With rising rates of obesity-one-third of Americans are obese, according to the National Institute of Diabetes and Digestive and Kidney Diseases-come increases in cases of type 2 diabetes. A new study reveals that case management and training in self-management could extend lives and reduce the numbers of complications among low-income minority populations.

Researchers in San Diego used data from Project Dulce, a culturally specific diabetes-management program in which an RN (also a certified diabetes educator) meets an average of five times with each patient, with the goal of improving hemoglobin (Hb)A_Ic, low-density lipoprotein cholesterol, and blood pressure levels. Nearly half of the participants in Project Dulce also meet with a bilingual nutritionist, and 50% take part in an eight-week self-management training group taught in the patients' native language by trained peer educators (promotoras, in Spanish). Patients learn about regular blood glucose level testing, medications, diet, and exercise and discuss their feelings about the disease and its treatment as well as beliefs that may impede self-care.

The researchers projected patients' probable health outcomes and the cost-effectiveness of their care over a 40-year period. They examined four cohorts: the uninsured, those with Medi-Cal coverage, those covered by County Medical Services (San Diego's insurance program for low-income adults who aren't eligible to receive Medi-Cal), and those with commercial insurance.

Figure. A nurse teaching a class of patients with diabetes. Teaching programs have been shown to be cost-effective and improve outcomes.

The program was found to be most cost-effective and most successful in preventing complications in the uninsured cohort, which was 81% Latino and had a mean baseline hemoglobin HbA_Ic value of 9.4%; this group showed the steepest decrease in HbA_Ic levels (1.3%) and the greatest gain in life expectancy (1.1 years). In contrast, only 16% of participants with commercial insurance were Latino, and that group had a much lower mean baseline HbA_Ic level (7.8); they also had the smallest reduction in HbA_Ic level (0.4%) and the slightest increase in life expectancy (0.2 years). The uninsured group also displayed the greatest improvements in low-density lipoprotein cholesterol and blood pressure levels.

According to projections, Project Dulce was most cost-effective in the uninsured group and least so in the group with commercial insurance. The long-term reduction in complications in the uninsured group could offset one-third of the program's costs. The authors conclude that because the underinsured and uninsured groups were younger overall, had had diabetes for less time, and had higher mean baseline HbA_Ic levels, these populations have the most to gain from a program like Project Dulce.

Jacob Molyneux, senior editor

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