinicians in treating obesity in the clinic, as well as bridging the related worlds of research and clinical practice. As The Obesity Society is committed to keeping the medical community and public informed of new advances, Dr. Turer will play an important role in the dissemination of our research results.

â–ş Meet Dr. Christy Boling Turer, one of our PaTH to Health: Diabetes study stakeholders!

Cool Connections

As a past chair (2013-2014) of the Clinical Management of Obesity Section of The Obesity Society, Dr. Turer is positioned to serve as a voice for clinicians who treat patients with obesity. The Obesity Society is the leading professional society dedicated to better understanding, preventing and treating obesity. The Clinical Management of Obesity Section has greater than 900 members. The purpose of this section is to form a collective group of practicing clinicians to improve our presence with the medical community, to help with common problems faced by practicing clinicians, and to promote good ethical treatment of the overweight patient by all practicing clinicians. Dr. Turer has extended her experience and expertise working with The Obesity Society to the research team to help inform our project.

Christy Boling Turer, MD, MHS,

Assistant Professor of Pediatrics, Department of Clinical Science, & Internal Medicine at UT Southwestern Medical Center



Meet Treva, a retired government employee of 34 years, who held positions at the Food & Drug Administration (FDA), Department of Defense (DOD), and Environmental Protection Agency (EPA). With a Bachelors of Science degree in Chemistry and a Masters degree in Environmental Management, Treva understands the science behind healthy eating. “You don’t have to tell me about carbohydrates,” she states knowingly. Yet, Treva represents one of 86 million Americans who are pre-diabetic. Diabetes runs in the family; her grandfather became blind from having type 2 diabetes, her aunt was on dialysis, and her mother was insulin-dependent. Given her genetic predisposition to developing diabetes, increased incidence among African Americans, and her personal weight struggles, Treva is well aware that a diabetes diagnosis is within arms reach. “It’s one of the things I’m supposed to get. It’s on my DNA according to the stats.” Yet, like the other one-third of the U.S. population, Treva is in a position to take control of her health. She has not yet received the official diagnosis. Although her A1c has been elevated in recent years, she hasn’t experienced the cardinal signs, such as increased thirst, frequent urination, or blurred vision, all typical symptoms of diabetes. While the “whistle hasn’t been blown,” Treva realizes it’s up to her to make sure it never is. So how does she do it? For starters, Treva is well aware that losing weight will help decrease her chances of developing diabetes and also improve her overall health. Therefore, she is starting to make healthier food choices. Admittedly she has a sweet tooth and realizes this points her in the direction of becoming diabetic so she knows she has to be careful. Although she frequently dines out, she can now go to a restaurant and avoid overeating. She is becoming a smarter shopper too. “There was a time I wouldn’t go to the grocery store without getting at least of five Ocean Spray juices, ” she recalls. “One day I got smart and read the label and saw that it was loaded with sugar. Now I don’t even bring them in the house.” Instead, she reminds herself to drink more water and be diligent with healither choices or the pendulum could swing in the wrong direction. 4 | WINTER/SPRING 2017 EDITION

“You have to be your own advocate for your health. You have to be in control.” Where Treva struggles, as do many of others who are at risk of developing type 2 diabetes, is with getting enough physical activity. “I’m not a lover of exercise. I got a D in college gym class because I wouldn’t change into my gym clothes!” She knows that she needs to exercise more to stay healthy and keep her A1c in check. Entering into the seventh decade of her life, Treva has already experienced a longer lifespan than her father. With every new year comes a boost in motivation, and Treva plans to use that as a springboard to exercise more. “The light bulb has come on. I know that I have to do this.” A big motivator for her is not wanting to be on medicine or become insulin dependent, like her mother was. “My biggest fear are the needles,” she admits. Treva’s advice to patients at risk of developing type 2 diabetes: “You have to be your own advocate for your health. You have to be in control.” Seeing her doctor three to four times per year keeps Treva accountable. She also keeps abreast of the latest diabetes research and has recently taken on a more active role by participating as a patient partner for our PaTH to Health: Diabetes study, where her voice and perspective is shared throughout each phase of the study to inform the research and enhance patientcenteredness. Additionally, she serves as a member on both the Executive and Steering Committees of the PaTH network, an electronic health record (EHR)-based data infrastructure across three states (Maryland, Pennsylvania, and Utah) that allows for collaborative research. In her spare time, Treva enjoys traveling, going to the theatre, and attending lectures. One of her pipedreams she plans to accomplish is to start a small baking business, and we look forward to seeing what diabeticfriendly delicacies will appear on the menu!



“In my practice I try to focus on telling patients what they should eat and drink as opposed to what they should not. For example, I always tell patients to make it their goal to eat five fruits and vegetables every day and to drink 64oz of water. I find that by simply making these two things their goals, they naturally eat and drink less carbs and sugars.”

– Tiffany Gonzalo, CRNP, Cocoa Family Medicine

Check out American Diabetes Association's website to learn how to make healthy food choices, understand carbohydrates, and receive food tips, visit ► Recent Trends in Diabetes Management

Although diabetes affects over 9% of the U.S. population, your chances increase at an alarming rate if you are Hispanic or African American. While previous research has pointed to genetics as the culprit for the dim outlook among disparate populations, new research findings suggest that environmental factors may play an even more decisive role in the subsequent development of diabetes. Stress factors such as poverty and discrimination experienced by minorities increase their cortisol levels, or “fight or flight” response. This leads to higher insulin resistance because the body has to store extra blood glucose to provide more energy to deal with stressful situations. Over time, ongoing insulin resistance wears out insulin-producing beta cells, thus causing type 2 diabetes. Exercise physiologist Rebecca Hasson, PhD, director of the Childhood Disparities Research Laboratory at the University of Michigan, is working with 150 children with obesity between ages 14 and 18 to measure associations between stress, race, and type 2 diabetes risk. Preliminary findings reveal that African American and Latino children in the study do indeed have higher cortisol levels, warranting stress reduction interventions in these populations. Read the full article here:

The Connection Between STRESS & Type 2 Diabetes



Smoked Paprika–Roasted Chicken with Roasted Vegetables Makes: 6 servings Serving Size: 1/6 recipe Preparation Time: 20 minutes Cooking Time: 1 hour, 20 minutes Ingredients: 1 Tbsp. smoked paprika 1 Tbsp. chipotle powder 1 Tbsp. honey 1 Tbsp. fresh lemon juice 2 tsp. olive oil 2 garlic cloves, minced 1/2 tsp. salt 1 4-lb whole chicken 3 celery stalks, cut into 2-inch chunks 3 med. carrots, cut into 2-inch chunks 2 large white onions, quartered 1/4 cup reduced-sodium chicken broth

Recipe by Ingrid Hoffmann; photography by RenĂŠe Comet; Photo Credit

Make Sunday dinner a cinch with this 255 calorie spin on a traditional roasted chicken.

Directions 1

Preheat the oven to 400 F. Spray a roasting pan with nonstick spray.


Combine the paprika, chipotle powder, honey, lemon juice, oil, garlic, and salt in a small bowl to make a paste.


Pat the chicken dry with paper towels. Gently loosen the skin from the breast and leg portions of the chicken by slipping your fingers under the skin. Rub the paste evenly under the skin and on top of the skin. Tuck the wing tips behind the chicken's shoulders and tie the legs together with kitchen string.


Make a bed for the chicken with the celery and carrots in the bottom of the pan. Place the chicken, breast-side up, on top of the vegetables. Add the onions and broth to the pan. Roast the chicken until an instant-read thermometer inserted into the thigh


(not touching the bone) registers 165 F, about 1 hour and 10 minutes. If the chicken is browning too fast, cover it with aluminum foil.


Transfer the chicken to a cutting board and let it stand for 10 minutes. Carve the chicken. Remove the chicken skin before eating. Serve the carved chicken with the roasted vegetables.

Quick, healthy and satisfying breakfast? Start your day off right with a recipe from one of our patient partners, Angela Evans.

Ingredients: One hard boiled egg one Tbsp of real bacon pieces The bacon is 25 calories, 190mg sodium, 0 carbs, 5mg choles, 0.5mg sat fat.

New Insight into How Diabetes Leads to

BLINDNESS Diabetic retinopathy, occurring when high blood glucose levels form abnormal blood vessels of the eye, is the leading cause of vision impairment and blindness among the working age population. New research led by Michael D. Dennis, PhD, an American Diabetes Association Pathway to Stop Diabetes awardee, is exploring how diabetes changes the kinds of proteins that are made in the eye. These changes may lead to diabetic retinopathy, a debilitating complication of diabetes and leading cause of blindness. Dr. Dennis is hypothesizing that high blood glucose changes which genes get made into proteins in a manner that contributes to retinopathy. Through his research, he has identified a molecular switch that occurs during high blood glucose levels, causing the abnormal development of blood vessels in the retina. This discovery is allowing researchers to identify new targets for therapies that could delay or prevent the development of diabetic retinopathy.

Patient Resources Learn all about blood glucose: Learn about your risk for pre-diabetes, type 2 diabetes and heart disease: Recently diagnosed with type 2 diabetes and don’t know where to begin? Start here: For several resources related to diabetes:

Photo Credit

Read the full article here: WINTER/SPRING 2017 EDITION | 7


Greater Philadelphia Tour de Cure DATE: Saturday, June 3, 2017 TIME: 6:00 AM - 12:00 AM LOCATION: Temple University - Ambler Campus, 580 Meetinghouse Road, Ambler, PA 19002 2017 DICK's Sporting Goods Pittsburgh Marathon DATE: May 6 – 7, 2017 LOCATION: Downtown Pittsburgh If current trends continue, one in three American adults will have diabetes by 2050. Please consider supporting the American Diabetes Association and helping the 400,000 Western Pennsylvanians with diabetes! Please note, registering as a fundraiser does not guarantee entry into the DICK's Sporting Goods Pittsburgh Marathon. There is no fundraising minimum but participating is easy! Visit to purchase race entry. Questions? Contact Kira Kellner: kkellner@ or call 412-824-1181 x4520

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Tour de Cure is more than just a cycling event. A day full of fun and excitement where riders of all levels join forces in the fight to Stop Diabetes® and raise critical funds for diabetes research, education and advocacy in support of the American Diabetes Association. So take the Ride of Your Life and sign up today!

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Give Back: Denim for Diabetes COMMUNITY EVENTS Want to make a difference at work? You're invited to participate in the American Diabetes Association's Campaign: Denim for Diabetes. For a suggested donation of $5, Business Information employees & coworkers will receive a Denim for Diabetes sticker entitling themCompany to wear denim to Business Address work - and making them ambassadors for diabetes Ambassadors Needed! awareness in your company and in our community. Contact Name/Title The American Diabetes Association has established To receive your kit, fill out and return the Denim Business Phone a program to train volunteers to implement for Diabetes registration form Business at Fax diabetes/wellness education workshops in DenimForDiabetes, or contact E-mail Shannon Davis at Address the Washington DC Metro Area. The idea is to give people who are passionate about health or 412-824-1181 ext. 4604. Dress Down Day Information promotion the resources they need to act by Approximate # of Participants leading workshops on diabetes/wellness in Do-It-Yourself Fundraising of Posters Requested their communities. These workshops will help Are you interested in to setting# up a fundraiser get the word out about prevention strategies to support the American Diabetes Association? # of Employees in Company and the dangers of uncontrolled diabetes. The There are many ways to do it! If you would like Association also hopes these workshops become assistance with creating a local event, please visit Date(s) Your Company Will Be Dressing Down:Davis at places community members can exchange ideas or contact Shannon about what they are doing to stay healthy. The or 412-824-1181 ext. 4604. ideal audience will be people that you know from Scan & Email Form To: your communities. Ambassador volunteers have Fax Form To: 412-471-1315 the opportunity to motivate friends, family and members of the community to join the fight to Mail Form To: American Diabetes Association StopStation Diabetes! Trainings to become 100 West Square Drive, Suite 1900 an American Pittsburgh, PA 15219 Diabetes Association Ambassador will be held ATTN: Shannon Davis every other month.

Registration Form

Volunteer Center Your involvement as an American Diabetes Association volunteer will help expand community outreach and impact, and inspire healthy living. Visit or http://bit. ly/VolunteerInPA to find volunteer opportunities in your area. „

If you, or someone you know, is interested in serving as an American Diabetes Association Ambassador, please contact Jackie DelAguila at 202-331-8303 ext. 4518 or For more details visit Page 1 of 1

PaTH to Health: Diabetes Study Newsletter Team

DESIGNER: Abbey Kinard CONTRIBUTORS: Treva Alston, Angela Evans, Tiffany Gonzalo, Brianna Hoglen, Christy Boling Turer

EDITORS: Treva Alston, Cynthia Bradley, Mully Chea, Angela Evans, Erica Francis, Brianna Hoglen, Jennifer L. Kraschnewski, Julie Tice