Action Plan Diabetes

Action Plan

Diabetes

June 2020

Dear Maryland Partners,

In some way, diabetes affects every Marylander. You may have

diabetes or know someone who does. You may have lost a loved one

to complications from the disease. You may be a parent seeking to

adopt healthy food and activity habits. You may be a health care or

program provider in the community treating or helping people with

diabetes. You may be an employer concerned about how diabetes

affects productivity and health insurance costs. Or you may be a

taxpayer considering how to reduce the diabetes burden to our

State’s vitality and economy. Regardless of where you live in our State,

diabetes takes a toll, but it is a disease we can prevent or mitigate.

Diabetes is the sixth leading cause of death in Maryland. According

to the federal government, the number of US adults diagnosed with

diabetes has more than doubled in the past 20 years. And in Maryland,

over a third of all adults have prediabetes, the condition that often

leads to diabetes.

There are many reasons for all Marylanders to get involved against this

preventable disease. To that end, the Maryland Department of Health

and others have created the State’s inaugural 2019-2024 Diabetes Action

Plan. The Plan provides information on the disease burden in Maryland,

and best practices for the State and its partners to implement to

prevent and manage diabetes. It will serve as the State’s guide by

which we will set speciﬁc goals and measure our successes. These

actions address all Marylanders:

• People who are at a healthy weight, to prevent the onset of

overweight and obesity;

• People who are overweight and obese, to achieve a healthy weight;

• People with prediabetes and gestational diabetes, to participate in

prevention programs to halt disease progression; and

• People with diabetes, to get the care they need to control their disease

and enjoy optimum health.

Informed by extensive input and comment from many partners,

the strategies in this Plan are far-reaching. We are grateful for the

enthusiastic support which was offered by so many as we developed

this Plan. Success in defeating diabetes requires broad and strong

collaboration between communities, organizations, businesses, local

governments and individuals across the State. We encourage you to

use the Plan to identify steps you can take to prevent and manage

diabetes. And, most importantly, let us know how you think your

group or community can get involved.

This is our shared call to action: to take steps today to build a Healthy

Maryland for ourselves and for future generations. We look forward to

working with you to improve the health of all Marylanders.

Yours in good health,

Frances B. Phillips, RN, MHA

Deputy Secretary for Public

Health Services

Robert R. Neall

Secretary

Maryland Diabetes Action Plan 20201

In Maryland, over 10 percent of the adult

population has diabetes. An additional 34

percent of adults are estimated to have

prediabetes, a condition of high blood sugar

not quite high enough to be diabetes.

Diabetes is the sixth leading cause of death

in Maryland, and the ﬁfth leading cause of

death for Black Marylanders in 2018. Diabetes

is also a major risk factor for developing

cardiovascular disease, the number one cause

of death for Marylanders. It is imperative to

launch a coordinated and meaningful initiative

to address the prevention and management

of diabetes in Maryland. The leading cause of

diabetes is overweight and obesity, the rate of

which has steadily increased to over 64 percent

of Maryland adults. Sedentary lifestyle is also a

risk; only 50 percent of Marylanders said they

participated in 150 minutes or more of physical

activity per week in 2017. Additionally, there are

disparities in how diabetes and its risk factors

affect Marylanders with racial/ethnic minorities,

those with less education, lower income, and

various disabilities disproportionately affected.

Diabetes and its complications cost the State

over $4.92 billion per year, and an additional

$2 billion in lost productivity.

The Maryland Diabetes Action Plan (the Plan)

includes details on the current burden of

diabetes and the factors impacting diabetes

risk. The Plan presents action steps that

organizations and partners can implement

to prevent and manage diabetes in Maryland.

These actions steps are categorized using a

systems change model approach, working

upstream to people at a healthy weight, then

progressing as the risk increases with people

who are overweight and obese, followed by

those with prediabetes or history of gestational

diabetes, and ﬁnally includes steps to improve

outcomes in those identiﬁed with diabetes

and diabetes complications.

Our vision is that an array of all Maryland

partners, across multiple sectors, will identify

opportunities, act in their areas of inﬂuence

in ways that align efforts, resources, and

Executive Summary

Action Plan

Diabetes

funds to reduce the burden of diabetes.

The Plan includes action tables that contain

strategies and action steps targeted to

support people across the continuum

of diabetes:

1. Keeping people at a healthy weight goal:

By 2024, 32 percent of Maryland adults will

be of healthy weight. The two objectives are

to increase access to healthy nutrition and

achieve and maintain recommended

physical activity levels for all Marylanders.

2. People who are overweight and obese goal:

By 2024, maintain the percentage of adults

with a BMI >25 at 66.5 percent; and reduce

by 10 percent the BMI >85th percentile in

high school students. The two objectives

are to improve clinical care services for

overweight and obese children and adults

and improve the availability of health lifestyle

options for overweight and obese children

and adults.

3. People with prediabetes and gestational

diabetes goal: By 2024, increase the

prevalence of Maryland adults who know

their prediabetes status by 30 percent.

The two objectives are to improve

prediabetes outcomes and reduce risk

of diabetes in women with a history of

gestational diabetes.

4. People with diabetes goal: By 2024, reduce

the age-adjusted diabetes mortality by 5

percent. The ﬁrst objective is to improve the

use of standardized quality of care for people

with diabetes at all levels of the health care

system by increasing the number of

health systems statewide that utilize the

chronic care model (CCM) framework, as

recommended by the American Diabetes

Association’s 2019 Standards of Medical Care

in Diabetes. The second objective is to

reduce the number of hospitalizations and

emergency department visits each by

5 percent for people with diabetes in the

state of Maryland.

In preparation of this Diabetes ActionPlan, a

process was completed to inventory obesity,

prediabetes, and diabetes programs in

Maryland. The aim of the inventory is to assess

the availability of programs across Maryland

that address diabetes prevention, care, and

management. While the required level of

service provision across the state cannot be

determined through the inventory alone, the

Maryland Department of Health aims to use

this process to begin to identify resource gaps

and opportunities to expand efforts to address

diabetes moving forward. The scope of the

inventory is all programs serving Marylanders,

including those that serve Medicaid enrollees,

Medicare enrollees, commercial and small

business health insurance enrollees, and

the uninsured population.

MDH published an online draft of the plan and

encouraged the public and partners to provide

feedback. Over 30 responses were submitted

by institutions and individuals. MDH worked to

integrate the feedback into this ﬁnal version.

As Maryland seeks to prevent and better

manage diabetes, all partners are encouraged

to implement action steps, while also sharing

innovative and best practices for expansion

across the state that aligns with the Diabetes

Action Plan and improves the health of

all Marylanders.

2Maryland Diabetes Action Plan 2020

EXECUTIVE SUMMARY .........................................................................................................................................................................................1

I. The Burden and Consequences of Diabetes in Maryland ...................................................................................... 6

What is Diabetes? ................................................................................................................................................................................................... 6

How Common is Diabetes in Maryland? .................................................................................................................................................7

Adults with Diagnosed Diabetes and Its Precursor Conditions in Maryland ............................................................7

Geographic Distribution of Diabetes in Maryland ...................................................................................................................... 8

How Serious are the Consequences of Diabetes for Maryland? ............................................................................................ 9

Diabetes as a Cause of Death .................................................................................................................................................................... 9

Complications of Diabetes ........................................................................................................................................................................ 10

Utilization Rates and Costs for Diabetes ............................................................................................................................................11

Diabetes-related hospital discharges in Maryland ..............................................................................................................11

Diabetes-related Prevention Quality Indicators (PQIs).....................................................................................................11

Diabetes Inpatient Hospital Charges ...........................................................................................................................................12

Diabetes Emergency Department Visits ..................................................................................................................................12

Utilization Differences for Medicaid Enrollees with Diabetes vs. Without Diabetes...................................13

Cost Burden of Diabetes in Maryland .........................................................................................................................................13

Medicaid Costs of Diabetes in Maryland .................................................................................................................................. 14

II. Determinants and Risk Factors for Diabetes: Opportunities for Intervention ...........................................15

Diabetes by Age and Sex ..................................................................................................................................................................................15

Diabetes and Weight ..........................................................................................................................................................................................17

Adult Prevalence of Excess Weight in Maryland .........................................................................................................................18

Overweight/Obesity in Women of Childbearing Age .............................................................................................................. 19

Excess Weight among Children .............................................................................................................................................................21

Diabetes and Physical Activity ..................................................................................................................................................................... 22

Diabetes and Tobacco .......................................................................................................................................................................................24

Diabetes and Oral Health ................................................................................................................................................................................ 25

Diabetes and Income .........................................................................................................................................................................................26

Diabetes and Level of Education ...............................................................................................................................................................27

Diabetes and Health Literacy .......................................................................................................................................................................28

Diabetes and Disability .....................................................................................................................................................................................29

Diabetes and Mental Health .........................................................................................................................................................................30

Gestational Diabetes ...........................................................................................................................................................................................31

Prediabetes ................................................................................................................................................................................................................31

Social Determinants of Health and Diabetes Risk ......................................................................................................................... 32

Diabetes and Health Equity ...........................................................................................................................................................................33

Table of Contents

Maryland Diabetes Action Plan 2020

Figure 1: Diabetes Risk Continuum ..............................................................................................................................................................7

Figure 2: Age-adjusted Adult Prevalence of Diagnosed Diabetes by Race/Ethnicity (R/E), ..................................

Maryland 2015-17 (BRFSS) ............................................................................................................................................................................7

Figure 3: Map of Age-Adjusted Adult Prevalence of Diagnosed Diabetes by Jurisdictions, ............................... 8

Figure 4: Age-adjusted Adult Prevalence of Diagnosed Diabetes by Jurisdiction, ................................................... 8

Figure 5: Age-adjusted Adult Prevalence of Diagnosed Diabetes by Race and

Jurisdiction, Maryland 2015-17 (BRFSS) ............................................................................................................................................. 9

Figure 6: Age-Adjusted Death Rate for Diabetes, by Race/Ethnicity, Maryland 2009-2018 ............................... 10

Figure 7: Age-adjusted Death Rate for Diabetes, Maryland and the United States,

2009-2018 ............................................................................................................................................................................................................ 10

Figure 8: Diabetes Composite (PQI 93) per 100,000 Population Aged 18+ in Maryland .......................................12

Figure 9: Adult Prevalence of Doctor-Diagnosed Diabetes, by Age and Sex, Maryland

2015-17 (BRFSS) ................................................................................................................................................................................................. 15

Figure 10: Age-adjusted Adult Incidence Rate of Diagnosed Diabetes, by Sex, U.S.,

1980 to 2017 (National Health Interview Survey)........................................................................................................................16

Figure 11: Age-adjusted Adult Prevalence of Doctor-Diagnosed Diabetes, by

Race/Ethnicity and Weight Status, Maryland 2015-17 (BRFSS) ........................................................................................17

Figure 12: Age-adjusted Adult Obesity Prevalence by Jurisdiction, Maryland

Figure 13: Weight Category Distribution of Women of Childbearing Age, by Race .................................................19

III. Intervention Strategies and Actions Steps for Diabetes Prevention and Control................................. 34

Rationale Behind Four Risk Populations for Diabetes ................................................................................................................34

Interventions for the Healthy Weight Population .......................................................................................................................... 36

Interventions for the Overweight and Obese Populations ...................................................................................................... 37

Interventions for the Gestational Diabetes and Prediabetes Populations ...................................................................38

Interventions for Managing Diabetes and Diabetes Complications ................................................................................40

Managing and Controlling Diabetes ........................................................................................................................................................41

IV. Action Tables for Diabetes Prevention and Control ............................................................................................ 43

V. Inventory of Diabetes-related Resources/Appendices ....................................................................................... 54

Development of a Diabetes Program Inventory .............................................................................................................................54

Diabetes Prevention and Care .....................................................................................................................................................................55

HealthChoice Diabetes Prevention Program (HealthChoice DPP) .............................................................................55

Investing in Prevention Programs.............................................................................................................................................................55

Acronyms ....................................................................................................................................................................................................................56

Contributors ..............................................................................................................................................................................................................57

Table of Figures

Maryland Diabetes Action Plan 2020

Figure 14: Crude Adult Prevalence of Diagnosed Diabetes by Physical Activity

Status and Race, Maryland 2011-13 (BRFSS) .................................................................................................................................22

Figure 15: Age-adjusted Prevalence of 150 Minutes per Week of Physical Activity .................................................23

Figure 16: Age-adjusted Adult Prevalence of Diagnosed Diabetes by Smoking Status ......................................24

Figure 17: Age-adjusted Adult Prevalence of Current Smoking, by Diabetes

Status, Maryland 2017 (BRFSS) .............................................................................................................................................................24

Figure 18: Age-adjusted Prevalence of Doctor Diagnosed Diabetes, By Income and

BMI Status (Maryland BRFFS 2015-2017) ........................................................................................................................................26

Figure 19: Age-adjusted Adult Prevalence of Doctor Diagnosed Diabetes, by Income

and Race, Maryland 2015-17 (BRFSS) ................................................................................................................................................26

Figure 20: Distribution of Household Income by Black or White Race ........................................................................... 27

Figure 21: Age-adjusted Adult Prevalence of Diagnosed Diabetes, by Education

and Black or White Race, Maryland 2015-17 (BRFSS) ............................................................................................................27

Figure 22: Distribution of Education Level, for NH Black and NH White Adults,

Maryland 2011-13 (BRFSS) ..........................................................................................................................................................................28

Figure 23: Age-adjusted Adult Prevalence of Doctor Diagnosed Diabetes, By Presence

or Absence of Selected Disabilities (Maryland BRFSS 2015-2017) ................................................................................. 29

Figure 24: Age-Adjusted Percent of Adults Ever Diagnosed with Depression,

by Diagnosed Diabetes Status, Maryland 2017 (BRFSS) .....................................................................................................30

Figure 25: Social Determinants of Health .............................................................................................................................................32

Figure 26: Diabetes Systems Thinking Model ...................................................................................................................................35

Figure 27: Three Buckets of Prevention .................................................................................................................................................35

Table 1: Diabetes-related Hospital Discharge Count and Rate per 1,000

Adult Marylanders ........................................................................................................................................................................................... 11

Table 2: PQI 93 Discharge Frequency and Rate per 1,000 Adult Marylanders .............................................................. 11

Table 3: Diabetes-related ED Visit Count and Rate per 1,000 Population ....................................................................... 12

Table 4: Admission, ED Visit, and Ambulatory Visit Prevalence and Rates; and Average

Payments Comparing Medicaid Enrollees with and without Diabetes, Maryland, 2017...............................13

Table 5: Trend in Age-adjusted Adult Prevalence of Weight Classiﬁcation (BMI groups),

Maryland 2013-2017 ........................................................................................................................................................................................18

Table 6: Pre-pregnancy BMI of Active Pregnant Women as of October 7, 2019 ........................................................20

Table 7: Prevalence of Weight Classes Among Children Participating in WIC

in Maryland (by Jurisdiction, July-December 2018; 40,935 Total Children) ............................................................ 22

Table of Tables

Maryland Diabetes Action Plan 2020

Action Plan

Diabetes

Section I:

The Burden and Consequences of Diabetes in Maryland

Diabetes is a chronic disease that affects the

way the body handles glucose, which is the

sugar in the blood used by the body for

energy. An inability of cells to properly absorb

glucose, due to inadequate insulin production

or a resistance of cells to the action of insulin,

or both, results in high blood glucose levels,

which is called diabetes. There are several types

of diabetes, the most common of which is type

2 diabetes. The other major types are type 1

diabetes, which usually has onset during

childhood and adolescence, and gestational

diabetes, which occurs during pregnancy.

Type 1 diabetes results from an autoimmune

attack against the cells in the pancreas that

produce insulin. This leads to an almost

complete lack of insulin, early severe

symptoms, and a dependence on insulin

treatment to sustain life. About 4 percent

of diabetes in the United States is type 1

diabetes.

The risk factors and interventions

discussed in this plan may not all apply to

type 1 diabetes.

Type 2 diabetes results in most cases from a

resistance to the action of insulin on cells.

This insulin resistance is related to overweight

and obesity, particularly fat located in the

abdomen. The degree to which the insulin

resistance manifests as high blood sugar

depends on how well, and for how long,

the pancreas can overproduce insulin to

compensate for the insulin resistance in the

cells. A decline in the insulin production

capacity with older age is one reason that type

2 diabetes often emerges at older ages. Type 2

diabetes can exist without symptoms for

years, which is why approximately 24 percent

of persons with diabetes don’t know that they

have it.

About 95 percent of diabetes in the

United States is type 2 diabetes. The risk factors

and most interventions discussed in this plan

are designed for type 2 diabetes.

Most public health surveillance data do

not distinguish between type 1 and type 2

diabetes but refer to the two combined.

However, since type 2 diabetes is 95 percent

of the total, patterns seen in the surveillance

data are the patterns of type 2 diabetes.

Public health data also often only measure

persons who know that they have diabetes,

which means that true diabetes prevalence

may be approximately one quarter higher

than the estimates of diagnosed

diabetes prevalence.

What is Diabetes?



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.

ADA website https://www.diabetes.org/resources/statistics/statistics-about-diabetes

Id fn 2

Maryland Diabetes Action Plan 2020

Prediabetes is a condition where blood

sugar levels are higher than normal, but not

high enough to be considered diabetes.

Prediabetes is a precursor condition on the

pathway from normal glucose levels to type 2

diabetes; the development of type 1 diabetes is

usually so rapid that there is no “prediabetes”

state that precedes type 1 diabetes. A fasting

glucose level of 100 to 125 mg/dL, a hemoglobin

A1C level of 5.7 percent to 6.4 percent, or a

two-hour glucose level in an oral glucose

tolerance test of 140 to 199 mg/dL

deﬁnes prediabetes.

Prediabetes often goes unrecognized by both

individuals and their health care providers;

nine of 10 adults who have prediabetes do

not know they have it.

CDC estimates that

34 percent of U.S. adults have prediabetes.

Diabetes and prediabetes are serious

conditions that can lead to complications

including heart disease and stroke,

blindness, amputations, nerve damage,

and kidney disease.

A disease is important to public health

if it is both common and has serious

consequences. Diabetes is both common

and serious in Maryland.



https://www.cdc.gov/diabetes/basics/getting-tested.html

https://www.cdc.gov/diabetes/basics/prediabetes.html

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.

Maryland Behavioral Risk Factor Surveillance System (BRFSS), 2017.

United States Census, 2017.

Diabetes Care. January 01 2019; volume 42 issue Supplement 1.

Based on Maryland Adult Population, sources: US 2017 Census; 2017 Maryland BRFSS; and Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease

Control and Prevention, U.S. Dept of Health and Human Services; 2017.

Control and Prevention, U.S. Dept of Health and Human Services; 2017. Categories are not equal, percentages in this ﬁgure do not equal 100.

Adults with Diagnosed Diabetes and Its

Precursor Conditions in Maryland

An estimated 10.5 percent of the adult

population in Maryland, or 488,942 adults,

have diabetes.

8,9

In Maryland an estimated

1.6 million adults or 34 percent of the adult

population have prediabetes (see Figure

1 on this page).

10,11

The adult prevalence of diagnosed diabetes is

highest in Non-Hispanic (NH) Blacks, followed

by Non-Hispanic Asians and Hispanics, and

lowest in Non-Hispanic Whites, as shown in

Figure 2 on this page.

How Common is Diabetes in Maryland?

Diabetes Risk Continuum

Figure 1

Healthy

Population

1,351,479

(32%)

Overweight

and Obese

2,799,259

(66.2%)

Prediabetes

1,575,829

(33.9%)

Diagnosed

Diabetes and

Diabetes with

Complications

488,942

(10.5%)

Age-adjusted Adult Prevalence of Diagnosed Diabetes

by Race/Ethnicity (R/E), Maryland 2015-17 (BRFSS)

Figure 2

15%

12%

8.0%

NH White

13.3%

NH Black

9.7%

NH Asian

9.4%

Hispanic

9.7%

All R/E

Maryland Diabetes Action Plan 2020

Geographic Distribution of Diabetes

in Maryland

Adult prevalence of diagnosed diabetes is

mapped in Figure 3 on this page. As shown in

Figure 4 on this page, the jurisdictions with

prevalence rates of adults with diagnosed

diabetes that exceed the Maryland Statewide

rate are Dorchester, Allegany, Prince George’s,

Garrett, Washington, Somerset, and Caroline

Counties and Baltimore City.

These high rates

of diabetes are seen in jurisdictions with high

minority populations (Baltimore City, Prince

George’s County) and in certain rural

jurisdictions in Western and Southern

Maryland and on the Eastern Shore. Notably,

all three jurisdictions in Western Maryland are

among the six highest prevalence rates.

There are several reasons for the high

diabetes prevalence rates in rural jurisdictions.

Many rural residents experience risk factors

for diabetes and may lack access to services

to prevent diabetes or manage their diabetes.

Rural residents, as well as the urban poor,

experience barriers to adequate physical

activity and healthy eating.

Additional

challenges revolve around access to health

care, including resource shortages of

physicians and providers located in rural

areas. Workforce shortages in rural areas

may decrease provider referral to National

DPP, Diabetes Self-Management Education

and Support (DSMES) programs, Chronic

Disease Self-Management programs and

nutrition programs, as well as the availability

of these programs. Other challenges include

limited access to transportation to travel to

appointments with primary care or specialty

care providers.

Map of Age-Adjusted Adult Prevalence of Diagnosed

Diabetes by Jurisdictions, Maryland, 2015-2017 (BRFSS)

Figure 3

Maryland BRFSS, 2015-2017.

O'Connor A and Wellinius G. Rural-urban disparities in the prevalence of diabetes and coronary heart disease. Public Health. October 2015, vol. 126: 813-820

Garrett

Allegany

Washington

Frederick

Carroll

Montgomery

Prince

Georges

Charles

St. Mary’s

Calvert

Anne

Arundel

Harford

Cecil

Kent

Queen

Anne’s

Caroline

Talbot

Dorchester

Wicomico

Worchester

Somerset

Baltimore

County

Howard

Balt.

City

Age-adjusted Adult Prevalence of Diagnosed Diabetes

by Jurisdiction, Maryland 2015-17 (BRFSS)

Figure 4

% with diagnosed diabetes

Dorch

Alleg

Prince G

B City

Garrett

Wash

Somer

St. Mary

Caroline

Maryland

Anne A

Calvert

Balt Co

Charles

Harford

Worc

Wico

Cecil

Fred

Talbot

Kent

Queen A

Howard

Mont

Carroll

15%

20%

10%

15%

13%

12%12%12%

11% 11% 11%

10%

9% 9% 9% 9% 9% 9% 9%

8% 8% 8%

7% 7% 7%

Maryland Diabetes Action Plan 2020

≤ 8.27%

≤ 9.13%

≤ 9.5%

≤ 11.53%

≤ 15.13%

Legend

The range of adult diabetes prevalence rates

becomes even greater when rates by race

and jurisdiction are examined, as shown in

Figure 5. The Non-Hispanic White rate in

Dorchester County is particularly high at 14

percent, with other Non-Hispanic White rates

ranging from 5 percent to 12 percent. The Black

rates start at a low of about 11 percent in

Howard and Montgomery counties and rise

to a high of 20 percent and 24 percent in

Dorchester and Talbot counties respectively

(among the jurisdicitons where the

Non-Hispanic Black rate is reportable).

Of note, Dorchester County has the highest

Non-Hispanic White rate, and the second

highest Non-Hispanic Black rate.

These data indicate that diagnosed diabetes is

common in Maryland, and that the burden of

diabetes prevalence varies by race and place.

The consequences of diabetes for Maryland are

presented below.

How Serious are the Consequences of Diabetes for Maryland?

Diabetes is the sixth leading cause of death

in Maryland; in 2018, 2.8 percent of all deaths

in the State were due to diabetes.

Diabetes

is also a risk factor for heart disease (leading

cause of death in Maryland) and stroke (third

leading cause of death in Maryland), and so

contributes to even more deaths in Maryland

than those speciﬁcally attributed to diabetes

on death certiﬁcates.

Figure 6 on the next page shows that the

age-adjusted diabetes mortality rate in

Maryland declined from 20.7 in 2009 to a

recent low of 18.3 in 2015, but then rose to 19.6

per 100,000 people in 2018. This increase from

2015 to 2018 occurred mostly in the NH Black

population and less so in the NH White

population. Consistent with the greater burden

of diabetes prevalence in the Black community,

the diabetes mortality rate for Blacks is about

twice as high as the mortality rate for Whites.

Comparing Maryland to the United States

(Figure 7), death rates were essentially

identical in 2009. From 2009 to 2015, Maryland

improved more rapidly than the US. However,

after 2015, the rising Black diabetes death

rate in Maryland has resulted in the overall

Maryland rate converging toward the

national rate.

Maryland Vital Statistics Annual report (2018): //health.maryland.gov/vsa/Documents/Reports%20and%20Data/Annual%20Reports/2018annual_rev3.pdf

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention

Id fn 15

Age-adjusted Adult Prevalence of Diagnosed Diabetes

by Race and Jurisdiction, Maryland 2015-17 (BRFSS)

Figure 5

% with diagnosed diabetes

15%

25%

10%

20%

Talbot

Dorch

Fred

Anne A

Wico

B City

Maryland

Prince G

Charles

Balt Co

Howard

Mont

Alleg

Calvert

Caroline

Carroll

Cecil

Garrett

Harford

Kent

Queen A

St. Mary

Wash

Worc

Diabetes as a Cause of Death

Maryland Diabetes Action Plan 2020

14%

10%

11%

12%

11%

24%

20%

18%

17%

16%

15%

13%

12%

11%

NH WhiteNH Black

Complications of Diabetes

Diabetes causes a variety of serious

complications related to its effects on large

and small blood vessels. Diabetes promotes

atherosclerosis, the process where

cholesterol builds up in the larger blood

vessels. This increases the risk of heart disease,

heart attacks, strokes, and peripheral vascular

disease (blocked arteries in the arms and legs).

The effects of diabetes on small blood vessels

leads to eye disease, blindness, kidney disease,

end-stage kidney failure that requires

transplant or dialysis, and nerve disease.

The combination of nerve disease and

vascular disease in the legs results in

amputations caused by diabetes.

Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention

Maryland Diabetes Action Plan 2020

Age-Adjusted Death Rate for Diabetes, by

Race/Ethnicity, Maryland 2009-2018

Figure 6

Rate per 100,000 population

Non-Hispanic Black

All Races

Non-Hispanic White

Hispanic

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

NH Black 34.5 35.9 34.3 31.2 32.2 33.7 28.2 31.7 33.8 32.4

All Races 20.7 19.8 20.8 19.1 19.0 19.6 18.3 19.6 20.3 19.6

NH White 17.5 15.5 17.4 16.1 15.5 16.4 16.0 16.1 16.3 16.4

Hispanic - - - 15.8 11.3 10.3 8.6 16.4 12.3 7.3

Source: Maryland Vital Statistics Annual report (2018)

Age-adjusted Death Rate for Diabetes, Maryland

and the United States, 2009-2018

Figure 7

Rate per 100,000 population

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

US 21.0 20.8 21.6 21.2 21.2 20.9 21.3 21.0 21.5 -

MD 20.7 19.8 20.8 19.1 19.0 19.6 18.3 19.6 20.3 19.6

PQI 93 Discharge Frequency and Rate

per 1000 Adult Marylanders

Table 2

2013 2014 2015 2016 2017 2018

PQI 93

Discharges

10,494 10,511 10,045 9,539 10,484 11,571

Discharges

per 1000

adults

2.34 2.34 2.24 2.13 2.34 2.58

Utilization Rates and Costs for Diabetes

Diabetes-related hospital discharges

in Maryland

In 2018, a total of 11,738 hospital discharges

(inpatient and observation stays greater than

or equal to 24 hours) were reported with

diabetes as the primary diagnosis among

Maryland adults aged 18 years or older. This is

equivalent to 2.5 hospital discharges per 1,000

Maryland adults.

20,21

In Table 1, the numerator is discharges with

diabetes-related primary diagnosis code at

Maryland hospitals among adults with

valid Maryland zip codes, denominator is

adult Maryland population based on

5-year American Community Survey. 2017

denominator is used for 2018 (as 2018 data

was not available at the time of this report).

Diabetes-related Prevention Quality

Indicators (PQIs)

PQIs reﬂect admissions for ambulatory-

care sensitive conditions that could have

been prevented with access to high-quality

outpatient care. The Agency for Healthcare

Research and Quality has speciﬁed four

individual PQIs for diabetes and

one composite:

22,23

• PQI 01 Diabetes Short-Term Complications

Admission Rate (primary diagnosis code of

diabetes with: ketoacidosis, hyperosmolarity,

or coma)

• PQI 03 Diabetes Long-Term Complications

Admission Rate (primary diagnosis code

of diabetes with: renal, eye, neurological,

circulatory, or complications not

otherwise speciﬁed)

• PQI 14 Uncontrolled Diabetes Admission

Rate (primary diagnosis code of diabetes

without mention of short-term or long-term

complications)

• PQI 16 Lower-Extremity Amputation among

Patients with Diabetes Rate (any-listed

diagnosis of diabetes and any-listed

procedure of lower-extremity amputation)

• PQI 93 Diabetes Composite (includes any of

the four above PQIs)

As indicated in the table below, the number

of Diabetes PQIs in Maryland and the rate

of Diabetes PQIs per 1000 adults have

ﬂuctuated over time but have generally

increased since 2013.

Diabetes-related Hospital Discharge Count

and Rate per 1000 Adult Marylanders

Table 1

2013 2014 2015 2016 2017 2018

Discharges

10,676 10,689 10,357 10,823 11,735 11,738

Discharges

per 1000

adults

2.38 2.35 2.26 2.35 2.52 2.53

Trends between the ICD9 period (2013-2015) and ICD 10 period (2016-2018) should be treated with caution due to ICD transition. For this section, diabetes refers to Type 1 and Type 2 diabetes.

MATCH, Health Service Cost Review Commission (HSCRC), Maryland Hospital Discharges and Ambulatory Care Data.

https://www.healthypeople.gov/2020/topics-objectives

Many, but not all, discharges with a primary diagnosis of diabetes are included in the PQI counts. For example, Marylanders younger than 18 and those transferred from another institution are not

included in the PQI counts

MATCH, Health Service Cost Review Commission (HSCRC), Maryland Hospital Discharges and Ambulatory Care Data.

Maryland Diabetes Action Plan 2020

The disease burden of diabetes also reﬂects

a healthcare disparity by race (see Figure 8).

Black Marylanders experience a higher rate

of diabetes-related avoidable hospitalizations

compared to white Marylanders, with 434

people having diabetes-related avoidable

hospitalizations for every 100,000 Black

Marylanders (or 4.34 per 1000) compared to

170 for every 100,000 White Marylanders

(or 1.7 per 1000) in 2017.

This means that the

black rate is 2.6 times as high as the White

rate, and that 62 percent of Black discharges

are excess (would not occur if Black rate was

the same as White rate).

Diabetes Inpatient Hospital Charges

In 2017, Maryland hospitals charged

approximately $197 million for diabetes-related

hospital stays for Marylanders, compared to

$150 million dollars in 2013, an increase of more

than 30 percent. This estimate includes

Maryland residents of all ages with a primary

diagnosis of diabetes or a diabetes-related

complication (such as lower-extremity

amputation). The estimate excludes patients

seen in the Emergency Department (ED)

and released without an inpatient stay.

Diabetes Emergency Department Visits

In 2017, there were a total number of 121,301

ED visits related to Diabetes.

This indicates a

rate of 20.23 visits per 1,000 Marylanders.

Id fn 24.

MATCH, Health Service Cost Review Commission (HSCRC), Maryland Hospital Discharges and Ambulatory Care Data.

Deﬁned based on CCS categories among all patients at Maryland hospitals.

Table 3

Diabetes-related ED Visit Count and

Rate per 1,000 Population

2013 2014 2015 2016 2017

Number of

ED visits

122,439 123,875 124,928 124,420 121,301

Population

5,834,299 5,887,776 5,930,538 5,959,902 5,996,079

Visit Rate

per 1,000

20.99 21.04 21.07 20.88 20.23

Maryland Diabetes Action Plan 2020

Figure 8

Diabetes Composite (PQI 93) per 100,000

Population Aged 18+ in Maryland

PQI 93 per 100k adults

500

400

300

200

100

2013 2014 2015 2016 2017

Black

466 402 424 406 434

Total

234 234 224 213 234

White

152 146 156 155 170

Utilization Differences for Medicaid Enrollees

with Diabetes vs. Without Diabetes

To further demonstrate the individual and

societal costs of diabetes, the data below shows

that compared to Medicaid enrollees without a

diagnosis of diabetes, those with diabetes

• Are 2.4 times as likely to have an

inpatient admission

• Have four times as many admissions

per enrollee

• Are 1.3 times as likely to have an ED visit

• Have 1.7 times as many ED visits per enrollee

• Are 1.1 times as likely to have an

ambulatory visit

• Have 2.3 times as many ambulatory visits

per enrollee

• Have 3.1 times the level of average

fee-for-service payment, and

• Have 2.5 time the level of average

MCO payment.

Cost Burden of Diabetes in Maryland

Diabetes and prediabetes cost an estimated

$7.01 billion in Maryland each year.

Serious

complications of diabetes include heart

disease, stroke, amputation, end-stage

kidney disease, blindness, and death.

People with diabetes have medical expenses

approximately 2.3 times higher than those who

do not have diabetes.

Total direct medical

expenses for diagnosed and undiagnosed

diabetes, prediabetes and gestational

diabetes in Maryland was estimated at

$4.92 billion in 2017. In addition, another $2.09

billion was spent on indirect costs from lost

productivity due to diabetes.

31,32

Maryland Department of Health, Health Care Financing/Medicaid, data provided September 2019.

Diabetes Care Volume 41, December 2018, https://care.diabetesjournals.org/content/diacare/41/12/2526.full.pdf

Diabetes Care. January 01 2019; volume 42 issue Supplement 1.

Id fn 29

The Hilltop Institute. (2016, May 20).Brieﬁng Report: An Examination of Service Utilization and Expenditures among Adults with Diabetes Enrolled in Maryland’s Medicaid Managed Care Program.

Baltimore, MD: UMBC. Retrieved from: https://www.medchi.org/Portals/18/ﬁles/pdfs/Hilltop%20Brieﬁng%20Report_Medicaid%20Diabetes%20Analysis_Final_5-20-16.pdf?ver=2016-10-27-143345-240.

Admission, ED Visit, and Ambulatory Visit Prevalence and Rates;

and Average Payments Comparing Medicaid Enrollees with and

without Diabetes, Maryland, 2017

Table 4

Calendar Year 2017

Medicaid Enrollees

with Diabetes

Medicaid Enrollees

without Diabetes

Ratio: Diabetes

to No Diabetes

% with One or More

Inpatient Admissions

24.8% 10.3% 2.4

Average Admissions

per Enrollee

0.4 0.1 4.0

% with One or More

ED visits

42.7% 33.2% 1.3

Average ED visits

per Enrollee

1.2 0.7 1.7

% with One or More

Ambulatory Visits

93.4% 87.0% 1.1

Average Ambulatory

Visits per Enrollee

11.8 5.1 2.3

Average Fee-for-Service

Payment

$12,334 $3,961 3.1

Average MCO Payment

$9,794 $3,909 2.5

Maryland Diabetes Action Plan 2020

Id fn 32

The average Medicaid expenditure does not adjust for participants for the length of enrollment in Medicaid (i.e., the costs for the one cohort could be higher because the cohort is enrolled for longer

periods in Medicaid and has more opportunity to receive services). The PMPM method adjusts for length of Medicaid enrollment.

The Hilltop Institute (2019, August 29). Analyses of Medicaid Expenditure Data for the Diabetes Action Plan, 2013-2017. Baltimore, MD: UMBC.

Kick payments are supplemental funds that the Department pays to managed care organizations (MCOs) outside of their regular capitation payments to better target resources for a speciﬁc set of

services or having a certain condition. For example, MCOs currently receive kick payments for the birth event and for beneﬁciaries receiving Hepatitis C treatment.

Medicaid Costs of Diabetes in Maryland

People with diabetes cost the State's Medicaid

program twice as much as those without the

chronic condition, a study commissioned by

MedChi, the Maryland State Medical Society

has found.

No other insurance utilization data

was available at the time of plan completion.

In CY 2017, total expenditures for Medicaid

participants with diabetes amounted to nearly

$1.9 billion. Between CY 2013 and CY 2017, total

Medicaid per-member-per-month (PMPM)

expenditures for individuals with diabetes was

two to three times higher than users without

diabetes ($1,652 vs. $688 in CY 2017). Similar

to the PMPM expenditures, average Medicaid

expenditures among eligible individuals with

diabetes was two to three times higher than for

individuals without diabetes ($18,202 vs. $7,516

in CY 2017). For individuals with diabetes, the

average Medicaid PMPM expenditure reduced

from $1,746 to $1,652 among users between

CY 2013 and CY 2017. This reduction was due

to a lower average fee-for-service PMPM

expenditure among Medicaid beneﬁciaries

with diabetes (from $1,362 in CY 2013 to $1,119

in CY 2017) and lower average PMPM capitation

and kick payments for beneﬁciaries with

diabetes enrolled in the HealthChoice

managed care program (from $1,031 in CY

2013 to $926 in CY 2017).

34,35,36

Maryland Diabetes Action Plan 2020

Action Plan

Diabetes

Section II:

Determinants and Risk Factors for Diabetes: Opportunities for Intervention

Diabetes by Age and Sex

Diabetes is more common in older adults. In

Maryland, in 2015-17 combined, about 26

percent of men and 20.2 percent of women

aged 65 and older had been diagnosed with

diabetes compared to about 5 percent of

adults aged 35-44 (Figure 9).

Diabetes in

older adults has been linked to a reduction

in functional status, higher mortality, and

increased risk of institutionalization.

The increasing prevalence of diabetes with

advancing age is part of the natural history

of the disease, which means that these age

differences are not an “age disparity.” Obesity

is more common at older ages, which

increases insulin resistance, and reduction

of insulin secretion also occurs at older ages.

Age is not a modiﬁable factor but

understanding age effects is important

to evaluating other determinants and risk



Maryland BRFSS, 2015-17.

% with diagnosed diabetes

Figure 9

Adult Prevalence of Doctor-Diagnosed Diabetes,

by Age and Sex, Maryland 2015-17 (BRFSS)

Maryland Diabetes Action Plan 2020

Age Group 35-44 45-54 55-64 65+

25%

20%

15%

10%

30%

Male

Female

5.5%

11.0%

19.4%

26.0%

5.1%

10.0%

15.9%

20.2%

factors. Because of this strong age effect, the

remaining analyses will display age-adjusted

diabetes prevalence rates to disentangle the

effects of age from the effects of other

determinants and risk factors.

Gender is generally not considered to be a

risk factor for diabetes. In Figure 9, male and

female prevalence is essentially the same

below age 55. While there are somewhat

higher rates for males at ages 55 and older,

this does not mean that females should be

considered a “low risk” group.

This is conﬁrmed by the equal incidence rates

(rate of new cases) between males and females

nationally shown inFigure 10on this page

(incidence rate data by sex is not available for

Maryland). (https://gis.cdc.gov/grasp/diabetes/

DiabetesAtlas.html#[DM1]).

Figure 10

Age-adjusted Adult Incidence Rate

of Diagnosed Diabetes, by Sex, U.S., 1980 to 2017

(National Health Interview Survey)

https://www.cdc.gov/nchs/nhis/shs/tables.htm

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

2016

rate per 1000 population

Male

Female

Maryland Diabetes Action Plan 2020



Maryland BRFSS, 2015-2017.



NIDDK, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-type-2-diabetes

Diabetes and Weight

In Maryland, as in the nation, the prevalence

of diabetes increases as weight classiﬁcation

moves from healthy weight, through

overweight, and to obesity. As seen in Figure

11 on this page, in Maryland there is a small

step-up in diabetes prevalence between

healthy weight and overweight, and a larger

step-up in prevalence between overweight

and obesity. This relationship of prevalence to

weight status is similar for Non-Hispanic Blacks

and Non-Hispanic Whites.

In addition, Figure 11 shows that the higher

diabetes prevalence for minorities presented

earlier (Figure 2) persists within weight

categories, with Non-Hispanic Black diabetes

prevalence higher than Non-Hispanic White

in all weight categories, and Hispanic and Asian

prevalence higher at overweight (the only

category with reportable data for those

populations in this analysis).

This indicates

that the racial/ethnic disparity in diabetes

prevalence is not simply an issue of more

excess weight in minority populations,

although for some groups that contributes

to the disparity.

Higher BMI correlates with greater abdominal

fat, and abdominal fat increases insulin

resistance, which can produce high levels of

blood glucose.

Insulin is produced by the

pancreas and is the hormone that moves the

sugar out of the blood and into the cells. When

an individual has excess body fat, the body’s

cells become resistant to insulin, which is

why overweight and obesity are risk factors

for diabetes. The body’s response to

insulin-resistant cells increases insulin

production to the point that the pancreas

begins to fail to keep up with the insulin

demand. Failure to produce and/or utilize

enough insulin results in diabetes.

Figure 11

Age-adjusted Adult Prevalence of Doctor-Diagnosed

Diabetes, by Race/Ethnicity and Weight Status,

Maryland 2015-17 (BRFSS)

Healthy Weight Over Weight Obese

20%

15%

10%

% with diagnosed diabetes

Maryland Diabetes Action Plan 2020

3.1%

6.2%

15.6%

8.6%

9.9%

19.0%

11.90%

14.6%

NH WhiteNH BlackNH Asian Hispanic

Adult Prevalence of Excess Weight

in Maryland

Based on data from 2017, in Maryland, 34.6

percent of the population is overweight, and

30.8 percent of the population is obese.

Five-year trend data shows that the proportion

of Marylanders who are obese is increasing,

and the proportion of Marylanders who are

overweight has been relatively stable. In

addition, the healthy weight population in

Maryland is decreasing from 35.1 percent in

2013 to 32.7 percent in 2017.

Figure 12 shows a wide range of obesity

prevalence rates by jurisdiction in Maryland,

ranging from a low of 20 percent in

Montgomery County to a high of 43 percent

in Caroline County. Several factors inﬂuence

the obesity prevalence rate in a jurisdiction,

including the racial and ethnic mix and the

socio-economic status of the population.



Maryland BRFSS, 2015-2017.



Maryland Behavioral Risk Factor Surveillance System (BRFSS), 2013-2017



Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS Prevalence & Trends Data.

https://www.cdc.gov/brfss/brfssprevalence/.



Maryland BRFSS, 2015-2017.

Adult Weight Classiﬁcation by Body Mass

Index (BMI) Age-Adjusted Prevalence and

Trend, Maryland 2013-2017

Table 5

2013 2014 2015 2016 2017

Obese

27.6% 29.0% 28.2% 29.4% 30.8%

Overweight

35.5% 34.9% 35.7% 34.1% 34.6%

Healthy Weight

35.1% 34.5% 33.7% 34.8% 32.7%

Underweight

1.9% 1.6% 2.4% 1.8% 1.9%

Age-adjusted Adult Obesity Prevalence by

Jurisdiction, Maryland 2015-17 (BRFSS)

Figure 12

30%

50%

20%

10%

40%

Caroline

Somer

Wash

Dorch

Garrett

St. Mary

Wort

Prince G

Charles

Wico

B City

Carroll

Alleg

Cecil

Calvert

Balt Co

Harford

Maryland

Kent

Anne A

Fred

Queen A

Talbot

Howard

Mont

% obese

43%

42%

40%

39%

36% 36% 36% 36%

35% 35% 35%

34% 34%

32%

31%

30% 30%

30%

28%

27%

26% 26%

23%

20%

Maryland Diabetes Action Plan 2020



Maryland BRFSS, 2015-2017.

Overweight/Obesity in Women

of Childbearing Age

The prevalence of overweight and obesity

among women of childbearing age is of

particular interest since this will determine

the prevalence of pre-pregnancy diabetes

and the incidence of gestational diabetes

among pregnant women. Both conditions

increase the risk of adverse infant and

maternal outcomes.

Figure 13 on this page shows the weight

category distribution of women age 18-44 for

Non-Hispanic Whites and Non-Hispanic Blacks.

For Non-Hispanic Whites, a slight majority of

the women are in the healthy weight category

(50.9 percent) while for Non-Hispanic Blacks

the most prevalent weight category is obesity

(40.8 percent). Both racial groups have similar

prevalence of overweight, but very different

prevalence in the healthy weight and

obese categories.

Maryland Diabetes Action Plan 2020

% in the weight category

Figure 13

Weight Category Distribution of Women

of Childbearing Age, by Race Maryland 2015-17 (BRFSS)

Healthy Weight Over Weight Obese

50%

40%

30%

20%

60%

50.9%

32.2%

27.1%

26.1%

40.8%

23.1%

10%

NH WhiteNH Black

Table 6 on this page shows the pre-pregnancy

BMI classiﬁcation for pregnant women active

in the Women Infants and Children (WIC)

program Statewide and by jurisdiction.

Statewide, 36 percent have an obese BMI,

with a range of 29 percent in Montgomery

and Garrett counties to 46 percent in Talbot,

48 percent in Dorchester and 61 percent in

Somerset counties.



Maryland Women Infant and Children Program, communicated October 7, 2019.

Pre-pregnancy BMI of Active Pregnant Women

as of October 7, 2019, Maryland WIC Program

Table 6

County

Underweight

BMI < 18.5

Normal Weight

BMI 18.5-24.9

Overweight

BMI 25.0-29.9

Obese

BMI > 30.0

Allegany 4% 43% 21% 32%

Anne Arundel 2% 35% 26% 36%

Baltimore City 4% 31% 24% 40%

Baltimore County 4% 35% 25% 36%

Calvert 4% 35% 28% 33%

Caroline 1% 35% 28% 35%

Carroll 6% 38% 24% 32%

Cecil 5% 36% 23% 35%

Charles 6% 35% 27% 33%

Dorchester 2% 29% 21% 48%

Frederick 3% 37% 30% 30%

Garrett 8% 44% 19% 29%

Harford 7% 31% 26% 36%

Howard 1% 35% 34% 30%

Kent 5% 30% 24% 41%

Montgomery 3% 34% 34% 29%

Prince George's 3% 31% 31% 35%

Queen Anne's 0% 35% 29% 36%

Somerset 7% 20% 12% 61%

St. Mary's 3% 33% 22% 42%

Talbot 6% 12% 36% 46%

Washington 4% 35% 21% 39%

Wilcomico 3% 35% 23% 40%

Worcester 5% 32% 29% 34%

State 3% 33% 28% 36%

Total Pregnant Women = 10,015

Maryland Diabetes Action Plan 2020

Excess Weight among Children

Maryland does not have state-level data on

diabetes in children. The SEARCH for Diabetes

in Youth study is aimed at understanding more

about diabetes among children and young

adults in the United States; the incidences of

both type 1 and type 2 diabetes among youths

increased signiﬁcantly in the 2002–2012 period,

particularly among youths of minority racial

and ethnic groups.

State level data on overweight and obesity

is available. In children and adolescents,

overweight and obesity are deﬁned by

comparing weight for height (the Body Mass

Index or BMI) to a reference population that

precedes the recent rise in rates of childhood

obesity. Comparisons are made to the

corresponding age and sex of the child.

Underweight is falling below the 5th percentile

of that reference population, normal weight is

being 5th to below 84th percentile, overweight

but not obese is being 85th to below 95th

percentile, and obese is being 95th

percentile or above.

The Maryland Youth Risk Behavior Survey

(YRBS) is an on-site survey of Maryland

students in a sample of middle and high

school classrooms focusing on health-related

behaviors and tobacco-use prevalence. The

survey does not include elementary schools.

The survey is conducted every two years and is

self-reported. According to the 2016 Youth Risk

Behavior Survey, 26.4 percent of Maryland high

school students are overweight or obese.

The percentage of high school students

who are overweight and obese were 11.5

percentand 14.9 percent, respectively. Based

on this data, interventions and strategies to

address overweight and obesity must be

targeted to children and youth as well as

adults to prevent diabetes.

The Women Infant and Children (WIC)

program childhood participants (children 2

to 5 years of age, July–December 2018) have

their height and weight checked during

regular WIC visits. Table 7 shows that of these

children, 17 percent were at or above 95th

percentile BMI (obese), and 16 percent were

of 85th to below 95th percentile BMI

(overweight but not obese).



Incidence Trends of Type 1 and Type 2 Diabetes among Youths, 2002–2012. Elizabeth J. Mayer-Davis, Ph.D., Jean M. Lawrence, Sc.D., M.P.H., M.S.S.A., Dana Dabelea, M.D., Ph.D., Jasmin Divers, Ph.D., Scott

Isom, M.S., Lawrence Dolan, M.D, Giuseppina Imperatore, M.D., Ph.D., Barbara Linder, M.D., Ph.D., Santica Marcovina, Ph.D., Sc.D., David J. Pettitt, M.D., Catherine Pihoker, M.D., Sharon Saydah, Ph.D., M.H.S.,

and Lynne Wagenknecht, Dr.P.H. et al., for the SEARCH for Diabetes in Youth Study*. https://www.searchfordiabetes.org.



https://www.cdc.gov/obesity/childhood/deﬁning.html.



Maryland Department of Health, Youth Behavior Risk Survey, 2016. https://phpa.health.maryland.gov/ccdpc/Reports/Pages/yrbs.aspx



Id fn 46

Maryland Diabetes Action Plan 2020



Id fn 51



National Physical Activity Guidelines;

https://www.cdc.gov/physicalactivity/index.html



Maryland BRFSS 2011-2013.

Prevalence of Weight Classes Among

Children Participating in WIC in Maryland

(by Jurisdiction, July-December 2018; 40,935 Total Children)

Table 7

County

Underweight

BMI < 5th

Percentile

Healthy WT BMI

between 5th to

< 84th percentile

Overweight BMI

between 85th to

< 94th percentile

Obese

BMI ≥ 95th

percentile

Maryland 3% 63% 16% 17%

Allegany 3% 67% 17% 13%

Anne Arundel 3% 65% 17% 14%

Baltimore City 3% 70% 15% 12%

Baltimore County 3% 62% 17% 18%

Calvert 4% 62% 15% 20%

Caroline 3% 68% 15% 14%

Carroll 3% 58% 18% 21%

Cecil 1% 69% 15% 16%

Charles 5% 63% 18% 15%

Dorchester 3% 60% 18% 19%

Frederick 3% 62% 17% 18%

Garrett 5% 68% 15% 12%

Greater Baden 5% 62% 14% 18%

Harford 4% 69% 14% 13%

Howard 3% 64% 15% 17%

Johns Hopkins 3% 65% 14% 17%

Kent 4% 66% 16% 14%

Montgomery 2% 59% 18% 21%

Prince George's 4% 62% 15% 18%

Queen Anne's 1% 64% 13% 22%

Somerset 7% 63% 13% 17%

St. Mary's 3% 67% 17% 13%

Talbot 1% 66% 15% 18%

Washington 4% 62% 18% 16%

Wicomico 4% 64% 15% 17%

Worcester 2% 67% 14% 17%

Diabetes and Physical Activity

Sedentary Lifestyle

The Physical Activity Guidelines for Americans

encourages adults to move more and sit less.

Adults should get at least 150 minutes of

physical activity each week and children should

be active for at least 60 minutes a day (preschool

children should be moving throughout the day).

A sedentary lifestyle puts individuals at increased

risk for developing a variety of chronic health

conditions, including type 2 diabetes. Research

shows that an active lifestyle reduces the risk of

chronic health conditions like diabetes. The adult

prevalence of diagnosed diabetes is higher in

those who do not meet weekly physical activity

guidelines compared to those who do meet those

guidelines (Figure 14).

Crude Adult Prevalence of Diagnosed

Diabetes by Physical Activity Status and Race,

Maryland 2011-13 (BRFSS)

Figure 14

Met Not Met

20%

15%

10%

% with diagnosed diabetes

11.2%

6.8%

15.2%

11.7%

NH Black

NH White

recommended weekly physical activity

Maryland Diabetes Action Plan 2020

The pattern of lower diabetes prevalence

in persons getting more physical activity is

seen for both Non-Hispanic Whites and

Non-Hispanic Blacks.

With physical activity being a determinant

of diabetes risk, the distribution of physical

activity participation across the State is

important to program planning. In Maryland,

adults without diabetes were more likely

to participate in at least 150 minutes of

moderate physical activity each week

(51.9 percent) versus those with diabetes

(44.2 percent). Meeting the physical activity

recommendation is more common for

Non-Hispanic Whites and Blacks compared

with Hispanics.

The jurisdiction-speciﬁc

prevalence of meeting the 150 minute per

week physical activity recommendation is

mapped in Figure 15 below.



Maryland BRFSS 2017.

Garrett

Allegany

Washington

Frederick

Carroll

Montgomery

Prince

Georges

Charles

St. Mary’s

Calvert

Anne

Arundel

Harford

Cecil

Kent

Queen

Anne’s

Caroline

Talbot

Dorchester

Wicomico

Worchester

Somerset

Baltimore

County

Howard

Balt.

City

Age-adjusted Prevalence of 150 Minutes per Week of Physical Activity

(Maryland BRFSS 2017)

Figure 15

Maryland Diabetes Action Plan 2020

≤ 41.5%

≤ 46.8%

≤ 50.5%

≤ 53.5%

≤ 57.9%

Legend



https://www.cdc.gov/tobacco/campaign/tips/diseases/diabetes.html



https://www.cdc.gov/diabetes/library/features/smoking-and-diabetes.html



Maryland BRFSS, 2015-2017.



Maryland BRFSS, 2015-2017.



Maryland Quitline, FY2019, communicated October 9, 2019.

Smokers have a 30 percent to 40 percent

higher risk of developing diabetes compared

to non-smokers.

Studies have shown that

smoking can increase blood sugar levels and

decrease the body’s ability to use insulin.

People with diabetes who smoke need larger

doses of insulin to control their blood sugar

than those who do not smoke. Smoking

can increase the risk of certain diabetes

complications,

particularly the large blood

vessel effects related to atherosclerosis

(cholesterol deposits). These complications

are heart disease, heart attacks, stroke,

peripheral vascular disease, and amputations.

In Maryland, the adult prevalence of diagnosed

diabetes is higher in current and former

smokers than it is in non-smokers (Figure 17):

about 8.8 percent of non-smokers have

diagnosed diabetes, compared to 11.0 percent

and 10.3 percent of former and current

smokers, respectively.

Because smoking is a synergistic cause with

diabetes for large blood vessel complications

(heart attacks, strokes, leg artery blockage and

amputations), smoking is an important risk

factor to target among persons with diabetes.

In 2017, 17.9 percent of Maryland adults with

diabetes were current smokers, compared to

the 13.9 percent proportion of current smokers

among adults without diabetes (Figure 18).

The Maryland Department of Health manages

the MD Quitline, a free service for Maryland

residents 13 years and older to help quit

tobacco use. The MD Quitline tracks

information about smokers with diabetes.

In ﬁscal year 2019, approximately, 1,500 of

Quitline participants reported being told

by a provider they have prediabetes, 160

participants reported type 1 diabetes and

1,000 participants reported type 2 diabetes.

In ﬁscal year 2019, the Quitline was used by

a total of 8,155 phone participants and 1,340

web participants.

Diabetes and Tobacco

Figure 16

Age-adjusted Adult Prevalence of

Diagnosed Diabetes by Smoking Status,

Maryland 2015-17 (BRFSS)

12%

10%

Never

Smoker

Former

Smoker

Current

Smoker

All

8.77%

11.00%

10.27%

9.67%

Figure 17

Age-adjusted Adult Prevalence of Current Smoking,

by Diabetes Status, Maryland 2017 (BRFSS)

30%

25%

20%

15%

10%

Doctor Diagnosed Diabetes (excl. women told only during pregnancy)

Doctor Diagnosed Diabetes No Diabetes

Percentage who are current smokers

Maryland Diabetes Action Plan 2020

17.9%

13.9%



“The Economic Burden of Elevated Blood Glucose Levels in 2012,” Diabetes Care, December 2014, vol. 37.



Centers for Disease Control and Prevention. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department

of Health and Human Services, Centers for Disease Control and Prevention, 2011.



American Dental Association, https://www.mouthhealthy.org/en/az-topics/d/diabetes



National Institute of Diabetes and Digestive and Kidney Diseases, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems



Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012; 55(1):21–31. doi:10.1007/s00125-011-2342-y.

Diabetes and Oral Health

Diabetes impacts almost every part of the

body and can result in many complications,

including the increased likelihood of oral

health complications. The American Dental

Association has identiﬁed periodontal disease

as the most common dental disease affecting

those living with diabetes, affecting nearly 22

percent of those diagnosed. This is especially

true with increasing age. Poor blood sugar

control increases the risk for gum problems.

People with diabetes are twice as likely to

develop periodontitis and periodontitis can

also elevate blood sugar levels.

Periodontal disease is more common in people

with diabetes, so people with diabetes need

to be especially diligent about getting regular

dental examinations.

According to the CDC,

diabetes can increase the risk of periodontitis

for the following groups:

• Among young adults, those with diabetes

have about twice the risk of developing

periodontitis as those without diabetes.

• Adults ages 45 or older with poorly

controlled diabetes (A1C >9 percent)

are 2.9 times more likely to have severe

periodontitis than those without diabetes.

• People who smoke and have persistently

elevated glucose levels have a 4.6 times

greater risk for developing periodontitis.

Elevated glucose levels in the mouth can also

cause pain, infection and associated problems

in the mouth, potentially affecting the teeth,

gums, jaw, and tissues such as the tongue, the

roof and bottom of the mouth, and the inside

of the cheeks. When diabetes is not controlled,

high glucose levels in saliva help harmful

bacteria grow. These bacteria combine with

food to form plaque. Plaque can cause a variety

of oral diseases ranging from gum disease

and bad breath to bone loss, and tooth decay

or cavities. Gum disease can be more severe

and take longer to heal if you have diabetes.

In-turn, having gum disease can make your

glucose hard to control.

Research continues

to show that bi-directional relationship

between periodontal disease and diabetes.

People with diabetes have a higher prevalence

of periodontal disease and those with

untreated periodontal disease have challenges

with glycemic control.

Maryland Diabetes Action Plan 2020



Maryland BRFSS, 2015-2017.



Maryland BRFSS, 2015-2017.

The prevalence of diabetes is strongly

determined by income. As seen in Figure 18

and Figure 19, prevalence of diagnosed

diabetes is higher for adults with income

below $15,000 compared to adults with

income at or above $75,000.

This gradient of higher diabetes prevalence

at lower levels of income is seen in all three

weight classiﬁcations (healthy weight,

overweight and obese). In addition, Figure

18 shows that for every level of income,

diabetes prevalence is higher for the obese

weight group. Income and weight status are

independentdeterminants (causes)

of diabetes.

This gradient of higher diabetes

prevalence at lower levels of income is also

seen in both Non-Hispanic Blacks and

Non-Hispanic Whites. In addition, Figure

19 shows that for every level of income,

Non-Hispanic Black diabetes prevalence is

higher than Non-Hispanic White diabetes

prevalence. This means that income does

not fully explain the disparity in diabetes

prevalence between Non-Hispanic Blacks

and Non-Hispanic Whites.

Diabetes and Income

Figure 18

Age-adjusted Prevalence of Doctor Diagnosed Diabetes,

By Income and BMI Status (Maryland BRFFS 2015-2017)

Figure 19

Age-adjusted Adult Prevalence of Doctor Diagnosed

Diabetes, by Income and Race, Maryland 2015-17 (BRFSS)

Maryland Diabetes Action Plan 2020

25%

20%

15%

10%

< 15K

15K to

<25K

25K to

<50K

50K to

<75K

>=75K

23.4%

20.4%

15.7%

14.6%

14.2%

9.5%

11.6%

8.4%

8.8%

6.5%

8.1%

8.2%

7.0%

2.9%

4.2%

Healthy

Over Weight

Obese

20%

15%

10%

< 15K

15K to

<25K

25K to

<50K

50K to

<75K

>=75K

14.9%

16.1%

14.2%

12.6%

10.8%

12.4%

12.8%

10.1%

8.1%

6.4%

NH WhiteNH Black



Maryland BRFSS, 2015-2017.



Maryland BRFSS, 2015-2017.

Figure 20

Distribution of Household Income by

Black or White Race, Maryland 2011-13 (BRFSS)

The prevalence of diabetes is strongly

determined by level of education. As seen

in Figure 21, adult prevalence of diagnosed

diabetes is more than twice as high for

persons with less than high school education

compared to persons with a college degree

or more education.

This gradient of higher diabetes prevalence

at lower levels of education is seen in both

Non-Hispanic Blacks and Non-Hispanic Whites.

In addition, Figure 21 shows for every level of

education, Non-Hispanic Black diabetes

prevalence is higher than Non-Hispanic

White diabetes prevalence. This means that

education does not fully explain the disparity

in diabetes prevalence between Non-Hispanic

Blacks and Non-Hispanic Whites.

Diabetes and Level of Education

While income does not fully explain the

disparity between Non-Hispanic Blacks and

Non-Hispanic Whites, it does contribute to the

disparity. Figure 20 shows that Non-Hispanic

Blacks are about half as likely (28 percent) to

have a household income at or above $75,000

compared to Non-Hispanic Whites (47

percent). Non-Hispanic Blacks have more

diabetes at every income level and are more

likely to be in the lower income categories

that have higher risk.

Figure 21

Age-adjusted Adult Prevalence of Diagnosed Diabetes, by

Education and Black or White Race, Maryland 2015-17 (BRFSS)

Maryland Diabetes Action Plan 2020

50%

30%

20%

10%

40%

< 15K

15K to

<25K

25K to

<50K

50K to

<75K

>=75K

12.8%

17.0%

25.6%

16.3%

28.2%

47.0%

15.9%

20.0%

12.3%

4.8%

25%

15%

10%

20%

< HS or

GED

HS or

GED

Tech, or

< 4Yr College

4+ Years

College

22.0%

14.8%

13.3%

10.2%

12.1%

9.3% 9.3%

5.2%

NH WhiteNH Black



Maryland BRFSS, 2011-2013.



U.S. Department of Health and Human Services, Ofﬁce of Disease Prevention and Health Promotion. (2010). National Action Plan to Improve Health Literacy. Washington, DC.

Level of education does contribute to the

Black vs. White disparity in diabetes prevalence

since Non-Hispanic Whites are more likely than

Non-Hispanic Blacks to have four or more

years of college/graduate school education,

as shown in Figure 22. About 37 percent of

the Non-Hispanic White adult population

has a college degree, compared to only

about 25 percent of the Non-Hispanic

Black population.

In addition to Non-Hispanic Blacks having

higher diabetes prevalence at each level of

education, Non-Hispanic Blacks are more likely

to have the lower levels of education, which

have higher risk for diabetes.

Income and education are closely related to

each other, with higher educational attainment

being associated with higher income at the

population level.

Figure 22

Distribution of Education Level, for NH Black

and NH White Adults, Maryland 2011-13 (BRFSS)

The Ofﬁce of Disease Prevention and Health

Promotion (ODPHP) of the US DHHS deﬁnes

health literacy as follows in its 2010 National

Action Plan to Improve Health Literacy:

"Health literacy is the degree to which

individuals have the capacity to obtain, process,

and understand basic health information and

services needed to make appropriate health

decisions. Limited health literacy affects

people of all ages, races, incomes, and

education levels, but the impact of limited

health literacy disproportionately affects lower

socioeconomic and minority groups. It affects

people’s ability to search for and use health

information, adopt healthy behaviors, and

act on important public health alerts. Limited

health literacy is also associated with worse

health outcomes and higher costs."

Limited health literacy has a variety of negative

impacts on health. The ODPHP plan describes

how limited health literacy reduces the use of

preventive services (mammograms, ﬂu shots,

etc.), and impairs the management of chronic

conditions such as diabetes. Limited health

literacy is also associated with higher rates of

preventable hospital visits and admissions.

One example of a successful intervention to

address limited health literacy in diabetes

is the IDEALL (Improving Diabetes Efforts

Across Language and Literacy) Project at

San Francisco General Hospital. It found

that providing patients with weekly phone

calls via an automated telephone diabetes

management system is effective at addressing

the literacy and language needs of

high-risk diabetes patients and enhancing

self-management. Demonstrating

improvements in communication and

self-efﬁcacy at a modest cost, especially among

low-literate and LEP populations, IDEALL

has proved to be an innovative approach to

transforming the health care delivery system.

Diabetes and Health Literacy

Maryland Diabetes Action Plan 2020

50%

30%

20%

10%

40%

< HS or

GED

HS or

GED

Tech, or

< 4Yr College

4+ Years

College

13.2%

30.9%

30.8%

36.8%

8.6%

26.8%

27.9%

25.1%

NH WhiteNH Black

Diabetes and Disability



https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html



https://www.cdc.gov/vitalsigns/disabilities/index.html.



Health and Human Services Data Collection Standards for Disability Status: http://aspe.hhs.gov/datacncl/standards/ACA/4302



Id fn 71

A disability is any condition or impairment

of the body or mind that makes it more

difﬁcult for the person with the condition to

do certain activities and interact with the world

around them.

More than 21 million US adults

18–64 years of age have a disability. These

are adults with serious difﬁculty walking

or climbing stairs, hearing, seeing, or

concentrating, remembering, or making

decisions.

72,73

Disability and diabetes

are interrelated.

The adult prevalence of diagnosed diabetes

in Maryland is consistently about twice as

high among persons with mobility, cognitive,

hearing, vision, self-care, or independent living

disabilities compared to persons without those

disabilities (Figure 23). In some cases, disability

may cause the diabetes, as in the situations

where the disability limits physical activity and

thus increases the risk of overweight or obesity.

In other cases, the disability may be the result

of the diabetes, for example when diabetes

causes vision loss and produces vision

disability. It is also possible that in some cases,

a factor that causes both diabetes and a

disability will result in the two conditions

occurring together, even without a causal

relationship between the diabetes and the

disability in that case.

People with disability who have a diagnosis

of diabetes often have higher rates of

unemployment, absenteeism on the job,

and health care utilization, and lower income

levels and capabilities in personal care and

activities of daily living.

Maryland Diabetes Action Plan 2020

Figure 23

Age-adjusted Adult Prevalence of Doctor Diagnosed

Diabetes, By Presence or Absence of Selected Disabilities

(Maryland BRFSS 2015-2017)

25%

20%

15%

10%

21%

18%

19%

18%

22%

20%

9% 9%

Mobility

With Listed Disability

Without Listed Disability

Cognitive Hearing Vision Self-care Indep living

Diabetes and Mental Health

Research shows that people with diabetes

are at increased risk for diabetes distress,

which refers to the negative emotional and

psychosocial worries and burden individuals

with the diagnosis of diabetes experience.

Diabetes distress could manifest as depression,

anxiety disorders, eating disorders,

inappropriate stress responses, substance

use disorders, and alcohol abuse.

The relationship of a diagnosis of depression

with a diagnosis of diabetes among adults in

Maryland is shown in Figure 24: the percent

ever diagnosed with depression is about twice

as high for adults with a diagnosis of diabetes

(34 percent) as for adults without a diagnosis of

diabetes (17 percent).

People who have mental health conditions

are at an increased risk for developing

diabetes and untreated mental health

conditions can make the management of

diabetes more difﬁcult. People with untreated

mental health conditions often deal with issues

like poor self-care, improper nutrition, barriers

to accessing primary care and mental health

care, and lack of exercise. Mental illness

reduces the likelihood a person with

diabetes will be properly treated.

Figure 24

Age-Adjusted Percent of Adults Ever Diagnosed with

Depression, by Diagnosed Diabetes Status,

Maryland 2017 (BRFSS)



Frayne, S.M., Halaynch, J.H., Miller, D.R., Wang, F., Lin, H., Pogach, L., et al. (2005). Disparities in diabetes care: Impact on mental illness. Archives of Internal Medicine, 165, 2631-2638



Maryland BRFSS 2015-2017.



Disability in Diabetics, Thomas Songer, PHD, Chapter 12, 1996.

50%

40%

30%

20%

10%

Doctor Diagnosed Diabetes (excl. women told only during pregnancy)

Doctor Diagnosed Diabetes No Diabetes

Percentage ever diagnosed with depression

Maryland Diabetes Action Plan 2020

34%

17.1%

Gestational Diabetes



NIDDK, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-type-2-diabetes



ACOG Releases Planline on Gestational Diabetes, American Family Physician, 2014 Sept 15; 90(6): 416-417



Percentage of Women Delivering a Live Birth Who Developed Gestational Diabetes, Maryland Vital Statistics, 2013-2017.



https://www.cdc.gov/diabetes/basics/getting-tested.html



https://www.cdc.gov/diabetes/basics/prediabetes.html



Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.

Gestational diabetes is diabetes that starts

during pregnancy and occurs when a

pregnant woman is not able to make and

use all the insulin needed during pregnancy,

which results in high blood sugar. Pregnant

women with gestational diabetes tend to have

larger babies, and mothers have an increased

risk of high blood pressure and infections

during pregnancy. Women with a history of

gestational diabetes are at risk of developing

gestational diabetes for future pregnancies.

Although gestational diabetes usually resolves

after pregnancy, women who have gestational

diabetes in their pregnancies are at an

increased risk for developing type 2 diabetes

later in life.

Providers usually test for and identify

gestational diabetes between the 24th and

28th weeks of pregnancy.

In Maryland, the

rate of gestational diabetes increased from

5.4 percent in 2013 to 7.3 percent in 2017, and

has far-reaching consequences for the health

of women, as well as the health of their babies

by increased risk for diabetes.

Factors

such as multiple pregnancies and being

overweight or obese at the beginning of

the pregnancy greatly increase the risk of

gestational diabetes.

Prediabetes

Prediabetes is a condition where blood sugar

levels are higher than normal, but not high

enough to be considered diabetes. Prediabetes

is a precursor condition on the pathway from

normal glucose levels to type 2 diabetes; the

development of type 1 diabetes is usually so

rapid that there is no “prediabetes” state that

precedes type 1 diabetes. A fasting glucose

level of 100 to 125 mg/dL, a hemoglobin A1C

level of 5.7 percent to 6.4 percent, or a two-hour

glucose level in an oral glucose tolerance test

of 140 to 199 mg/dL deﬁnes prediabetes.

Prediabetes often goes unrecognized by both

individuals and their health care providers;

nine out of ten adults who have prediabetes do

not know they have it.

CDC estimates that

34 percent of U.S. adults have prediabetes.

Diabetes and prediabetes are serious

conditions that can lead to complications

including heart disease and stroke,

blindness, amputations, nerve damage,

and kidney disease.

Prediabetes and gestational diabetes indicate

higher risk for the development of diabetes, as

well as higher risk for some other bad health

outcomes. While prediabetes and gestational

diabetes do not cause diabetes per se, they

represent points in the chain of progression

to diabetes that are very near to crossing the

threshold to a diagnosis of diabetes. More

information on these interventions for these

conditions is found in Section III.

Maryland Diabetes Action Plan 2020



https://www.cdc.gov/socialdeterminants/index.htm



https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health



Id fn 85.

Social Determinants of

Health and Diabetes Risk

Social Determinants of Health (SDOH) are the

conditions in which people are born, grow, live,

work and age. SDOH have an impact on many

chronic diseases like diabetes.

The Maryland

data provided earlier show an increased

prevalence of diabetes among people with

lower levels of income and education, and

among racial and ethnic minorities. People

in these categories often may not have the

ﬁnancial means to pay for healthier foods,

may struggle with food security, and may not

have safe areas for physical activity. The stress

related to poverty and racism has physiologic

effects that can promote the progression to

diabetes as well as impacting diet and

physical activity behaviors. All these societal

issues affect a person’s health.

Figure 25

depicts the ﬁve main categories of social

determinants of health which is the framework

used by Healthy People 2020.

Figure 25

Social Determinants of Health

Source: Healthy People 2020,

Ofﬁce of Disease Prevention

and Health Promotion

Neighborhood

and Built

Environment

Economic

Stability

Education

Health and

Health Care

Social and

Community

Context

SDOH

Maryland Diabetes Action Plan 2020

Diabetes and Health Equity



https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities



Id fn 88



Kolb H. and Martin S. Environmental/lifestyle factors in the pathogenesisand prevention of type 2 diabetes. BMC Medicine. July 2017; volume 15,131; doi:10.1186/s12916-017-0901-x.



Walker RJ, Strom Williams J, Egede LE. Inﬂuence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci. 2016;351: 366-373.

Healthy People 2020 deﬁnes health equity as

the “attainment of the highest level of health

for all people. Achieving health equity requires

valuing everyone equally with focused and

ongoing societal efforts to address avoidable

inequalities, historical and contemporary

injustices, and the elimination of health and

health care disparities.”

Healthy People 2020 deﬁnes a health disparity

as “a particular type of health difference that

is closely linked with social, economic, and/or

environmental disadvantage. Health disparities

adversely affect groups of people who have

systematically experienced greater obstacles

to health based on their racial or ethnic group;

religion; socioeconomic status; gender; age;

mental health; cognitive, sensory, or physical

disability; sexual orientation or gender

identity; geographic location; or other

characteristics historically linked to

discrimination or exclusion.”

The Maryland data presented above have

shown differences in diabetes prevalence in

high burden populations, such as by age, by

race/ethnicity, by geography, by level of income

and by level of education. Differences by other

factors likely exist as well, which cannot be

documented in our current data systems.

Determinants such as poor diet, low physical

activity, overweight/obesity, and high chronic

stress drive physiologic changes that lead to

diabetes. Social determinants such as income,

education, housing, unsafe neighborhoods,

food insecurity, lack of transportation, and lack

of health care access drive differences in diet,

activity, stress and preventive care regardless

of race. Finally, racial injustice has produced

persistent disadvantage in social determinants

of health for racial and ethnic minority

populations, creating racial/ethnic disparities

in diabetes outcomes.

The data presented above suggest the

following multiple opportunities to intervene

to move toward health equity with respect to

diabetes incidence, morbidity and mortality.

Factors on which to intervene include:

The physiologic determinants of diabetes:

• Unhealthy diet

• Low physical activity

• Stress

The social determinants of diabetes:

• Income

• Education

• Housing

• Unsafe neighborhoods

• Food insecurity

• Lack of transportation

• Lack of health care access

Populations to target with interventions

on the factors listed above:

• Certain racial/ethnic minority populations

• Certain urban populations

• Certain rural populations

• Low income population

• Low educational attainment population

• The population with mental

health conditions

• The population with disabilities

Maryland Diabetes Action Plan 2020

Action Plan

Diabetes

Section III:

Intervention Strategies and Actions Steps for Diabetes Prevention and Control



Meigs, JB, Muller, DC, Nathan, DM, Blake, DR, Andres, R. The Natural History of Progression From Normal Glucose Tolerance to Type 2 Diabetes in the Baltimore Longitudinal Study of Aging.

Diabetes 2003 Jun; 52(6): 1475-1484. https://doi.org/10.2337/diabetes.52.6.1475.



Kim, D.,

https://thesystemsthinker.com/introduction-to-systems-thinking

Rationale Behind Four Risk Populations for Diabetes

The natural progression of type 2 diabetes

is a risk continuum from healthy weight,

overweight and other risk factors, normal

glucose, impaired glucose, and glucose

intolerance to diabetes.

The Maryland

Diabetes Action Plan uses a systems-

thinking model approach to frame the

actions and strategies needed to address all

components and populations along the

continuum (Healthy; Overweight/Obese;

Prediabetes/Gestational Diabetes; and

Diabetes and Diabetes Complications). This

approach recognizes upstream factors which

affect the full population (those factors that

can beneﬁt all risk level components) to those

at highest risk downstream (Diabetes and

Diabetes Complications) (Figure 26).

Using

this approach can also address high burden

populations (as discussed in Section II). In the

systems-thinking model (Figure 1), the actions

take place between the risk factors.

Action Plan Framework

Maryland Diabetes Action Plan 2020



Auerbach J. The 3 Buckets of Prevention. J Public Health Manag Pract. 2016;22(3):215–218. doi:10.1097/PHH.0000000000000381.

Using additional public health frameworks,

such as the Three Buckets of Prevention,

categorizes actions to be taken in healthcare,

at the intersection of the community and

healthcare, and at the community-wide level

(Figure 27).

The “buckets” show sectors for

action, between the health care system, the

community and public health.

A brief description of evidence which informs

the development of action steps in the four

components in Section III is listed below. The

vision is for all Maryland partners, across

multiple sectors, to identify areas where they

currently work or have the capability of

working, to align their efforts to make strides

in reducing the diabetes burden in the state.

Figure 26

Diabetes Systems Thinking Model

Figure 27 Three Buckets of Prevention

Keeping a

healthy

population

Reducing

overweight and

obesity

Managing diabetes

and diabetes

complications

Reducing risk

with prediabetes and

gestational diabetes

Bucket 3:

Community-wide

interventions

(ex: policies to increase

access to healthy

nutrition and

physical activity)

Bucket 2:

Community-

health care

Interventions

(ex: national diabetes

prevention program)

Bucket 1:

Health systems

(ex: care management

and diabetes self

management education)

Health Care Public Health

Traditional Clinical

Prevention

Innovative Clinical

Prevention

Total Population or

Community-Wide

Prevention

Increase

the use of

evidence-based

services

Provide

services

outside the

clinical setting

Implement

interventions

that reach whole

populations

Maryland Diabetes Action Plan 2020



Id fn 71



Maryland BRFSS, 2017.



https://www.cdc.gov/obesity/index.html



tfah.org/stateofobesity2018

. Accessed August 18, 2019.



https://www.cdc.gov/policy/hiap/index.html. Accessed August 18, 2019.



http://www.mdot.maryland.gov/newMDOT/Planning/Bike_Walk/Bike_Ped_Plan_Update.html. Accessed August 18, 2019.



W.H. Dietz; Obesity and Excessive Weight Gain in Young Adults, New Targets for Prevention; JAMA; July 18, 2017;



https://www.cdc.gov/breastfeeding/about-breastfeeding/index.html, accessed August 29, 2019.



https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives, accessed August 29, 2019.



Maryland PRAMS Report, 2017 Births.

Interventions for the Healthy Weight Population

In Maryland, over 32.7 percent of the adult

population is of a healthy weight.

The

Keeping a Healthy Weight population actions

focus on community-wide approaches, which

will also impact the health of the other three

population components downstream by

implementing multi-faceted, multi-sector

collaborations to make healthy eating

and active living accessible, affordable,

and convenient.

What is a Healthy Weight:

Healthy weight is a weight at which an

individual is considered at a low or reduced risk

for adverse health conditions. Body Mass Index

(BMI) is used as a screening tool to determine if

an individual is overweight or obese based on

their height and weight. For adults it is a BMI

of 18-24. A child whose BMI is between the 5th

percentile to 84th percentile is in the healthy

weight range.

Trust for America’s Health and the Robert

Wood Johnson Foundation recommend three

guiding principles to address healthy weight

(reducing obesity): 1) Promote polices and scale

programs that take a multi-sector approach;

2) Adopt and implement policies that help

make healthy choices easy; and 3) Invest in

programs that level the playing ﬁeld for all

individuals and families.

Additionally, the

movement around Health in All Policies

(HiAP) recognizes that health is created by a

multitude of factors beyond healthcare and,

in many cases, beyond the scope of traditional

public health activities.

Interventions targeted at keeping all people

at a healthy weight speciﬁcally creates access

to healthy nutrition and physical activity,

using broad and large-scale actions which

include environmental change and policies

to reach all citizens. For example, the 2040

Maryland Bicycle and Pedestrian Master Plan

addresses actions to increase use of and access

to bike and pedestrian usage in the state.

Other system level change actions in this

component can also include improving

access and polices within institutions, such

as worksites and schools. Worksites can

implement breastfeeding policies which

include dedicated space and time for

employees to breastfeed, as well as policies

to increasing available healthy food options

in cafeterias and working with food service

vendors to supply low fat/low sodium

products. Increasing farm production

statewide and access to farmers markets with

Electronic Beneﬁts Transfer (EBT) access for

healthy foods are actions also recommended

by Trust for America’s Health and the Robert

Wood Johnson Foundation.

Targeting healthy weight in speciﬁc

populations, such as women of childbearing

age, should be encouraged for preconception

healthy weight.

100

Increasing breastfeeding

initiation and duration have lasting beneﬁts for

infants, reducing the risk of obesity, and also

reducing the risk of diabetes and other chronic

diseases for mothers.

101

Healthy People 2020

targets are to increase the proportion of those

infants who were ever breastfed from 74

percent to 81.9 percent, in Maryland 89.4

percent of live births were ever breastfed

in 2017.

102,103

Maryland Diabetes Action Plan 2020



Maryland BRFSS 2017.



Endocr Pract. 2016;22:Supp3;1-205.



Id fn 105



https://www.montgomeryparks.org/about/parks/park-prescription/. Accessed August 18, 2019.



https://ihcw.aap.org/resources/Documents/algorithm_brightfutures_032819.pdf. Accessed August 27, 2019.

Interventions for the Overweight and Obese Populations

In Maryland, over 65.4 percent of the adult

population is overweight or obese, the leading

risk factor in diabetes.

104

As the model moves

downstream according to risk, all people in

this population will be impacted by the

broad actions in the Keeping a Healthy

Weight component.

What is Overweight or Obesity:

In children, overweight is deﬁned as a BMI

measurement greater than the 85th percentile

for age and sex of the child. Obese is deﬁned

as a BMI measurement greater than the 95th

percentile for age and sex. Adult overweight is

deﬁned as a BMI equal to or greater than 25,

while obesity is a BMI equal to or greater than

30. In adolescents, a BMI >25/30 or above 85/95

percentile, whichever is lower. There are three

classes of obesity, ranging from BMI 30-34 for

Class 1, BMI 35-39 for Class 2, and BMI greater

than 40 for Class 3.

In the Overweight/Obese component, the

focus is to reduce the risk of diabetes by

moving the population back to a healthy

weight through behavior change and health

system intervention for weight loss in adults

and to slow weight gain in children. Action

steps addressed in this component focus

on speciﬁc actions which target those

Marylanders who are overweight and obese,

while acknowledging the action steps in the

earlier Keeping a Healthy Weight component

will be available to support Marylanders in the

actions in this component.

Obesity is a complex, adiposity-based

chronic disease, where management targets

both weight-related complications and

adiposity to improve overall health and quality

of life. Recommendations allow for clinical

decision-making for patients with obesity,

which include screening, diagnosis, and

evaluation, selection of therapy, treatment

goals, and individualization of care with the

goal of facilitating high-quality care of

patients with obesity and provide a rational,

scientiﬁc approach to management that

optimizes health outcomes and safety.

105

Strategies for treating overweight include

preventing progressive weight gain and

lifestyle change; obesity treatment weight

loss, lifestyle change, considering/adding

pharmacotherapy and considering

bariatric surgery.

106

Providers need resources and tools to address

the complicated needs of patients who are

overweight or obese. Increasing use of

provider billing for weight management is

one strategy to help providers afford the

additional time needed to counsel and refer

patients. Some prescription programs which

link patients to healthy lifestyles have proved

successful; one example is the Montgomery

County Parks program which implements a

park prescription program, linking health

care providers and patients to parks for

physical activity.

107

Recommendations for assessing and

managing childhood obesity center on

prevention, structured weight management,

a comprehensive multi-disciplinary approach,

and if needed, tertiary care interventions.

Supporting lifestyle change with the patient

and the family using supports, such as a

diverse team trained in motivational

interviewing, is appropriate and helpful.

108

Maryland Diabetes Action Plan 2020



Prediabetes in Maryland—Maryland BRFSS Surveillance Brief. Vol. 1, No. 1. Baltimore, MD: Maryland Department of Health and Mental Hygiene, Center for Chronic Disease Prevention and Control,

October 2016



Maryland BRFSS 2018.



Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017.



CDC 2017 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed August 18, 2019.



Maryland BRFSS, 2018.



https://www.diabetes.org/risk-test;



https://www.cdc.gov/prediabetes/takethetest



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.



https://amapreventdiabetes.org/tools-resources



CDC 2017 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed August 18, 2019



US Census 2016.



Maryland BRFSS 2017.

Interventions for the Gestational Diabetes and Prediabetes Populations

Among Maryland adults who have never

received a diagnosis of diabetes, 58.9 percent

report having a blood sugar test in the previous

three years. In Maryland residents age 45 and

older, for whom risk of prediabetes is increased,

69.5 percent report having been tested in the

previous three years.

109

Screening and testing

rates need to be improved so providers will be

able to refer at-risk people to resources to

prevent progression to type 2 diabetes. Based

on 2018 Maryland BRFSS data, 13 percent of

Maryland adults ages 18 and older had been

told they have prediabetes.

110

This number is far

below the CDC estimate of 34 percent of adults

ages 18 and older with prediabetes, which

suggests there are many Maryland adults

who have prediabetes who do not know

their status.

111

What is Prediabetes and

Gestational Diabetes:

Prediabetes occurs when people have elevated

blood glucose (sugar) levels, which places

them at higher risk for developing type 2

diabetes. This group includes people with A1C

of 5.7-6.4 percent, or fasting plasma glucose

between 100 and 125 mg/dL, regardless of BMI.

Gestational Diabetes occurs in pregnant

women who have high blood glucose levels

during pregnancy with no history of diabetes

mellitus prior to pregnancy. Gestational

diabetes is typically tested between 24-28

weeks with Oral Glucose Tolerance Test (OGTT)

levels exceeding normal range fasting, 1 hour,

and 2 hours. Even if the blood glucose

reduces back to normal levels after delivery,

the woman has an increased risk for type 2

diabetes mellitus later in life as does the child.

It is estimated that approximately 1 in 4

people with diabetes do not know they have

it.

112

In Maryland, only 13 percent of the adult

population has been told they have

prediabetes, however, CDC estimates that

34 percent of adults has prediabetes.

113

Screening and testing asymptomatic people

for prediabetes and diabetes can be done

by informally evaluating risk factors with

simple prediabetes risk tests, as those available

from the ADA and CDC.

114,115

Screening tools

are recommended at age 45 for people with no

symptoms and for people who are overweight

and obese. The screening results can help

determine whether blood tests are needed to

further evaluate for abnormal blood sugars.

Screening and testing with blood tests should

be considered at any age for people who are

overweight or have obesity (BMI ≥25 kg/m

≥23 kg/m

in Asian Americans) and who also

have one or more of the following risk factors:

• First-degree relative with diabetes;

• High-risk race/ethnicity (e.g., African

American, Latino, Native American, Asian

American, Paciﬁc Islander);

• History of cardiovascular disease;

• Hypertension (≥140/90 mmHg or on therapy

for hypertension);

• HDL cholesterol level <35 mg/dL and/or a

triglyceride level >250 mg/dL;

• Women with polycystic ovary syndrome;

• Physical inactivity; and

• Other clinical conditions associated with

insulin resistance (e.g., severe obesity,

acanthosis nigricans).

116

Four blood tests are used to diagnose diabetes.

The most common are the fasting blood

glucose and the hemoglobin A1C, but an oral

glucose tolerance test (OGTT) may also be

used. The fourth diagnostic test is non-fasting

blood sugar, which if over 200 mg/dL in the

presence of typical signs and symptoms of

diabetes, indicates diabetes. Two positive tests

are required to conﬁrm a diagnosis of diabetes,

which can be two different tests on the same

blood sample (such as fasting glucose and

A1C from the same blood draw). Intensive

adherence to authoritative clinical guidelines

and use of EHR tools should be encouraged

with providers and health systems.

117

CDC estimates over 34 percent of the adult

population has prediabetes, which translates

to approximately 1.6 million adults in Maryland.

In 2017, 1.7 percent of Maryland adult women

reported a history of gestational diabetes.

120

118,119

Maryland Diabetes Action Plan 2020



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.



Diabetes Prevention Program Research Group, Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin; N Engl J Med 2002; 346:393-403.



Id fn 122



Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study. Am J Prev Med. 2008;35(4):357–363.

doi:10.1016/j.amepre.2008.06.035.



DPRP State-Level Evaluation Report, CDC, July 2019.



Maryland BRFSS 2018.

Both prediabetes and gestational diabetes

signiﬁcantly increase the risk of

progression to diabetes.

121

Prediabetes and Diabetes

Screening in Adults

Testing to detect prediabetes and diabetes is

recommended for adults of any age who are

overweight or obese and who have one or

more additional risk factors for diabetes. For all

others, especially those who are overweight,

testing should begin at age 45. People with

prediabetes who are at risk for type 2 diabetes

can prevent or delay the disease by making

modest lifestyle changes to lose ﬁve to seven

percent of body weight and increasing

physical activity to at least 150 minutes per

week.

122

In Maryland, people with prediabetes

can participate in a National Diabetes

Prevention Program (National DPP). The

National DPP is an evidence-based lifestyle

change program designed to help participants

make these lifestyle changes to avoid

developing type 2 diabetes.

As the model continues to move downstream,

people with prediabetes and a history of

gestational diabetes will be impacted by the

broad actions in the Keeping a Healthy Weight

component, as well as the targeted weight

control/reduction actions in the Reducing

Overweight and Obesity component. In the

Prediabetes/Gestational Diabetes component,

the focus is to test those at risk and refer to

aggressive risk reduction resources, such as

the National DPP.

The original DPP study was shown to reduce

the risk by 58 percent in the group who made

behavior change that resulted in a 7 percent

weight loss and at least 150 minutes a week

of moderate physical activity. The metformin

(low cost drug to lower blood glucose) group

showed a 34 percent decrease.

123

The research

into practice for this program demonstrated

similar outcomes from small group sessions

led by lay health coaches.

124

The CDC launched

the National DPP in 2012 to set standards and

assure ﬁdelity and create a recognition registry

of programs throughout the country.

Maryland currently has 53 National DPP

lifestyle programs (12 fully recognized);

since 2012, 5,296 citizens participated in

the program.

125

Public payer reimbursement for the National

DPP is a step toward sustainability. In April

2018, Medicare DPP services became available

to eligible beneﬁciaries nationwide,

creating a billing framework based on

outcomes of participants. In 2016, Maryland

Medicaid implemented a CDC-funded

demonstration to implement a delivery model

for the National DPP in Medicaid managed

care organizations (MCOs). Four of Maryland’s

nine HealthChoice MCOs participated,

successfully enrolling 637 enrollees into a

participating CDC-recognized lifestyle change

program. Key outcomes of the demonstration,

which concluded in January 2019, included

the creation of an eligibility algorithm, and

a sustainability plan culminating in

Medicaid applying to CMS for a Section 1115

demonstration waiver amendment that would

authorize continued provision of the National

DPP lifestyle change program in HealthChoice.

CMS approved the waiver request in April 2019,

and HealthChoice DPP has been implemented

statewide effective September 1, 2019.

As the prevalence for Maryland adults who

are told their prediabetes status by providers

is dramatically lower (13 percent) than those

estimated through national clinical studies,

implementing mechanisms or tools within

provider practice systems to increase testing

for those at risk of diabetes is the ﬁrst step for

provider practices.

126

The Maryland Primary Care Program (MDPCP)

is driving the adoption of advanced primary

care in Maryland practices including

management and prevention of chronic

disease. Currently, practice performance

is measured on critical chronic disease areas

including diabetes and hypertension

management. A focus of the program is

aligning with the State's population health

goals which includes reducing the incidence

of diabetes. MDPCP is working on adding a

performance measure for 2020 to drive

diabetes prevention efforts that would

emphasize BMI and blood glucose

assessment and making subsequent

referrals to evidence-based programs such

as the National DPP. The MDPCP anticipates

regular training for its practice coaches

and the participating practices and Care

Transformation Organizations, entities that

Maryland Diabetes Action Plan 2020



Auerbach J. The 3 Buckets of Prevention. J Public Health Manag Pract. 2016;22(3):215–218. doi:10.1097/PHH.0000000000000381.



Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes; a systematic review. Diabetes Care 2002;25:1862-1868.



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.



http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 Accessed July 18, 2019.



Centers for Disease Control and Prevention. Put the brakes on diabetes complications. Accessed November 13, 2019 at

https://www.cdc.gov/diabetes/library/features/prevent-complications.html



Diabetes Care. January 01 2019; volume 42 issue Supplement 1.

provide stafﬁng and technical assistance to

practices as well as provider referral

mechanisms to increase referrals.

The National Nurse Study showed an increased

risk of the conversion to diabetes in those with

a history of gestational diabetes.

127

Priority

actions for women with gestational

diabetes focus on postpartum testing to

rule out undiagnosed prediabetes, or type 1

or type 2 diabetes. Postpartum continued

follow-up for women with a history of

gestational diabetes should include regular

testing, healthy lifestyle support and potentially

use of metformin.

128

Working with the healthcare team to ensure

postpartum testing of women with gestational

diabetes is a standard of care practice that is

underutilized. In 2016, Maryland Medicaid and

Maryland Public Health engaged two MCOs to

develop and implement system level tools and/

or policies to ensure testing for women with a

history of gestational diabetes.

Interventions for Managing Diabetes and Diabetes Complications

The American Diabetes Association (ADA)

recommends population health approaches for

managing diabetes be timely, evidence-based,

and in collaboration with each patient.

Health care systems should consider using

frameworks such as the Chronic Care Model

(CCM) for achieving high quality care of

people with diabetes which encourages six

essential elements to move health systems

toward having a prepared, proactive team

and an informed, activated patient. These

core elements are: community resource

mobilization; health system that operates

with safe, high quality care as part of its

culture; self-management support to

strengthen decision-making and agency;

delivery system design to assess what care

is needed and deliver it to keep patients as

healthy as possible; evidence-based

decision-making and patient-centered

care; and clinical information systems that

are comprehensive and facilitate effective

and efﬁcient care.

129

What is Diabetes and its Complications:

This group includes people with a diagnosis

that is conﬁrmed by two tests; fasting plasma

glucose over 126 mg/dL or A1C of 6.5 percent or

higher, regardless of BMI. Diabetes is also

diagnosed with an oral glucose tolerance

test result greater than 200mg/dL or random

plasma glucose greater than 200mg/dL with

typical symptoms of diabetes (blurred vision,

excess thirst, excess hunger, frequent

urination). When not well managed or

when it has been present for many years,

diabetes slowly damages the blood vessels in

the body and results in problems of organs or

organ systems in the body, including the heart,

eyes, kidneys, skin, and nerves. The resulting

complications, like blindness, kidney failure,

nerve pain, and extremity amputations, can

be debilitating and signiﬁcantly impact quality

of life.

130

Actions for managing diabetes and controlling

complications are complex and rely on a

team-based approach, which includes

behavior change for self-care and a healthy

lifestyle. Diabetes self-care requires daily

decisions about food, physical activity, stress

management, and daily self-monitoring of

glucose levels. Self-management education

facilitates the knowledge, skill, and conﬁdence

for individuals with diabetes to manage their

own health, a concept known as patient

activation. Self-management education is

designed to help individuals adopt and sustain

the necessary skills and behaviors to achieve

proper diabetes self-care on an ongoing basis,

and has been shown to positively affect

outcomes, and all people with diabetes should

participate in diabetes self-management

education and support programs.

131

Telemedicine is an opportunity to improve

patient access to primary care and to

Maryland Diabetes Action Plan 2020



Siminerio L, Rubbert K, Huber K, Toledo FGS. Telemedicine for Reach, Education, Access, and Treatment (TREAT): Linking Telemedicine with Diabetes Self-management Education to Improve Care in

Rural Communities, The Diabetes Educator.



Ciemins E, Coon P, Peck R, Halloway B and Min SJ. Using Telehealth to Provide Diabetes Care to Patients in Rural Montana: Findings from the Promoting Realistic Individual Self-Management Program.

Telemedicine Journal and e-Health. 2011 Oct; 17(8):596-602. Doi: 10.1089/tmj.211.0028.



DLee SWH, Chan CKY, Chua SS, Chairyakunapruk N. Comparative Effectiveness of Telemedicine Strategies on Type 2 Diabetes Management:A Systematic Review and Network Meta-analysis.

Scientiﬁc Reports. 2017 Oct4;7(1):12680.Doi: 10.1038/s41598-017-12987-z.



American Diabetes Association Clinical Planlines.



Maryland BRFSS, 2017.



Centers for Disease Control and Prevention.National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2017.Atlanta, GA: US Department of Health and Human

Services; 2017. Accessed 11/14/2019 athttps://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf



Matheus AS, Tannus LR, Cobas RA, Palma CC, Negrato CA, Gomes MB. Impact of diabetes on cardiovascular disease: an update.Int J Hypertens.2013;2013:653789.



National Institute of Diabetes and Digestive and Kidney Diseases,

https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems.



Centers for Disease Control and Prevention, https://www.cdc.gov/diabetes/managing/problems.html

community supports and services, and

telehealth strategies have been effective

for improving patient self-activation and

engagement, for increasing patient blood

glucose self-monitoring and dietary adherence,

and for decreasing A1C in many settings.

132,133,134

Managing and Controlling Diabetes

The American Medical Association and the

American Diabetes Association (ADA)

recommend individuals diagnosed with

diabetes should be aware of how to manage

their disease, and nearly all general

practitioners and their staff should be trained

on diabetes management. Once a person is

diagnosed with diabetes, they ideally should be

trained on how to monitor their blood glucose

levels, administer insulin injections if necessary,

take other diabetes medications, receive

annual eye and foot exams, and be vaccinated

for inﬂuenza, pneumonia and other

vaccinations based on clinical protocols.

Blood levels should be checked daily for

glucose levels. In addition, A1C testing should

be performed at least twice yearly in patients

who have achieved stable glycemic control.

For those patients who are not at goal or for

whom therapy recently changed, quarterly

A1C testing is recommended.

135

According to self-reported data from BRFSS,

in 2017, 10.2 percent of Maryland adults with

diagnosed diabetes did not visit their doctor

regularly, 4.0 percent did not have dilated eye

examinations, 5.2 percent did not receive

A1C testing, 21.1 percent did not have foot

examinations, 31.6 percent did not receive an

inﬂuenza or a pneumonia shot at any time,

and 47.5 percent never attended a diabetes

self-management course, which are offered

regularly at hospitals and doctors’ ofﬁces.

136

Because diabetes increases the risk of

cardiovascular disease two to four times

more than people who do not have diabetes,

cardiovascular disease is still the most

common cause of death for people with

diabetes.

137,138

Controlling blood pressure and

monitoring cardiovascular risk factors should

be part of diabetes care plans.

High blood sugar increases the level of sugar

in saliva. Sugar feeds the bacteria in the mouth,

and when bacteria are combined with food, it

creates optimum conditions for tooth decay to

occur. Additionally, people with diabetes are

more likely to have gum disease, which can

lead to tooth loss. Gum disease can also make

blood sugar levels rise and make diabetes

harder to manage. Treating gum disease

can lower blood sugar over time and reduce

the chance of other diabetes-related

complications, such as heart disease and

kidney failure.

139

For people with diabetes, optimum

management of mouth and diabetes health

should include:

• Keeping blood sugar as close to target levels

as possible.

• Brushing teeth at least twice a day and

ﬂossing once a day.

• If wearing dentures, removing and

cleaning them daily and informing the

dental provider of any denture-related

soreness in the mouth.

• Getting regular dental checkups and

informing the dental provider of the

diabetes diagnosis.

• Stopping smoking or not starting.

140

Many common signs of diabetes appear in

the mouth, such as red swollen, tender, or

bleeding gums. All signs of infection should be

reported to a dental provider immediately.

However, gum disease may not cause

immediate pain or visible signs, so regular

dental cleanings and exams every six months

are essential to prevent the development of

Maryland Diabetes Action Plan 2020



National Institute of Diabetes and Digestive and Kidney Diseases, https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems.



American Dental Association, https://www.mouthhealthy.org/en/az-topics/d/diabetes



Maryland BRFSS, 2016.



Healthy People 2020 - Oral Health Topic: OH Objective 14.3. https://www.healthypeople.gov/2020/topics-objectives/topic/oral-health/objectives

more extensive damage.

141

Research also

suggests that treating gum disease can help

improve blood sugar control in patients living

with diabetes, decreasing the progression of

disease.

142

In Maryland in 2016, approximately

68 percent of adults with diagnosed diabetes

reported having visited a dentist in the

past year.

143

The integration of dental and medical practice

can also play an important role in the

management of diabetes and oral disease.

The U.S. Department of Health and Human

Services’ Healthy People 2020 oral health

objectives include increasing the proportion of

adults who were tested or referred for glycemic

control from a dentist or dental hygienist in the

past year.

144

The promotion of medical-dental

integration to reach these goals can potentially

have a signiﬁcant impact on reducing the

prevalence of diabetes in Maryland.

Maryland Diabetes Action Plan 2020

Action Plan

Diabetes

Section IV:

Action Tables for Diabetes Prevention and Control

The interventions and action steps for the

Diabetes Action Plan are targeted to keep

people at a healthy weight, prevent overweight

and obesity, halt diabetes progression by

addressing prediabetes and gestational

diabetes, and improve care for people with

diabetes and better manage complications.

By addressing the diabetes risk continuum

with partners in all sectors across Maryland,

the burden of diabetes can be reduced

statewide. Because people with diabetes

have high risk for cardiovascular disease, the

number one cause of death in Marylanders,

addressing diabetes at the population level is

an important step in reducing the overall

number of deaths in our state.

The Diabetes Action Team developed actions in

each of the four components, and the next

section contains detailed action tables.

The actions are separated in two main

categories—Priority State Action Steps and

Suggested Action Steps for the State and its

Partners. The Priority action steps are those

MDH has prioritized and for which MDH will

assume responsibility. The “other” steps are

those where partners have inﬂuence to

impact change and assume a lead.

Additionally, data-related Action Steps are

included where there may be gaps in

important diabetes data and sources.

The goals and action steps included in the

plan are based on trend data, with reach

objectives for each population aimed at

reducing diabetes risk. For example, in the

Reducing Overweight and Obese Population,

the goals for the adults were identiﬁed based

on trend data that show a steady increase in

adult overweight and obesity; therefore the

goal is based on action steps that will halt

the increase in weight, and will keep the

overweight/obesity population from increasing.

Whereas, the high school youth overweight

and obese rates trend data have remained

relatively stable; therefore a goal to reduce

current overweight and obese by 10 percent in

4 years for the youth is needed to reduce the

risk of overweight and obesity in adulthood.

Maryland Diabetes Action Plan 2020

Healthy Weight Population

Deﬁnition

Healthy weight is a weight at which an individual is considered at a low or reduced

risk for adverse health conditions. Body Mass Index (BMI) is used as a screening tool

to determine if an individual is overweight or obese based on their height and weight.

For adults, it is a BMI of 18-25. A child whose BMI is between the 5th percentile to 85th

percentile is in the healthy weight range.

2019-2024 Goal

By 2024, 32 percent of Maryland adults will be of healthy weight.

Action Step Objectives

Increase access to healthy nutrition.

Achieve and maintain recommended physical activity levels for all Marylanders.

Reducing Overweight and Obese Populations

Deﬁnition

In children, overweight is deﬁned as a BMI measurement greater than or equal to the

85th percentile for age and sex of the child. Obese is deﬁned as a BMI measurement

greater than or equal to the 95th percentile for age and sex. Adult overweight is

deﬁned as a BMI equal to or greater than 25, while obesity is a BMI equal to or greater

than 30. In adolescents, the deﬁnitions are a BMI of 25 or 30 or above 85 and 95

percent respectively, whichever is lower. There are three classes of obesity, ranging

from BMI 30-34 for Class 1, BMI 35-39 for Class 2, and BMI greater than 40 for Class 3.

2019-2024 Goal

By 2024, maintain the percentage of adults with a BMI >25 at 66.5 percent;

and reduce by 10 percent the BMI >85th percentile in high school students.

Action Step Objectives

Improve clinical care services for overweight and obese children and adults.

Improve the availability of healthy lifestyle options for overweight and obese children

and adults.

Prediabetes and Gestational Diabetes Populations

Deﬁnition

Prediabetes occurs when people have elevated blood glucose (sugar) levels, which

places them at higher risk for developing type 2 diabetes. This group includes people

with A1C of 5.7-6.4 percent, or fasting plasma glucose between 100 and 125 mg/dL,

regardless of BMI. Gestational Diabetes occurs in pregnant women who have high

blood glucose levels during pregnancy with no history of diabetes mellitus prior to

pregnancy. Gestational diabetes is typically tested between 24-28 weeks with Oral

Glucose Tolerance Test (OGTT) levels exceeding normal range fasting, 1 hour, and

2 hours. Even if the blood glucose reduces back to normal levels after delivery, the

woman has an increased risk for type 2 diabetes mellitus later in life as does the child.

2019-2024 Goal

By 2024, increase the prevalence of Maryland adults who know their

prediabetes status by 30 percent.

Action Step Objectives

Improve prediabetes outcomes.

Reduce risk of diabetes in women with a history of gestational diabetes.

Maryland Diabetes Action Plan 2020

Managing Diabetes and Controlling Diabetes with Complications

Deﬁnition

This group includes people with two conﬁrmed tests; fasting plasma glucose over

126 mg/dL or A1C of 6.5 percent or higher, regardless of BMI. Diabetes, when not well

managed or when it has been present for many years, slowly damages the blood

vessels in the body and results in problems of organs or organ systems in the body,

including the heart, eyes, kidneys, skin, and nerves.

2019-2024 Goal

By 2024 reduce the age-adjusted diabetes mortality by 5 percent.

Action Step Objectives

Improve the use of standardized quality of care for people with diabetes at all levels

of the health care system by increasing the number of healthcare systems statewide

that utilize frameworks such as the chronic care model (CCM), as recommended by

the American Diabetes Association’s 2019 Standards of Medical Care in Diabetes.

Reduce the number of hospitalizations and emergency department visits each by

5 percent for people with diabetes in the state of Maryland.

Action Steps by Partner

Table 1: Activities for Health Care Providers

Maryland Diabetes Action Plan 2020

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and awareness

of healthy eating.

• Promote increased physical

activity and decreased sedentary

activity through collaborations

and referral networks with

physical activity providers in

the community.

• Implement strategies for healthy

eating and increase physical

activity as part of a population

health plan.

• Promote initiation of and length

of breastfeeding.

• Refer overweight children

and adults to appropriate

evidence-based weight and

lifestyle counseling.

• Establish referral mechanisms to

refer obese children and adults to

obesity specialists for treatment.

• Establish screening and

documentation processes for

annual BMI for children older

than 2 years of age and adults.

• Establish medical homes for

screening and treatment of

overweight/obesity for members

of higher-risk groups.

• Address barriers to participating

in healthy lifestyle activities

and programs.

• Increase number of people at

risk for prediabetes who are

tested, referred and complete

and reach evidence-based lifestyle

change program target goals.

• Utilize an e-referral application

within CRISP to facilitate referrals

to the BeHealthyMaryland.org

referral page and National DPP

Lifestyle Change Programs.

• Address barriers to participation

in lifestyle programs

(i.e. transportation, childcare,

healthy food access, exercise

program availability, etc.)

• Use a framework, such as the

Chronic Care Model (CCM), clinical

guidelines, EHR best practice

advisories, and dashboards to

achieve better compliance with

routine care such as timely

intervals for checking A1C and

urine for proteinuria, for referring

for eye/foot exams, and for

addressing oral health.

• Increase access and address Social

Determinants of Health (SDOH)

in DSMES and National DPPs.

• Ensure patients are appropriately

linked with case management.

• Address barriers to participating

in healthy lifestyle activities

and programs.

46Maryland Diabetes Action Plan 2020

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Promote healthy lifestyle family

planning within OB/GYN practices

with women of childbearing age.

• For pediatricians and adult

medicine practitioners, promote

the replacement of screen time

with increased physical

activity alternatives.

• Establish universal Social

Determinants of Health screening

tools and use of z-codes in

primary care and pediatrician

practices for overweight/obese

patients (food insecurity, poverty,

housing instability, neighborhood

safety, and provide social and

case management support).

• Establish use of mobile and

telehealth technology by case

managers, licensed dietician

nutritionists, and health care

providers to monitor high risk

patients to help them achieve

weight management goals.

• Establish nutrition counseling

services via primary care and

community-based providers and

increase those billing for

nutrition counseling.

• Perform or arrange for healthy

behavior screening for

overweight/obese patients,

including food insecurity and

prescribe food and physical

activity interventions

for weight management.

• Implement mechanisms and tools

within provider practices to test for

diabetes at 4-12 weeks postpartum

for women with history of

gestational diabetes and adhere

to clinical guidelines for women

with a history of gestational

diabetes for regular testing,

healthy lifestyle support and

potential use of medication to

reduce risk.

• Implement coordinated strategies

to encourage women with a

history of gestational diabetes

to breastfeed.

• Utilize the CRISP e-referral tools to

refer women with gestational

diabetes history to evidence-based

lifestyle change programs

or interventions.

• Ensure adherence to clinical

postpartum glucose testing

guidelines for women who have

a history of gestational diabetes.

• Encourage bidirectional referral

systems between dentists and

primary care to Identify patients

who have diabetes or at risk for

diabetes and refer them to for

diagnosis and treatment.

• Following the delivery system design principle of

frameworks such as CCM, engage clinical team

members to improve efﬁciency in quality care

delivery by (i.e. dentists, optometrists/

ophthalmologists, podiatrists, pharmacists, nurses,

medical assistants, social workers, case managers,

lab technicians) to achieve more intensive disease

management and decrease delays in implementing

the most effective care for each person

with diabetes.

• Advance and support public policies to use available

telemedicine services to improve patient access to

primary care and to assist in self-management

of diabetes.

• Establish increased dental to primary care provider

partnerships to refer patients at high risk to primary

care providers for potential diabetes diagnosis/

management.

• Implement standard clinical education for all health

professional trainees on all aspects of the CCM, as

supported by the American Diabetes Association’s

Standards of Medical Care in Diabetes – 2019.

• Implement mechanisms and tools in provider

practices to ensure referral to self-management and

lifestyle management programs.

• Implement system mechanisms in provider

practices to assure all patients with diabetes have an

Emergency Preparedness Plan.

• Encourage the use of Diabetes Self-Management

Education and Supports, Chronic Disease

Self-Management Program, and Diabetes

Self-management program among patients with

diabetes and the use of telemedicine/virtual

methods to improve support for self-management

of diabetes as needed.

• Refer patients appropriately for vision, oral, podiatry

services and cognitive testing.

• Adhere to Community Preventive Services Task

Force (CPSTF) recommendations for intensive

lifestyle interventions (based on Look Ahead trial/

DPP model) for overweight/obese patients with

type 2 diabetes to prevent complications.

• Engage licensed dietician nutritionists, behavioral

therapists, and exercise physiologists to participate

in care teams and provide additional diabetes

related training.

Table 2: Activities for Health Systems

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and

awareness of healthy eating.

• Promote initiation of and length

of breastfeeding.

• Promote healthy lifestyle family

planning within OB/GYN practices

with women of childbearing age.

• Implement healthy eating

strategies as part of the population

health plans and address food

insecurity in partnership with

community based food and meal

providers, such as Area Agencies

on Aging.

• Collaborate with community

partners to promote increased

physical activity and decreased

sedentary activity.

• Implement strategies to increase

physical activity as part of the

population health plan.

• Implement policies that support

healthy eating in health system

facilities (cafeterias, vending

machines).

• Engage academia for medical

schools to include nutrition

education and obesity

pathophysiology and prevention/

treatment into curriculum to

maintain accreditation by

professional associations.

• Establish community investment

to support healthy lifestyles

in communities

• Encourage healthcare providers

to refer overweight children and

adults to appropriate

evidence-based weight

and lifestyle counseling.

• Establish referral mechanisms in

healthcare system to refer obese

children and adults to obesity

specialists for treatment.

• Establish screening and

documentation processes for

annual BMI for children older than

2 years of age and adults.

• Establish medical homes for

screening and treatment of

overweight/obesity for members of

higher-risk groups.

• Establish universal Social

Determinants of Health screening

tools and promote providers use

of z-codes in primary care and

pediatrician practices for

overweight/obese patients

(food insecurity, poverty, housing

instability, neighborhood safety,

and provide social and case

management support).

• Establish use of mobile and

telehealth technology by case

managers, registered dieticians,

and healthcare providers to

monitor high risk patients to

help them achieve weight

management goals.

• Establish nutrition counseling

services via primary care and

community-based providers and

increase those billing for

nutrition counseling.

• Identify risk, test at-risk people,

diagnose (using ICD-10 codes)

prediabetes, and implement

practice mechanisms to assure

referral of patients to interventions.

• Develop and train providers to

utilize an e-referral application

within CRISP to facilitate referrals to

the BeHealthyMaryland.org

referral page and National DPP

Lifestyle Change Programs.

• Engage healthcare and WIC

providers to implement

mechanisms and tools within

provider practices to test for

diabetes at 4-12 weeks postpartum

for women with history of

gestational diabetes.

• Build knowledge and ability of

providers to adhere to clinical

guidelines for women with history of

gestational diabetes for regular

testing, healthy lifestyle support

and potential use of medication

to reduce risk.

• Implement coordinated strategies

to encourage women with a history

of gestational diabetes to breastfeed.

• Develop and train providers to

utilize the CRISP e-referral to refer

women with gestational diabetes

history to evidence-based lifestyle

change programs or interventions.

• Increase number of people at risk

for prediabetes who are tested,

referred and complete and reach

evidence-based lifestyle change

program target goals.

• Enable CRISP to collect and aggregate

electronic health record data from

participating clinical partners to facilitate

population health decision making action

for diabetes.

• Encourage use of a framework, such

as the CCM for adherence to clinical

guidelines and increase use of EHR best

practice advisories, dashboards, and

provider referencing of guidelines to

achieve better compliance with routine

care items such as A1C, eye/foot exams,

dental health, urine proteinuria/

nephropathy screening.

• Following the delivery system design

principles of frameworks such as the

CCM, engage clinical team members to

improve efﬁciency in quality care

delivery by (i.e. dentists, optometrists/

ophthalmologists, podiatrists,

pharmacists, nurses, medical assistants,

social workers, case managers, lab

technicians), to achieve more intensive

disease management and decrease

delays in implementing the most

effective care for each person

with diabetes.

• Use available telemedicine services to

improve patient access to primary

care and to assist in self-management

of diabetes.

• Establish increased dental-to primary

care provider partnerships to refer

patients at high risk to primary care

providers for potential diabetes

diagnosis/management.

• Implement mechanisms and tools

in provider practices to ensure referral

to self-management and lifestyle

management programs.

• Implement system mechanisms in

provider practices to assure all patients

with diabetes have an Emergency

Preparedness plan.

• Support CRISP and the Maryland

Institute for Emergency Medical Services

Systems (MIEMSS) in efforts to identify

and track diabetes-related patient

encounters that do not result in

emergency department visits or

hospital admissions.

Maryland Diabetes Action Plan 2020

Table 3: Activities for Community groups (Faith-based and community organizations, and local government)

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy nutrition

messages to be used to promote knowledge and

awareness of healthy eating.

• Expand implementation of healthy cooking and

healthy eating education and skill-building offered

by evidence-based programs.

• Promote initiation of and length of breastfeeding.

• Develop and sustain a uniﬁed statewide summer

feeding program (breakfast and lunch through

summer months) in underserved communities.

• Increase access to farmers markets and the number

of farmers and urban farms participating in markets.

• Encourage community collaboration to implement

formal walking plans.

• Expand the number of physical activity and healthy

eating offerings at parks and recreation centers,

places of worship, community and civic centers,

and senior centers.

• Sponsor weight loss competitions by partnering

with community groups, and faith-based groups.

• Promote the replacement of screen time with

increased physical activity alternatives.

• Promote opportunities to use shared community

green spaces for physical activity.

• Assess the feasibility of subsidizing gym

memberships through public-private partnerships.

• Access the feasibility of increasing the use of

wearables (ﬁtness trackers) to increase

physical activity.

• Establish community investment to support healthy

lifestyles in communities.

• Embrace shared use agreements to improve health

and equity (i.e. churches opening their center for

free exercise classes to the community).

• Establish physical activity opportunities speciﬁcally

for overweight/obese children and adults outside of

work and school.

• Advocate for and promote legislation that institutes

incentives for grocery stores to provide affordable,

healthy food options in underserved communities.

• Support counties in assessment

of county food environment by

mapping healthy food priority

areas to elucidate relationship

between food insecurity/

inadequate healthy food access

and obesity in each county

(Ex. https://planning.baltimorecity.

gov/baltimore-food-policy-

initiative/food-environment)

• Establish and promote physical

activity opportunities speciﬁcally

for overweight/obese children

and adults outside work

and school.

• Expand the implementation of

healthy cooking, teaching

kitchens and healthy eating

education and skill-building

opportunities amongst

overweight/obese adults

and children.

• Engage community health

workers (CHWs) to screen and

refer to weight reduction and

diabetes prevention programs.

• Address barriers to participating

in healthy lifestyle activities

and programs.

• Engage partners to build evidence

for diabetes prevention outcomes

on new and existing weight

management and loss programs.

• Address barriers to participation

in lifestyle programs

(i.e. transportation, childcare,

healthy food, exercise programs).

• Explore opportunities by which

certiﬁed Community Health

Workers can specialize in and join

care teams to provide a range of

diabetes-related community work,

including prevention, referral and

patient support.

• Advocate for payment models that

support diabetes education

and care delivery.

• Collaborate with health care

providers and health systems to

make linkages to home meal

services for people with diabetes.

• Use available telemedicine services

to improve patient access to

primary care and to assist in

self-management of diabetes.

• Collaborate with partners, such

as Maryland Chapter of the

American Diabetes Association to

establish support groups for

people with diabetes.

• Address barriers to participating

in healthy lifestyle activities

and programs.

Maryland Diabetes Action Plan 2020

49 Maryland Diabetes Action Plan 2020

Healthy Population

• Implement policies that support healthy eating

in institutions (vending machines, prayer

breakfasts, etc.)

• Increase access to farmers markets and the number

of farmers and urban farms participating in markets.

• Promote policies that improve the built environment

to link people to everyday destinations such as work,

school, parks and green spaces.

• Sponsor weight loss competitions.

• Promote the replacement of screen time with

increased physical activity alternatives.

• Engage partners to build evidence for diabetes

prevention outcomes on new and existing weight

management and loss programs.

• Address barriers to participation in lifestyle

programs (i.e. transportation, childcare, healthy food,

exercise programs).

• Establish walking clubs in communities.

• Establish community investment to support healthy

lifestyles in communities.

Table 4: Activities for Schools

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and awareness of

healthy eating.

• Support wellness policies and teams

that improve healthy eating in

institutions such as school cafeterias.

• Assess the feasibility of implementing

digital platforms to improve school

nutrition programs (i.e. allowing

parents and students to electronically

preorder nutritious school meals).

• Expand implementation of healthy

cooking and healthy eating education

and skill-building offered by

evidence-based programs in schools

for parents and children.

• Develop and sustain a uniﬁed

statewide summer feeding program

(breakfast and lunch through summer

months) in underserved communities.

• Implement frameworks, such as

Whole School, Whole Community,

Whole Child to increase opportunities

for healthy food and physical activity

opportunities throughout the school

day and after school.

• Promote the replacement of

non-curricular screen time with

increased physical activity alternatives.

• Promote policies that improve the

build environment to link people to

everyday destinations such as work,

school, parks and green spaces.

• Engage MSDE and others to seek

opportunities for education about and

implementation of increased physical

activity as a required element of a

school day.

• Provide technical assistance and

program development to local

education agencies wishing to

implement school based BMI

screening and/or surveillance

processes.

• Explore feasibility of incorporating

speciﬁc questions related to

prediabetes into the school physical

form and increasing the frequency

with which the forms must be

provided to schools to align with

immunization (IZ) requirements.

• Engage school-based centers to

refer children at risk of diabetes to

providers and community-based

risk-reduction services.

• Identify opportunities to utilize

Medicaid and MCO data to identify

and track children at risk for diabetes

and/or with prediabetes served in

school-based health clinic.

• Work with MSDE to expand

School-based health clinic data

collection related to diabetes risk

and prediabetes screening

and reporting.

• Advance and support public policies to

facilitate expansion of tele-health in

schools to improve access to care and

support school nurses to foster

self-management of diabetes among

students with diabetes.

• Identify opportunities for schools to

address the unique needs of students

with type 2 diabetes that focus on

healthy eating and physical activity.

Maryland Diabetes Action Plan 2020

Table 5: Activities for Employers

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and awareness of

healthy eating.

• Establish breastfeeding policies

for worksites.

• Collaborate with farmers markets

at worksites.

• Encourage multiple modes of

transportation and commuting.

• Implement policies that support

physical activity and healthy eating

in worksites.

• Assess the feasibility of subsidizing

gym memberships through

public-private partnerships.

• Assess the feasibility of increasing the

use of wearables (ﬁtness trackers) to

increase physical activity.

• Promote stair climbing and walking

during breaks.

• Offer weight management programs

as a covered beneﬁt and offer classes

at work.

• Expand implementation of healthy

cooking and healthy eating education

and skill-building offered by

evidence-based programs.

• Promote policies that improve the

build environment to link people to

everyday destinations such as work,

school, parks and green spaces.

• Establish community investment

to support healthy lifestyles

in communities.

• Offer diabetes prevention programs

as a covered beneﬁt.

• Partner with a diabetes prevention

program to offer classes at work sites.

• Partner with weight loss programs.

• Provide incentives for milestone and/or

completing weight loss programs.

• Provide third party reimbursement

for nutrition counseling for overweight/

obese employees and their covered

family members.

• Screen and test employees

conﬁdentially and refer as appropriate.

• Establish the National DPP as a beneﬁt

option for employees.

• Connect with the Maryland Quitline for

tobacco cessation for employees.

• Offer diabetes prevention programs

free or as no/low cost covered beneﬁt.

• Partner with a diabetes prevention

program to offer classes at worksites.

• Cover and incentivize routine

post-partum 6 week check-ups for

pregnant women.

• Allow employees to attend National

DPP and weight loss programs

during work day.

• Support persons with diabetes in

the workplace through coverage of

self-management services and

wellness programs, and

encouragement to remain

engaged with primary care providers.

• Partner with local public health to

offer recognized DSMES at work.

• Cover insulin pumps and insulin as a

copay and ensure beneﬁts package

allows for similar co-pays on insulin

pens and syringes.

• Offer refrigerators at work for

insulin storage.

• Offset the cost of medications and

premium reductions for persons who

maintain an A1C under seven.

• Engage community partners to

provide diabetes education

to employees.

• Allow employees to attend DSMES

programs during work day.

Maryland Diabetes Action Plan 2020

Table 6: Activities for Health Insurance Payors

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and awareness of

healthy eating.

• Improve current beneﬁt structures

to encourage prevention and health

living, such as value-added beneﬁts to

insurance plans and employee beneﬁts

to encourage healthy behavior change

activities and participation in

prevention programs.

• Explore expanded public and private

insurance coverage for clinically

supervised weight loss for obese

children and adults without secondary

co-morbidities.

• Establish reimbursement models

for nutrition counseling for overweight/

obese children and adults.

• Establish the National DPP as a

beneﬁt option for employers using a

pay-for-performance model.

• Cover and incentivize routine

post-partum 6 week check-ups for

pregnant women.

• Engage partners across the state

to support payment mechanisms, that

support high quality, state of the art

diabetes care and prevention including

the use of telemedicine, case

managers, and community health

workers, and implement payment

incentives to encourage the use of

DSMES, CDSMP, and DSMP among

people with diabetes.

• Reimburse for diabetes testing

supplies and medication with no or

low cost copay.

Table 7: Activities for State Government

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Utilize a statewide uniﬁed healthy

nutrition messages to be used to

promote knowledge and awareness of

healthy eating.

• Implement policies that support

healthy eating in institutions, such as

worksites, health systems, senior

centers and school cafeterias.

• Assess the food supply chain for

opportunities to address healthy food

pricing, cost of fresh fruits and

vegetables and access to healthy foods.

• Assess and forecast access to fresh

fruits and vegetables by geography.

• Advocate for and promote legislation

that institutes incentives for grocery

stores to provide affordable,

healthy food options in underserved

communities.

• Implement statewide policies that

increase opportunities for students

to be physically active throughout the

school day and after school.

• Promote policies that improve the

build environment to link people to

everyday destinations such as work,

school, parks and green spaces.

• Establish a reliable population-level

data source for child body mass index.

• Engage MSDE and others to seek

greatly increased opportunities for

physical activity as a required element

of a student’s life.

• Identify prevalence of school districts in

the state with a minimum time

requirement for physical education.

• Assess the percentage of third-party

payers covering comprehensive obesity

management services for adults

and children.

• Align quality metrics across health care

programs in Maryland to require at-risk

screening (e.g. MDPCP has proposed to

CMS to add weight assessment and

counseling as a P4P measure in 2020).

• Complete return on investment (ROI)

for Maryland diabetes prevention

efforts to track progress.

• Maintain and foster a statewide

network to increase the number of

evidence-based lifestyle change

programs, including group, virtual

and blended programs.

• Increase capacity of evidence-based

lifestyle change programs, such as the

CDC-recognized lifestyle change

program, in the state to deliver and

bill payers and insurers for lifestyle

change programs.

• Implement a communication

campaign on prediabetes to increase

screening and testing, with targeted

messages to enroll and retain

HealthChoice DPP and Medicare

enrollees.

• Build knowledge and ability of

healthcare providers to identify risk,

test at-risk people, diagnose

prediabetes, and implement practice

mechanisms to assure referral of

patients to interventions.

• Align quality metrics across health care

programs in Maryland to require at-risk

screening (e.g., MDPCP has proposed

to CMS to add weight assessment and

counseling as a pay-for-performance

measure in 2020)

• Complete return on investment (ROI)

for Maryland diabetes prevention

efforts to track progress.

• Develop and encourage use of

standardized social determinants of

health screening tools for use

statewide for all patients with diabetes.

• Convene and sustain a statewide

diabetes clinical collaborative

committee to develop universal quality

measures for diabetes.

• Encourage the use of Diabetes

Self-Management Education and

Supports, Chronic Disease

Self-Management Program, and

Diabetes Self-management program

among patients with diabetes and the

use of telemedicine/virtual methods to

improve support for self-management

of diabetes as needed.

• Explore opportunities for certiﬁed

Community Health Workers to

specialize in and join care teams to

provide a range of diabetes-related

community work, including prevention,

referral and patient support.

• Establish a diabetes platform to collect

and track data on aggregated patient

care outcomes, coordinate care across

specialties, identify gaps in care and

assure quality care.

Maryland Diabetes Action Plan 2020

53 Maryland Diabetes Action Plan 2020

Healthy Population Overweight/Obesity Prediabetes/Gestational Diabetes Diabetes Management

• Incentivize employers to encourage

multiple modes of transportation

and commuting.

• Implement the Maryland (MDOT)

Pedestrian and Bicycle Plan.

• Increase access to farmers markets and

the number of farmers and urban

farms participating in markets.

• Promote initiation of and length

of breastfeeding.

• Establish community investment to

support healthy lifestyles in

communities.

• Increase existing CDC-Recognized

Organization’s capacity to bill for new

coverage (i.e. Medicaid and Medicare)

and business acumen.

• Establish insurance regulations and

engage elected ofﬁcials to introduce

new legislation related to preventing

and treating prediabetes.

• Establish data source for women

with gestational diabetes and

postpartum testing.

• Support counties in assessment of

county food environment by mapping

healthy food priority areas to elucidate

relationship between food insecurity/

inadequate healthy food access and

obesity in each county (Ex. https://

planning.baltimorecity.gov/

baltimore-food-policy-initiative/

food-environment).

• Explore expanded public and private

insurance coverage for clinically

supervised weight loss for obese

children and adults without secondary

co-morbidities.

• Maintain and foster a statewide

network to increase the number of

evidence-based lifestyle change

programs, including group, virtual

and blended programs.

• Increase existing CDC-Recognized

Organization’s capacity to bill for new

coverage (i.e. Medicaid and Medicare)

and business acumen.

• Establish insurance regulations and

engage elected ofﬁcials to introduce

new legislation related to preventing

and treating prediabetes.

• Establish a data source of women

with gestational diabetes and

postpartum testing.

• Engage healthcare and WIC providers

to implement mechanisms and tools

within provider practices to test for

diabetes at 4-12 weeks postpartum for

women with history of gestational

diabetes.

• Build knowledge and ability of

providers to adhere to clinical

guidelines for women with a history of

gestational diabetes for regular testing,

healthy lifestyle support and potential

use of medication to reduce risk.

• Establish a diabetes education,

screening, and referral program in

dental practices throughout Maryland.

• Establish a data source to track adult

dental patients screened for diabetes

or prediabetes during routine

dental visits.

• Engage partners, such academia, to

build evidence for diabetes prevention

outcomes on new and existing weight

management and loss programs.

• Enable CRISP to collect and aggregate

electronic health record data from

participating clinical partners to

facilitate population health

decision-making actions for diabetes.

• Develop a health literacy program to

increase awareness of the importance

of oral health for adults at risk for

and with diagnosed diabetes and

the connection between diabetes and

oral health.

• Develop a set of guidelines for primary

care and oral healthcare providers that

includes state-speciﬁc guidance on

oral health care for adults at risk for

and with diagnosed diabetes, including

statistics on oral healthcare utilization,

clinical practice guidance, and

educational resources.

• Investigate barriers to payment

models that support diabetes

treatment and education.

• Explore reimbursement of DSMES

for Medicaid enrollees.

• Encourage use of a framework, such

as the CCM for adherence to clinical

guidelines and increase use of EHR

best practice advisories, dashboards,

and provider referencing of guidelines

to achieve better compliance with

routine care items such as A1C, eye/foot

exams, dental health, urine

proteinuria/nephropathy screening.

Action Plan

Diabetes

Section V:

Inventory of Diabetes-related Resources/Appendices

In June 2019, the Maryland Department of

Health (the Department) initiated a process to

inventory obesity, prediabetes, and diabetes

programs in Maryland. The aim of the inventory

is to assess the availability of programs across

Maryland that address diabetes prevention,

care, and management. While the required

level of service provision across the state

cannot be determined through the inventory

alone, the Department aims to use this process

to begin to identify gaps and opportunities to

expand efforts to address diabetes.

The scope of the inventory is all programs

serving Marylanders, including those that

serve Medicaid enrollees, Medicare

beneﬁciaries, commercial and small business

health insurance enrollees, and the uninsured

population. The inventory includes programs

that serve speciﬁc minority groups. The

programs are categorized according to where

the target population is situated along the

disease progression continuum: 1) Keeping

a Healthy Weight Population; 2) Reducing

Overweight and Obese Populations;

3) Prediabetes and Gestational Diabetes

Populations; 4) Managing Diabetes and

Controlling Complications. The normal clinical

management of diabetes patients within a

primary care or hospital setting was excluded

from the scope.

The Department conducted a review of a

wide range of available resources, initially

including: Community Health Needs

Assessments (CHNAs); Local Health

Improvement Plans (LHIPs); Hospital

Community Beneﬁt Reports; Maryland

Hospital Association’s (MHA) “Innovations

for Better Health” website; the Centers for

Disease Control and Prevention’s (CDC)

national registry of all recognized diabetes

prevention programs; Maryland Community

Health Resources Commission (CHRC)

grantees; Minority Outreach and Technical

Assistance (MOTA) grantees; the American

Diabetes Association website; the American

Association of Diabetes Educators website; the

Supplemental Nutrition Assistance Program

Education (SNAP-Ed) program; the Expanded

Food and Nutrition Education Program

(EFNEP); the Curves program; the Take Off

Pounds Sensibly program (TOPS Club); and the

WW (formally Weight Watchers) program.

The Department sought input from Local

Health Departments (LHDs), Local Health

Improvement Coalitions (LHICs), and minority

outreach groups in the development of the

inventory. The Department presented its plans

for a Diabetes Program Inventory at the July

2019 Local Health Ofﬁcers (LHO) Roundtable

and incorporated the feedback received at this

meeting into its approach. Jurisdiction-speciﬁc

reports of programs were shared in advance

of publication with Local Health Ofﬁcers; LHIC

leaders, where these are different; and MOTA

partners. Information on additional programs

received because of this outreach is included

in the draft inventory. Through the publication

of the Maryland State Diabetes Action Plan, the

Department is now seeking input from a wider

range of stakeholders.

The inventory will continue to be reﬁned

and updated and can be accessed at

https://phpa.health.maryland.gov/CCDPC/

Pages/diabetes-action-plan.aspx. As a next

step, the Department aims to gather more

details on the reach and capacity of diabetes

programs. Along with available data on obesity

and diabetes, the Department will use a ﬁnal

inventory to generate a detailed assessment of

gaps in service provision and promote action

to address these gaps. Emphasis will be placed

on identifying data sources, including from

the school system, and developmentally

appropriate interventions for children.

Development of a Diabetes Program Inventory

Maryland Diabetes Action Plan 2020

Diabetes Prevention and Care

While diabetes care services have long been

part of Maryland Medicaid’s comprehensive

beneﬁts package (COMAR 10.9.67),

145

diabetes

prevention services were recently approved

by Centers for Medicare and Medicaid (CMS)

and added as part of the HealthChoice

beneﬁt package.

HealthChoice Diabetes Prevention

Program (HealthChoice DPP)

Maryland Medicaid has been a leader in

integrating diabetes prevention into its

HealthChoice program through its MCOs.

In 2016, through a cooperative agreement

with CDC, the National Association of Chronic

Disease Directors (NACDD) awarded funding

to Maryland Medicaid in collaboration with

the Center for Chronic Disease Control and

Prevention (the Center) to implement the

Maryland Medicaid and National DPP

demonstration. The purpose of the

demonstration was to promote Medicaid

delivery models for the National DPP through

Managed Care Organizations. Maryland

enrolled 637 HealthChoice enrollees into the

National DPP lifestyle change program during

the demonstration period. As a result of this

demonstration, the Department applied for

and received a §1115 HealthChoice

demonstration waiver amendment that

authorizes Medicaid to offer the National

DPP lifestyle change program to HealthChoice

enrollees beginning September 1, 2019.

By identifying beneﬁciaries early through

screening and testing for prediabetes and

referring them to the National Diabetes

Lifestyle Change Program, the Department

hopes to reduce the incidence of diabetes

and increase the quality of life for

individuals at-risk for type 2 diabetes

in the HealthChoice program.

From 2016-2018, Maryland Medicaid, in

collaboration with Maryland State Health

Department’s Center for Chronic Disease

Prevention and Control, was funded to

implement the National DPP Medicaid

Demonstration project in Maryland. The

National DPP Lifestyle Change Program is an

evidence-based program established by CDC

to prevent or delay the onset of type 2 diabetes

through healthy eating and physical activity.

Diabetes prevention programs that are

recognized by the CDC, known as

CDC-recognized type 2 diabetes prevention

programs, participated with MCOs to establish

a reimbursement mechanism within Medicaid

to administer the program. Adults with

prediabetes between the ages of 18 and

64 were eligible to participate.

Investing in Prevention Programs



10.09.67 Maryland Medicaid Managed Care Program: Beneﬁts Authority: Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, .24 Beneﬁts — Diabetes Prevention and Care

Services (2019).

Maryland Diabetes Action Plan 2020

Acronyms

A1C Glycosylated Hemoglobin

ADA American Diabetes Association

BRFSS Behavioral Risk Factor Surveillance System

BMI Body Mass Index

CDC Centers for Disease Control and Prevention

CDSMP Chronic Disease Self-Management Plan

CHNA Community Health Needs Assessment

CHRC Community Health Resource Commission

CMS Centers for Medicare and Medicaid Services

CPSTF Community Preventive Services Task Force

CY Calendar Year

DPP Diabetes Prevention Program

DSMES Diabetes Self-Management Education and Support

DSMP Diabetes Self-Management Plan

EBT Electronic Beneﬁt Transfer

ED Emergency Department

EFNEP Expanded Food and Nutrition Education Program

FPG Fasting Plasma Glucose

HiAP Health in All Policies

ICD International Classiﬁcation of Diseases

LHD Local Health Department

LHIC Local Health Improvement Coalition

LHIP Local Health Improvement Plan

LHO Local Health Ofﬁcer

MCO Managed Care Organization

MDOT Maryland Department of Transportation

MDPCP Maryland Primary Care Program

MHA Maryland Hospital Association

MOTA Minority Outreach and Technical Assistance

NACDD National Association of Chronic Disease Directors

NH Non-Hispanic

OGTT Oral Glucose Tolerance Test

P4P Pay for Performance

PMPM Per-Member-Per-Month

PQI Prevention Quality Indicator

SDOH Social Determinants of Health

SNAP Supplemental Nutrition Assistance Program

TOPS Taking off Pounds Sensibly

WW Weight Watchers

YRBS Youth Risk Behavior Survey

Maryland Diabetes Action Plan 2020

Contributors

Diabetes Action Team

1. Uma Ahluwalia, MSW, Principal, Health Management Associates

2. Olubukola Alonge, MD, MPH, Program Administrative Specialist, Ofﬁce of Minority Health and Health Disparities

3. Craig Behm, MBA, Executive Director, CRISP Maryland

4. Noel Brathwaite, PhD, MSPH, Director of Ofﬁce of Minority Health and Health Disparities

5. Ernest Carter, MD, Acting Health Ofﬁcer, Prince Georges County Health Department

6. Cheryl DePinto, MD, MPH, FAAP, Director, Ofﬁce of Population Health Improvement

7. Geoff Dougherty, PhD, MPH, Deputy Director, Population Health, Health Services Cost Review Commission

8. Lindsey Ferris, MPH, CPH, PMP, Program Director, HIE Projects, CRISP

9. Stephanie Garrity, MS, Special Assistant, Ofﬁce of the Deputy Secretary for Public Health Services

10. Donna Gugel, MHS, Director, Prevention and Health Promotion Administration

11. Howard Haft, MD, MMM, CPE, FACPE, Executive Director, Maryland Primary Care Program

12. Debony R. Hughes, DDS, Director, Ofﬁce of Oral Health

13. Lee Hurt, DrPH, MS, Director, Vital Statistics Administration

14. Mangesh Joglekar, MS, PharmBS, SSGB, RPh, Chief, Clinical Services Division, Maryland Medicaid Pharmacy Program

15. Sandra Kick, MsPH, Senior Manager, Ofﬁce of Innovation, Research and Development, Medicaid, Ofﬁce of Health Care Financing

16. Theressa Lee, MPA, CPHQ, Director, Center for Quality Measurement and Reporting, Maryland Health Care Commission

17. Suzan Lowry, MD, FAAP, Health Ofﬁcer, Charles County

18. Mark Luckner, Executive Director, Maryland Community Health Resources Commission

19. David Mann, MD, PHD, Epidemiologist, Ofﬁce of Minority Health and Health Disparities

20. Mark Martin, PhD, MBA, Deputy Director, Ofﬁce of Minority Health and Health Disparities

21. Eleanor L. Mason, MSc, Health Policy Analyst Advanced, Medicaid Ofﬁce of Innovation, Research, and Development

22. Deidre McCabe, Director of Communications, Maryland Department of Health

23. Clifford S. Mitchell, MS, MD, MPH, Director, Environmental Health Bureau

24. Chad Perman, MPP, Program Director, Program Management Ofﬁce for Maryland Primary Care Program.

25. Sadie Peters, MD, MHS, Medical Director, Cancer and Chronic Disease Bureau

26. Frances B. Phillips, RN, MHA, Deputy Secretary, Public Health Services

27. Kristi Pier, MHS, MCHES, Director, Center for Chronic Disease Prevention and Control

28. Tiffanie Powell, Operations Coordinator, Ofﬁce of Population Health Improvement

29. Annie Olle, MPP, Analyst, Prevention and Health Promotion Administration

30. Katherine Roulston, MPH, Health Policy Analyst, Ofﬁce of Innovation, Research and Development, Medicaid

31. Tequila Terry, Deputy Director, Center for Payment Reform and Provider Alignment, Health Services Cost Review Commission

32. Pamela Williams, MHA, Director, Cancer and Chronic Disease Bureau

Maryland Diabetes Action Plan 2020

Diabetes Committee Members from the Health and Wellness Council

33. James Ebeling, MD, Veterans Administration

34. Jessica Kiel, RDN, LDN, CPT, CCRP, Clinical Research Manager, Scientiﬁc & Clinical Affairs, Medifast

35. David McShea, Executive Director, Maryland Chapter, American Diabetes Association

36. Vivienne A. Rose, MD, Director Medical Weight Loss Program, University of Maryland School of Medicine

37. Stephen Shaul, University of Maryland, Diabetes by the Numbers Podcast

38. Deanna Tran, PharmD, BCACP, Assistant Professor, University of Maryland School of Pharmacy

Maryland Diabetes Action Plan 2020