Project title: Making a Dent in Diabetes Total Funding Requested: $149,953 Project duration: Two years Proposed start

date: January 1st 2014 Proposed end date: January 1st 2015 Project director: Pollyanne Rystrom, 2856 Johnson Avenue San Luis Obispo CA 93410 530-514-1069, prystrom@calpoly.edu Award can be made out to: Sacramento County Health Association 1321 Jackson Road, Sacramento CA 94203 (530)-622-8567 Funding Organization: Coalition for Healthy Communities

Abstract:
The result of diabetes care has cost the US around 245 billion dollars in medical expenditures and lost productivity in 2007 and is continuing to rise. Seeing as though diabetes affects 25.8% of the US population, action needs to be taken to educate individuals with diagnosed diabetes to reduce further negative harm from their diabetes. The risk for the non-Hispanic black community is much higher with 17% of the population having diabetes. This intervention seeks to educate low income non-Hispanic black woman over the age of 20 years old that have been diagnosed with diabetes on how to manage their diabetes before further diabetes related risk-factors occur. To accomplish this, a program is in place that involves a cooking class, where the woman will learn how to cook a healthy meal at a low cost, accompanied by an education lesson about selfmonitoring diabetes.

Needs Assessment: Diabetes affects on 25.8% of the U.S. population and continues to be on the rise (Klein, Jackson, Street, Klein, & Whitacre. 2013). With such high numbers, action needs to be taken to insure a digression occurs among the disease and among its effects. Healthy People 2020 have a goal to increase the proportion of persons with diagnosed diabetes who receive formal diabetes education (CDC/PHSPO, 2008). In 2008, the proportion of people over 18 who report they have been diagnosed with diabetes and have had a formal education consisting of a course or class on diabetes self-management was 56.8 (CDC/PHSPO, 2008). The target for Healthy people 2020 is for 62.5% of people with diagnosed diabetes to receive a formal education (CDC/PHSPO, 2008). The desire for increased education rates among those diagnosed with diabetes has stemmed from not only the countless health problems that occur as a result of diabetes, but also the billions of dollars spent because of these problems. Prevalence among people who have been diagnosed with diabetes has been increasing with age, and therefore shows that an education program needs to happen at all ages and most importantly should start right after the diagnosis. The HP 2020 study targets American adults over the age 18, particularly since there are 11.8% of the American population have diagnosed diabetes among individuals over age 20 (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li, 2008). Among the population of diagnosed diabetes, minorities are greatly affected. Non-Hispanic blacks make up 12.8% of Americans with diagnosed diabetes while Mexican Americans compose 8.4% (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li, 2008). The occurrence of diagnosed and undiagnosed diabetes within the two groups is 70-80% higher than that of non-Hispanic white subjects (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li, 2008). Since these

minorities have the greatest prevalence of diabetes, they are at high risk to develop diverse affects of diabetes and are therefore in great need for education. Education programs would also greatly benefit people diagnosed with type 2 Diabetes since 90-95% of all cases of diagnosed diabetes result from people with type 2. Implementation of education among those with diagnosed diabetes is essential, and must be addressed. For a start, diabetes is the 7th leading cause of death in the U.S. and in 2007 alone contributed to 231,404 deaths (Cowie, Rust, Ford, Eberhardt, ByrdHolt, & Li, 2008). With a self-management education leading to a 1% reduction in A1c levels, there is a risk reduction of 21% for death, 14% for myocardial infarctions, and 37% micro vascular complications (Klein, Jackson, Street, Klein, & Whitacre, 2013). Other conditions that can be limited or reduced by diabetes education include blindness, kidney damage and failure, cardiovascular disease, nerve damage, lower-limb amputations, as well as many other health complications (Klein, Jackson, Street, Klein, & Whitacre, 2013). Diabetes education was found to have an overall benefit of both health and psychosocial impacts. Not only can certain health problems can be avoided or limited with the inclusion of education amongst diagnosed diabetes, but many health care costs can also be avoided. Diabetes care currently accounts for about 9% of all expenditures for health care in the U.S. totaling around 245 billion dollars in medical expenditures and lost productivity in year 2012, drastically increasing from the economic cost of 174 billion dollars in 2007 (Rickheim, Weaver, Flader, & Kendall, 2001). Both the onset and farthing conditions of type-2 diabetes most often occur within low-income populations. This may be a result of barriers families face in making the right food choices. These barriers include the price of fresh healthy food as well as the time

and convenience of food options that are not as nutritious. Parents in low-income families are having to work multiple jobs for little pay, and cannot afford the time or money it takes to make a nutritious meal. Other key factors that play a role in this would be the onset of other noncommunicable diseases such as obesity where there is a lack of activity and poor food choices made (Garber, 2012). When poor dietary choices are continually made, the body can become more resistant to insulin and result in diabetes or diabetes complications. Factors that include prevention of worsening the disease include decisions made by patients to control their own blood glucose. It is easy for a doctor to prescribe medication, yet that isnt getting at the heart of the issue and will not create lifelong habits for change. It takes education to understand how to manage blood glucose and not just take in a pill to get momentary relief (Rickheim, Weaver, Flader, & Kendall, 2001). There is a lack of people seeing the need for diabetes education, even though the statistics are approaching more obscene numbers that have never been seen before. From years 1988-1994 and 2005-2006, diagnosed diabetes in both genders and all age groups increased significantly especially amongst the non-Hispanic black community (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li. (2008)). The large increase of diabetes in non-Hispanic blacks and in the United States as a whole is due to many factors such as decreased access to health care. Another contributor is the increased rate of Obesity in Americans throughout the years. Obesity proposes a high risk for diabetes since the body can become resistant to insulin from the increased glucose and calorie consumption. Since energy dense foods leading to obesity are so readily available and at such a low price, populations with a low income and decreased availability to a healthier diet are at a

higher risk for furthering the effects of diabetes. One study showed a strong link between local food environments and obesity and Diabetes. In fact, 75% of teens in California live and go to school in less healthy food environments (Babey, Susan, Joelle Wolstein, and Allison Diamant(2011)). This is especially common in communities that house ethnic minorities, such as non-Hispanic blacks, where the trends among food environment are not only visible around schools but also near the workforce. To counteract the poor food choices available that adds to obesity and farthing effects of diabetes, efforts are being used among the food bank in different communities. The food banks goal is to try to increase the amount of produce consumed, providing the lower income communities better food options. This enables low-income minorities to make better food choices to prevent diabetes or slow its effects. The lack of diabetes education is especially imperative in communities where diabetes has become more prevalent. There are many factors contributing to high rates of diabetes including genetics, food availability, obesity, the inaccessibility of facilities and the unavailability of programs offering diabetes education. One of the populations, as seen previously, that contain a high number of individuals with diabetes is non-Hispanic blacks; with about 12.8% who have been diagnosed diabetes and 17% with both diagnosed and undiagnosed diabetes (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li. (2008)).The prevalence of diagnosed and undiagnosed diabetes between Non-Hispanic black and Mexican American minorities is 70-80% higher than the prevalence in the non-Hispanic white populations. Non-Hispanic black minorities are twice as likely as non-Hispanic white populations to be diagnosed with diabetes (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li. (2008)). Education for

people with diagnosed diabetes is specifically targeted towards populations where diabetes has had a great effect on the community, yet diabetes education implementation is lacking. In California alone, there are 1.5 million people, or 5.9% of the population, who have been diagnosed with diabetes and 1.8 million more who are at risk or have undiagnosed diabetes (Diamant, Allison, Susan Babey, Richard Brown, and Neetu Chawla (2003)). According to a study conducted among people living in California, this reality is due to the high proportion of people who have a sedentary lifestyle and are obese or overweight. One fifth of non-Hispanic blacks report a sedentary lifestyle; increasing their risk for diabetes (Diamant, Allison, Susan Babey, Richard Brown, and Neetu Chawla (2003)). As a result of the large number of individuals with a sedentary lifestyle, physical activity education would be highly beneficial to reduce the risk factors associated with diabetes. Trends in California have also shown that the likelihood of diabetes increases with the age of the individual. The cultural disparities are also significant among adults in California; where 20.5% of non-Hispanic black adults ages 50-64 year old have diabetes and 25.6% over age 64 (Diamant, Allison, Susan Babey, Richard Brown, and Neetu Chawla (2003)). Low-income households, especially those living below the federal poverty level, also significantly affect the proportion of adults with diabetes. The devastating affects of diabetes are also seen in a higher proportion in nonHispanic blacks. The increased risk of health related problems due to diabetes shows the need for education among these communities. For example, a study was conducted to compare diabetic retinopathy, one of the most frequent and severe effects of diabetes,

among different ethnic groups in the US. Results of this study showed that Non-Hispanic Blacks had an increased prevalence and severity of retinopathy compared to nonHispanic whites. The prevalence in non-Hispanic Blacks with diagnosed diabetes that had any lesions of retinopathy was 46% higher when compared with for non-Hispanic whites. The high prevalence in these two populations may in part be attributed to the high risk factors on retinopathy among these ethnic groups, such as higher Hemoglobin A1c levels and high blood pressure (Cowie, Catherine , Ronald Klein, Maureen Harris, Michael Roland, and Danita Byrd-Holt (1998)). As diabetes-related health complications in non-Hispanic blacks heighten nationally as well as locally, aggressive treatment and preventative actions should be taken for the future. This can happen through education, but education on selfmanagement of blood glucose-levels must be sensitive to differing cultures. Prevention in ethnic groups must be handled with respect and recognition of their unique cultural values. Studies have shown that education is done most effectively when the diabetes educators and health care providers consider specific beliefs, customs, food patterns, and health care practices, with the goal of incorporating these cultural factors into a practical and beneficial treatment regimen.(Ramond, Nicole , and Gail D'Eramo-Melkus(1993)). Even when non-Hispanic blacks do know about self-monitoring, they are not educated on the importance of continuing to self-monitor. A study was performed to evaluate self-monitoring of blood glucose in both race and education levels among people who had diagnosed diabetes. Results showed that non-Hispanic blacks were 60% less likely to test their blood-glucose levels at least once per day compared to other ethnicities (Harris, Maureen , Catherine Cowie, and Jean Howie (1993)). When people have had

education and are aware of the benefits to self-regulation, they may be more prone to actually test their blood-glucose levels and attempt change. Another studys data showed that people with diabetes who had poor glycemic control were put at a higher risk for diabetic complications revealing the need for education on the importance of glycemic control among these populations (Harris, Eastman, Cowie, Flegal, and Eberhardt (1999)). Other barriers in the education of low-income non-Hispanic black community above the age of 18 that have diagnosed diabetes may be the lack of availability and accessibility in their communities. Facilities used for education may be lacking in their communities or may be inaccessible due to distance. Among the low-income population, education programs may also be too expensive for families in need of the training to see benefit in the outcome. It is important to address these barriers to make headway for the lives of nonHispanic blacks that are at such a high risk of diabetes. Since there is such a need and importance in education, opportunities should be put into place where this minority may receive low-price education right in their own neighborhoods. Due to a shift in proportion of individuals with diagnosed diabetes in the last 1015 years among non-Hispanic blacks, the amount of available education cannot fulfill the need (Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li. (2008)). There are a few diabetes education solutions put in place now, some effective while still others found to be almost completely ineffective. One trial was done to compare the effectiveness of group education verse individual education. The results showed that both methods were equally effective. They found that group educating exhibited even slightly greater improvements in those with diagnosed diabetes, delivering a more efficient and cost effective education

program (Rickheim, Weaver, Flader, & Kendall, 2001). There have been some attempts in the last few years to increase education, yet solutions are not simple. In the past, work has been done in public health to try to educate on a large scale with posters and billboards, yet effectiveness of this method was not sound. The health care providers past and presently have attempted to educate on the individual level, yet because of health insurance and low-income families of the non-Hispanic black community, this kind of education is limited. There is motivation in a group of supporters and co-journers that are trying to manage their diagnosed diabetes. There is a feeling of community; that they are in the process together. To provide an educational intervention on self management for non-Hispanic black low-income women over the age of 18 with diagnosed diabetes, the implementation program would be more beneficial in Sacramento county where 10% of the population is non-Hispanic blacks (US Census Bureau (2011)). This kind of program would both address people on the individual level as well as in their communities. Since many women over age 18 are wives and mothers, the impacts of the education will reach far beyond themselves. Once educated, diagnosed diabetic woman have the ability to affect their own life, yet also the lives of their family who may also be facing diabetes. The program would also allow the woman to relieve stress with an enjoyable, free cooking class that will provide motivation to hear about self-management techniques. This kind of community based program provides a low threatening, non-judgmental way to ensure woman know the importance of self-monitoring, yet still have motivation to come.

Since the prevalence of Diabetes continues to climb in a generation where noncommunicable disease are increasing and communicable diseases are decreasing, there needs to be a switch of what issues are at hand. The United States now needs to take action with how they are going to deal with the problems that are most predominant, diabetes being a large contributor. Since so much of the population has been diagnosed, the next step should be to prevent further issues that could arise with their disease. To prevent further pain, problems, and medical bills, education is in order. Education is what will drive this country to change and respond, and is essential for a continually growing population of individuals with diabetes. Benjamin Franklin said, An investment in knowledge pays the best interest. If the US focuses their funds on educating people before health care costs become an issue, this country could save much pain and heartache in the lives of its citizens. Goals and Objectives: In an effort to promote education for low-income non-Hispanic black woman over the age of 20 years old with diagnosed diabetes and reduce their risk of further diabetes related risk factors, goals and objectives have been put in place to achieve in our program. The Goals of the program, titled Making a Dent in Diabetes, are as follows; Goal 1: Woman would obtain confidence to cook and eat healthy. 1. Objective 1: To increase the number of women that make home cooked meals. 2. Objective 2: To increase the amount of produce used in families meals. 3. Objective 3: To increase the number of woman that can eat healthy on a budget. Goal 2: That woman would gain knowledge of how to prevent further risk factors associated with Diabetes.

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1. Objective 1: To increase the amount of woman that performs self-monitoring of blood glucose levels. 2. Objective 2: To increase the number of woman that teach their families how to self monitor their blood glucose levels 3. To increase the amount of woman that exercise regularly. Methods: Participants: In partnering with hospitals, clinics and food banks in Sacramento, flyers will be distributed among these locations targeting low-income non-Hispanic black women over the age of 20 who have been diagnosed with diabetes. The technological staff working on the project will make the flyers and will emphasis the free cooking class portion of the program. The flyer will also highlight the free amenities given to the woman who attend the program such as free childcare and self-monitoring equipment, as a motivation for woman to attend the program (See appendix B). The free amenities are large motivators for our low-income population to attend the program and learn more than just how to cook. After the flyers are made, they will be placed in four locations; Sutter Health Hospital in Sacramento, Shifa Clinic, the Willow Clinic, and the Sacramento Food bank in an attempt to address the target population of low income non-Hispanic black women over the age of 20 who have been diagnosed with diabetes. These facilities provide care for low-income individuals that are in need of health services. Both of the clinics as well as the food bank are free to the public and the hospital emphasizes their acceptance of the low-income population. All of these facilities are located in near proximity to the non-

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Hispanic black population neighborhoods where they will be likely to interact with our population of interest. As flyers are placed in these businesses, a signup sheet will also be made available at the front desk for the program. As we partner with the hospitals and clinics, the staff will recommend and encourage our program to their women patients who have just been diagnosed with diabetes or who have diagnosed in the past. The health facilities will distribute flyers to these patients and encourage sign ups directly after. It is best to educate individuals directly following diagnoses so that there many be a lower risk of further complications with diabetes. Flyers will also be placed around the food bank and will be promoted by staff. The actual program will be located in the Nord Community Center in Sacramento that was strategically chosen for its proximity to the non-hispanic black neighborhoods in Sacramento. At this location, women will be more motivated to attend and travel expenses will be minimal if any. The close distance will also encourage women to walk to the program, promoting a further healthy lifestyle. Since many women over the age of 20 will have young children, a further motivator to have them attend, is the free childcare availability that will be provided by Making a Dent in Diabetes. Also, having the program held in the afternoon, will free time for the mothers to attend while their older kids are at school. In order to keep the class size manageable for the designed activities, thirty women will be able to attend each session. With this number, women will really be able to get first hand experience with the activities, and will get to do hands on learning so that they will have to confidence and competence to continue skills acquired after the session

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is over. Since there will be eight sessions available throughout the two-year project and no one will be able to retake the classes, 240 women total will be able to participate. Project Design: The project, titled Making a Dent in Diabetes, will consist of two different parts of each of the one and a half hour sessions. About an hour of the session will entail a healthy and low cost take on cooking classes in order for the women to be able to have the confidence to cook healthy meals on a budget. The other half hour will an educational lesson on how to manage diabetes so that risk factors for diabetes will be kept at a minimum. Throughout the two years, there will be two weeks breaks in between each of the eight-week sessions to evaluate and adjust the program for improvement for the following program. Before either of these activities takes place preparation work needs to take place. Preparation Period: For each meeting, there are a variety of tasks that must be accomplished in order for the activities to run smoothly. In the first two months of the preparation period, the project director as well as the project directors assistance must advertise for the program, discussed earlier, as well as develop a team to work alongside of them throughout the course of the two years. Registered Dieticians that specialize in culinary ability and diabetes will be made available from the organization, Sacramento County Health Promotion, that will be hired to work each monday during the program and before the program. In partnering with colleges in the area, job posting will be available on the portal sites for students to apply. This will enable students to gain experience in their interests

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and to have a part time job that is a low time commitment while in college. Three students will be hired for the technological team that will be in charge of creating flyers, handouts and evaluation forms and will mostly work towards the beginning of the program. Much of their work will be done in this preparation period so that word can get out about the program as quickly as possible. One student will be hired to go grocery shopping right before the program each week and will be in communication with the registered dietitians to supply the food for the cooking lessons. Lastly, five students will be hired to do childcare for a two-hour period each week, arriving 15 minutes early and leaving 15 minutes after the program is done to allow room to spare. Payment is outlined in the budget later on. Lastly, a group of volunteer interns from nearby colleges will be hired to get hands on experience during the actual program and will be required to attend each week to help the woman with different needs. Promotion for this will involve the directors assistant going into health related classrooms to advertise for the experience. The directors assistant will hold interviews for both paid and unpaid staff to ensure trust in the staff. Pre-Activity: Before each session, registered dieticians will plan out that week's meal and cooking lesson, making adjustments as they see fit. After they have nailed down the recipes, they will get in contact with the weekly shopper. The shopper will go the a nearby grocery store to purchase the food needs for the cooking demonstration as well as the food the women will be making following the demonstration. The other two registered dietitians will plan out their lesson for diabetes education, and will make sure

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they have the supplies needed for their message. They will be in charge of ensuring that all the equipment needed has been previously purchased and ready to bring or give out to the woman. Activities Part 1: Cooking Class In order for women to be able to obtain confidence to cook and eat healthy meals with the whole family, a cooking component is added into the program. Upon entrance into the community center, women will be assigned a specific table. There will be five women at each of the six tables to allow each woman the ability to gain this confidence in their cooking skills. Tables will be labeled with a number that corresponds to the number given to each woman that enters.

12:00-12:15- drop off children, check in, finding tables; welcome and announcements.

12:15-12:30- A short demonstration will be shown by registered dietitians for what meal is being made that day.

12:30-1:50- The woman at each table will work together to use ingredients on the prep table to make the demonstrated dish for the table. The team at each table will work together to cook and clean up after each meal.

12:50-1:20-while the food bakes or chills, part 2 of the session will take place 1:20-1:30-The meals will be dishes out to people after for towards the end of part 2 so that the women will stay the whole time in order to get the food. Each session will begin at 12:00 pm and 15 minutes will be allotted for check in

at each week's meeting. Since free childcare will also be provided at each of the 7 regular

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sessions to encourage moms with young kids to attend, the moms will check in and drop off their kids during this time. Once everyone is at their tables, a welcome and the agenda will be announced to the audience to instruct them for what to do each week. Then the two registered dietitians will share what they are making and how it will benefit the woman. Following the explanation, the dietitians will do a demonstration on how to make the dish. Each week the dieticians will focus on a different topic to emphasis and compliment that topic in the dish that will be prepared (See appendix C). For example, on week focuses on making healthy dinners from items all available at the food bank. The dish that week would then be a chicken salad where all the ingredients for the salad may be acquired at the food bank. After the dietitians are finished, they will hand off the recipes to the women so that they may work together in their teams to cook the demonstrated meal confidently. Ingredients purchased by the shopper will be provided in front and made available for the women to measure out of their own. The idea is having them make the food after the demonstration is to show that they can integrate healthy foods on a low budget when making home-cooked meals. The self-efficacy of this aspect of the project while instill confidence in the lives of the women to translate the actions done in this class to their home lives. The woman will be given handouts for each of the recipes each week and encouraged to make them for their families. While waiting for the dish to cook or chill, the women will sit and listen to the educational part of the session (discussed later), and will not leave for this portion since they have not eaten their food yet. This serves a motivation to have the women stick around for the whole portion of the diabetes management talk.

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At the end of the program, session eight, there will be a potluck. The potluck will be a time for the women to come an exhibit their ability to cook a low cost healthy meal. The potluck allows women to show their families and fellow community members what they have been cooking to show that they have the competence to take what they learned and apply it. During this session, the women will be able to bring their families and enjoy what they have made and what their fellow community members have made. At this session, there will also be evaluation forms for the woman to fill out regarding what they learned (more detail later). Part 2: Diabetes self management: In order for woman would gain knowledge of how to prevent further risk factors associated with Diabetes, the woman must be educated. In order to achieve this goal, the women should not just listen to a talk on how to manage diabetes, but they must also engage in self-management activities. Throughout the eight weeks, two registered dietitians focusing on diabetes will come in each week and instruct the women on different ways to regulate diabetes. The lessons will range from testing blood glucose levels to physical exercise to minimize the negative effects of diabetes (see appendix C). The program will provide equipment for each of the woman. This will include a blood glucose monitor, lancets, and test strips for each woman. During these sessions, women will learn how to use the equipment as well as how to interpret the results. The women will also be encouraged to share this information with their own families and help other people monitor their blood glucose levels. By having RDs there to teach blood glucose monitoring and go around to each woman to help them, the women will gain knowledge, confidence and ability to perform these methods after leaving the program. This portion

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of the session will also provide handouts teaching on self-management so that the women may take the information home to remember the steps for themselves and to teach others. During this session, women will also be educated and encouraged in the benefits of daily physical activity and other diabetes management efforts. In-Between Sessions: The program will take two week breaks in between each session to evaluate and re-examine tactics (see appendix 1). The project director, directors assistant, interns and registered dieticians will meet during the two weeks to discuss what aspects of the program went well and where their is room for improvement. This time also allows for preparation for the next session, such as printing more handouts, getting needed equipment, and making recipe cards for the cooking portion. This break allows the staff time to rejuvenate so that the program does not burn them out at the end of the two years. Since there are four programs each year, there will be a following four break periods each year (see appendix 1). Final two months: There will be a remaining two months for the project set aside as a time to do a final evaluation of the overall assessment of the programs effectiveness. This will be discussed further in the subsequent headings. Community Partners: 1. Sutter Health Hospital in Sacramento, Shifa Clinic, the Willow Clinic, and the Sacramento Food bank each reach out to our population of interest. Each of these facilities help low income populations in Sacramento by making them free to the public, such as the food bank and the clinics, or at an affordable price like the

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Sutter Health Hospital in Sacramento. We will partner with these Businesses to help promote our program in areas where our population of interest may reside. For a low cost, the doctors and clinics will hand out flyers for our program to women who have just recently diagnosed with diabetes or have been struggling with it for a period of time. The hospitals and clinics will also make the flyers available in the lobby for others to see. There will be sign up sheets for our program in these facilities for a two year time period, or until the spots have filled up. We will also work with the food bank to advertise for our program and reach the low income of our population. We will hang up flyers around the food bank and leave a sign up sheet at the front with the staff. As partners with these organizations they have offered to promote our programs, and in turn we will pay them $100 each year in order to supplement their time. 2. Community Center on Nord. We have partnered with the Community Center on Nord Street to house our program. They have been gracious enough to give us a discount to use the facility and the supplies that come along with it. The Community Center appreciates the work we are doing for the community and are willing to reduce the price of the facility by one third. The community center on Nord is the perfect location to have the program seeing as it has a kitchen and play yard for the children. 3. Universities and Community Colleges in Sacramento: The project will partner with local Colleges to set up an intern program. This program will allow students interested in the Nutrition or health field to be able to gain hands on experience through relevant opportunities. The internship will be a yearlong internship

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commitment where the interns will help with preparation work, evaluation work as well as assisting the Registered Dieticians and the project director. Staff will go into different classes before the program starts to advertise for the internship position and find hard working interns for the year. After year one, a new group of interns will replace the old ones, so that more people can gain experience. This is an unpaid program with the college students but the program will be good experience on a resume. Making a Dent in Diabetes will also partner with these colleges to post child care jobs on the jobs listing page for college students. This will allow college students work, while gaining employees that have had experience working with kids. Interviews will be conducted by the directors assistant to ensure trustworthy staff will be working with the children. The organization will also post jobs for the technological team in charge of designing flyers, handouts, and evaluations, and will also post a job for the weekly shopper. 4. Free Style Freedom Company: This company sells each of the different components needed in order to monitor glucose levels in the blood. These materials include the actual glucose monitors, lancets, and the test strips. Since our overall purchase for the program is around $6000, the company is supplying us extra lancets and testing strips for no additional cost. As a result, each attendee of the program will be able to receive more supplies in order to monitor their blood glucose levels for a longer period of time. Evaluation: Making a Dent in Diabetes will evaluate the projects effectiveness through summative evaluation and impact evaluation:

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Summative Evaluation: As discussed earlier, evaluations will be done before the program is fully implemented at the end of each eight each program. This evaluation process will help to access the programs effectiveness and continue to make improvements for the next eight-week session. In order to do a truly evaluate the results of the program from the members; a ending questionnaire is highly effective. The technological staff team is in charge of creating an evaluation that addresses the different measurable objectives that were designed for the projects. An example questionnaire from the Stanford Research Patient Education Center is provided (see appendix A) in order to measure dietary changes, physical activity level changes, and the level of confidence people had in order to change their lifestyle (Stanford University School of Medicine (2004).) Though this evaluation is helpful on a lot of levels to measure objectives, it is lacking questions regarding competence in cooking healthy low cost meals. To compensate for that, the technological team will create an effective survey that addresses all of the objectives in the program. This summative evaluation is responsible for documenting the success of the program and how well program objectives were achieved. There is also an evaluation time in the last two months. This will look over the questionnaires over the past two years and what methods were the most effective and what methods had room for improvement. This time of evaluation included the project director, directors assistant, and interns for both years, technological staff, and RDs. The group will look over the programs effectiveness as a whole to see if and how the objectives were accomplished. Impact:

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To measure the impact of the program, the potluck lunch has been put in place for women to demonstrate their knowledge gained from the program. Through this activity, the staff is able to see to what extent the participants improved their knowledge, skills and attitudes towards cooking and self-monitoring their diabetes. The addition of their families attending the potluck gives the staff the ability to see the effects that the women played into their families lives and evaluates the impact of the program in a variety of ways. Sustainability: Though is this a short-term project, two years, it provides long-term benefits to the community. Not only do the women come and simply listen to the beneficial information that is provided by the program, but they also receive hands on experience that will translate to other times in their lives. The ability to provide interactions with the participants and engage them in the activities being taught provides these women with the self-efficacy to continue these positive habits. One of the positive benefits in working with women over the age of 20 years of age is the influence they have on those around them. By teaching the wives, friends, and mothers of the neighborhood, they have the ability to take the skills learned in the program and rely these skills onto the others around them. Not only women are experiencing the negative effects of diabetes, but there is a high prevalence of men and children facing the risks as well. By educating the woman, there is a domino effect that is relayed to those around her, because of power she has in her family. Another way that this program is sustainable is in the materials provided each week. Not only does the program engage each week, but also it provides leave behind

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materials that the women can take home and continue after the program is finished. These materials include recipe cards from each weeks recipes, handouts on monitoring diabetes, and equipment in order to test blood glucose levels. These materials can then be continually used by the women, but also shared with the people around her. Though each session, may only be eight weeks, the impact spans far longer than can be measured. Though at the surface the program seems to affect the lives of 240 woman in one neighborhood for two weeks on how to manage diabetes, the ripple of these womens live could multiply the change in the lives around them. Work Cited Babey, Susan, Joelle Wolstein, and Allison Diamant(2011). "Food Environments Near Home and School Related to Consumption of Soda and Fast Food [eScholarship]." eScholarship | University of California. N.p., 27 July 2011. Web. 19 May 2013. <http://escholarship.org/uc/item/5w17p523#page-1>. Cowie, Catherine , Ronald Klein, Maureen Harris, Michael Roland, and Danita ByrdHolt (1998). "Is the Risk of Diabetic Retinopathy Greater in Non-Hispanic Blacks and Mexican Americans Than in Non-Hispanic Whites With Type 2 Diabetes?: A U.S. population study ." Diabetes Care . N.p., n.d. Web. 19 May 2013. <http://care.diabetesjournals.org/content/21/8/1230.full.pdf+html>. Cowie, Rust, Ford, Eberhardt, Byrd-Holt, & Li. (2008). Full Accounting of Diabetes and Pre-Diabetes in the U.S. Population in 19881994 and 20052006 . Diabetes Care . Retrieved April 24, 2013, from http://care.diabetesjournals.org/content/32/2/ CDC/PHSPO. (2008). Risk Factor Surveillance System (BRFSS); Centers for Disease Control and Prevention, Public Health Surveillance Program Office (CDC/PHSPO). 2020 Topics & National Data - Tech Specs. Healthy People 2020 - Improving the Health of Americans. Retrieved April 23, from http://healthypeople.gov/2020/topicsobjectives2020/TechSpecs.aspx?hp20 20id=D-14 Diamant, Allison, Susan Babey, Richard Brown, and Neetu Chawla (2003). "Diabetes in California: Nearly 1.5 Million Diagnosed and 2 Million More at Risk [eScholarship]." eScholarship | University of California. N.p., 1 Apr. 2003. Web. 19 May 2013. <http://escholarship.org/uc/item/2rr7x0h6>. Garber, AJ.(2012). "Obesity and type 2 diabetes: which patie... [Diabetes Obes Metab. 2012] - PubMed - NCBI." National Center for Biotechnology Information. N.p. Web. 1 May 2013. <http://www.ncbi.nlm.nih.gov/pubmed/2207

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Harris, Eastman, Cowie, Flegal, and Eberhardt (1999). "Racial and ethnic differences in glycemic control of adults with type 2 diabetes. ." Diabetes Care . N.p., n.d. Web. 19 May 2013. <http://care.diabetesjournals.org/content/22/3/403.> Harris, Maureen , Catherine Cowie, and Jean Howie (1993). "Self-Monitoring of Blood Glucose by Adults With Diabetes in the United States Population ." Diabetes Care . N.p., 1 Apr. 1993. Web. 19 May 2013. <http://care.diabetesjournals.org/content/16/8/1116.> Klein, Jackson, Street, Klein, & Whitacre. (2013). Diabetes Self-Management Education: Miles to Go. National Center for Biotechnology Information. Retrieved April 24, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/P Ramond, Nicole , and Gail D'Eramo-Melkus(1993). "Non-Insulin-Dependent Diabetes and Obesity in the Black and Hispanic Population: Culturally Sensitive Management ." The Diabetes Educator . N.p., n.d. Web. 19 May 2013. <http://tde.sagepub.com/content/19/4/313.>. Rickheim, Weaver, Flader, & Kendall. (2001). Assessment of Group Versus Individual Diabetes Education . Diabetes Care . Retrieved April 24, 2013, from http://care.diabetesjournals.org/content/25 US Census Bureau (2011)."Sacramento County QuickFacts from the US Census Bureau." State and County QuickFacts. N.p., n.d. Web. 20 May 2013. <http://quickfacts.census.gov/qfd/states/06/06067.html>. Stanford University School of Medicine. (2004). "Diabetes Questionnaire." Stanford Research Patient Education Center. N.p., n.d. Web. 8 June 2013. <patienteducation.stanford.edu/research/diabquest.pdf>. Vaccaro, Feaster, Baum, Lobar, Magnes, and Huffman(2013). "Medical advice and diabetes self-management reported by Mexican-American, Black- and White-non-Hispanic adults across the United States." National Center for Biotechnology Information. N.p., n.d. Web. 19 May 2013. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362774/>

Appendix 1: Time Line: Task Initial Planning and Preparation Session 1 Assessment and Evaluation Jan X Feb X Mar Apr May Jun Jul Aug Sep Oct Nov Dec

X X

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Session 2 Assessment and Evaluation Session 3 Assessment and Evaluation Session 4 Assessment and Evaluation Task-Year 2 Jan Feb Mar Apr

X X

X X

X X

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Initial Planning and Preparation Session 1

Assessment and Evaluation Session 2

Assessment and Evaluation

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Session 3

Assessment and Evaluation Session 4

Final Assessment and Evaluation

Time Frame: Task Preparation for the program. Talking with partnering companies, advertising to the community, preparing the RDs and assistants Session 1 of program; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what could be done differently Session 2 of program; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what could be done differently Session 3 of program; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what Time to Complete 8 weeks Personnel Responsible PD, 4 RDs, DA

8 weeks

All personnel

2 weeks

PD, 4 RDs, DA

8 weeks

All personnel

2 weeks

PD, 4 RDs, DA

8 weeks

All personnel

2 weeks

PD, 4 RDs, DA

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could be done differently Session 4 of program; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program in preparation for the new year; what could be changed or done better, how could the program teach more effectively? Session 1 of program year 2; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what could be done differently Session 2 of program year 2; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what could be done differently Session 3 of program year 2; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of program, time for correction and improvement, preparing for the next session and what could be done differently Session 4 of program year 2; Woman come to the program and have cooking lessons each week and learn about monitoring diabetes. Evaluation of the program as a whole; overall effectiveness, did it accomplish the desired goals and objectives?

8 weeks

All personnel

4 weeks

PD, 4 RDs, DA

8 weeks

All personnel

8 weeks

PD

2 weeks

All personnel

8 weeks

PD, CV

2 weeks

All personnel

4 weeks

PD, CV

24 weeks

All personnel

8 weeks

AS

*PD=Project director, DA=directors assistant, RD=registered dietician, ** All personnel includes; Project director, directors assistant, 4 registered dieticians, 5 babysitters, 1 shopper, and interns. Appendix 2 Budgeting:

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Facility: 1. Nord Community Center Project Staff: 1. Project Director: 2. Director Assistant 3. 4 Registered Dieticians: 4. Shopper 5. 5 Baby Sitter 6. Technological team Advertisements: 1. Locations Printing Costs: 1. Flyers, Handouts, Surveys Equipment: 1. Glucose monitors, Lancets, test strips$6,000 2. Cooking equipment 3. Sound equipment Food: Project Total: Budget Narrative: Facility: 1. Nord Community Center, $150/use for eight-week session, eight times in two years is $9,600. The organization has formed a partnership with the community $300 $1.472 $20,000 $149,953 $921 $800 $30,000 $20,000 $44,800 $1,680 $7,280 $3,900 $12,800

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center and the community center has reduced the price of renting their facility by 1/3rd. There is an additional cost for utilities, use of the playground (for the children), use of tables and chairs, and use of the kitchen and utilities cost an additional $3,200. Project Staff: 1. Project Director: The project director is in charge of coordinating what needs to be done and delegates roles for who needs to accomplish them. The director will work to prepare for the program as well as find people qualified to educate. The director also orchestrates the evaluation process to figure out changes that need to be made. The project director will be working continuously throughout the two years in order to make the program the best it can be. Salary: $20,000/ year. 2. Director Assistant: the Assistant does not work full time but helps the project director coordinate with organizations and partnerships. The directors assistant will also be in charge of the hiring process by conducting interviews with the other part of the staff team. 3. 4 Registered Dieticians: The program will require two registered dieticians to plan and demonstrate the cooking lesson. The two dieticians will switch off having the role of planning each meal and cooking lesson and the other has the role of assisting; the next week it will switch. The Dieticians will be in charge of coordinating with the shopper for what food needs to be purchased. $200/session for 7 weeks*/program times 8 programs= 11,200x2=$22,400. The other two registered dieticians will switch off leading the lessons on the diabetes education aspect of the lesson and assisting. This will require research and training in

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diabetes education and equipment as an RD. $200/session for 7 weeks*/program times 8 programs= 11,200x2=$22,400. 4. Shopper: The role of the shopper is to purchase and bring the food to the Community Center each week. The shopper should be in contact with the registered dieticians each week to know what foods to buy. $30/session for 7 weeks*/program for 8 programs=$1,600 5. 5 Baby Sitters: Since childcare is provided, there needs to be a large number of staff members watching the kids to ensure their safety. $13/hr for two hours for 7* weeks/program time 8 programs=1,456x 5 sitters=7,280. 6. Technological Team: The tech team will consist of three people who will be in charge of creating the flyers, handouts and evaluations for the program. Their work will mostly be at the beginning of the program, though further work is necessary in the improvement of handouts and evaluations. Since example evaluation do not measure all the objectives set for the program, this team will create questionnaires tailored to Making a Dent in Diabetes. They will be paid $25/hour and work approximately 52 hours each on the projects assigned to them, totaling $3,900 Advertisements: 1. Locations: The placement of flyers and signup sheets into different venues to promote the program. These advertising sites are hospitals, two clinics, and food bank all in the local neighborhood housing the population of interest. With a relationship with each of these places, they are only requiring $100/year to supply information and flyers. $100/year x two years x 4 locations= $800

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Printing Costs: 1. Flyers, Handouts, Surveys: The flyers (see appendix A) used to advertise for the program cost 20 cents to copy in color x 2,000 copies= $400. The handouts are for both recipes during the cooking portion of the afternoon (20 cents/ color copy x 30 people x 7 cooking demos x 8 programs =$336) and other handouts are for information during the diabetes education portion ($1.00/instructional handout booklet for 30 people x 2 handouts distributed for 8 programs=$480). Lastly the evaluation surveys will need to be taken at the end of each program (.2/survey x 2 surveys x 30 people x 8 programs=$96)=$921 Equipment: 1. Glucose monitors, Lancets, test strips: As part of the program, equipment will be demonstrated and then given to each woman participant. Glucose Monitors: $10/monitor x 30 woman x 8 programs= 2,400. Lancets: $3/ 25 pack x 30 woman x 8 programs=$720. Testing strips: $10/ 25 pack x 30 woman x 8 programs= 2,400 for a total of =$5,520. Extra supplies also required=$480 2. Cooking equipment: Though much of this will be supplied by the organization Sacramento County Health Promotion, , extra utensils will need to be purchased for the multiple tables. Cooking equipment: $10/utensil x 5/table x 6 tables=$300. 3. Sound equipment: Some parts of the sound equipment, not previously purchased by the organization, Sacramento County Health Promotion, will need to be rented out. $23/session x 8 sessions x 8 programs= $1,472 Food: Is the responsibility to communicate to get everything needed on is the shopper. Since cooking demonstrations and preparations by the tables happens each week, food for

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30 woman; $300/week x 8 weeks/ programs x 8 programs =19,200, plus $800 for problems that may occur. *Week 8 is potluck for the whole family and will not require food, shoppers or registered dieticians, or childcare. Appendix A Evaluation: Daily Activities During the past 4 weeks, how much... (Circle one) Not at all Slightly Moderately Quite a bit

Almost totally

1. Has your health interfered with your normal social activities with family, friends, neighbors or groups?..............................0 1 2 3 4 2. Has your health interfered with your hobbies or recreational activities?....0 1 2 3 4 3. Has your health interfered with your household chores? ..............................0 1 2 3 4 4. Has your health interfered with your errands and shopping?......0 1 2 3 4 Your Glucose Testing 1. Do you have a machine to measure your blood sugar (glucose) level? - Yes - No 2. On how many days in the last week did you test your blood sugar level? (If you were sick in the last week, think of the most recent 7 days when you were NOT sick) ________ days 3. On days that you test your blood sugar, how many times do you test on average? _______ times 5. Physical Activities During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following? (Please circle one number for each question.) none less than 30 min/wk 30-60 min/wk 1-3 hrs/week more than 3 hrs/wk 1. Stretching or strengthening exercises (range of motion, using weights, etc.......0 1 2 3 4 2. Walk for exercise................................................0 1 2 3 4 3. Swimming or aquatic exercise............................0 1 2 3 4 4. Bicycling (including stationary exercise bikes)..................................................0 1 2 3 4 5. Other aerobic exercise equipment (Stairmaster, rowing, skiing machine, etc.)..0 1 2 3 4 6. Other aerobic exercise Specify_________________________...............0 1 2 3 4 Confidence About Doing Things For each of the following questions, please circle the number that corresponds with your confidence that you can do the tasks regularly at the present time. 1. How confident do you feel that you can eat your meals every 4 to 5 hours every day, including breakfast every day? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 2. How confident do you feel that you can follow your diet when you have to prepare or share food with other people who do not have diabetes?

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Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 3. How confident do you feel that you can chose the appropriate foods to eat when you are hungry (for example, snacks)? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 4. How confident do you feel that you can exercise 15 to 30 minutes, 4 to 5 times a week? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 5. How confident do you feel that you can do something to prevent your blood sugar level from dropping when you exercise? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 6. How confident do you feel that you know what to do when your blood sugar level goes higher or lower than it should be? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 7. How confident do you feel that you can judge when the changes in your illness mean you should visit the doctor? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident 8. How confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do? Not at all confident -1 2 3 4 5 6 7 8 9 10 - Very confident Your Diet 1. How many times last week did you eat breakfast when you got up? __ times last week 2. This morning, did you eat any of the following foods for breakfast? (Please check all that apply) o milk ( cup) o cheese T yogurt o eggs o meat, poultry, or fish o beans *(Stanford University School of Medicine. (2004).) Appendix B: Example Flyer:

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Appendix C: Program Specifics for each Session: Weeks Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Cooking Topic Food Groups Eating well on a budget Healthy meals with little time Meals for the whole family Dinner from the food bank From can to plate No appliance needed meal Potluck with the kids Dish Rice salad Tacos Veggie frittata Spaghetti with a boast Casserole Chicken salad Fresh sandwiches Evaluation Diabetes Lesson How eating well can lower risk factors of diabetes Introduce equipment and how it works Time to practice with the equipment Teach the importance of managing blood glucose Other ways to self monitor How to share with others about management Other ways to lower risk factors of diabetes none

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