1. HEALTH
PROMOTION
OF THE
UNSUSPECTING
INDIVIDUAL
In accordance with HIPAA Federal Law
(The Health Insurance Portability and
Accountability Act of 1996), this human
subject has given explicit consent for
use of her identifiers.
Presentation by: Heather L. O’Leary

2. WHO? Lois, a 71-year-old
Caucasian female,
retired from
administrative
assistant positions

3. HEALTH HISTORY
• Type II Diabetes Mellitus for 16 years
• Hypertension for approximately 30 years
• Dyslipidemia for approximately 20 years
• Coronary artery disease status post PTCA with
stent of LAD March 2007
• Degenerative disks with two herniations for
approximately 25 years
• Osteoarthritis for
approximately 25 years

4. HEALTH ASSESSMENT
• Body mass index at lower end of obesity range (value
withheld per patient request)
• Waist-to-hip ratio indicative of android figure (value
withheld per patient request), thus increasing risk of
obesity-related diseases and early mortality (Jarvis,
2004)
• Hemoglobin A1c 6.4% (high); HDL 35mg/dL (low); LDL
70mg/dL (normal); triglycerides 130mg/dL (normal) as
of September 3, 2008
• Blood pressure 128/72; resting pulse 78, regular;
respirations 14, regular, even, and unlabored;
temperature 36.8°C
• Medications include Glucophage 800mg twice daily;
Amaryl 1mg daily; Byetta 10mg twice daily; Lipitor 40mg
daily; Toprol XL 50mg daily; Norvasc 5mg daily

5. Psychosocial and Cultural
Concepts
• Middle-class, suburban dweller entire life;
residency solely limited to Lorain, Ohio
• High-school education, with some college
courses, but no degree/diploma
• Divorced after 16 years of marriage
in 1986 with two daughters
• Born at the end of the Great Depression; heard many recounts of
period, but does not feel as though ever personally affected
• Practicing Jehovah’s Witness
• Full confidence in Western medicine; skeptical of holistic approaches
• Maintains network of friends with regular scheduled and unscheduled
outings
• Never considered self physically active “because ladies were not . . .
unless housework counts”

6. “ No, because ladies were not
expected to be physically active
“
unless housework counts.
”
EXERCISE?

7. Psychosocial and Cultural
Concepts (continued)
• Ex-smoker, 3 pack-per-day habit, beginning at age 15 until age
44 with short periods of cessation secondary to quitting
attempts and pregnancies
• Socially consumes alcohol, 2 drinks biweekly
• Relates not experiencing much stress after retiring six years
ago, with the exception of occasional financial concerns;
recognizes that such concerns are often due to “retail therapy”
• Expresses some distaste for polypharmacy secondary to act of
consumption itself alone

8. Health Beliefs
• Acknowledges having some control over health (e.g.
improving diet and increasing physical activity) yet
states, “It is also taken care of with medicine.”
• Recent visit of similarly-aged friend in nursing home
revealed new perspective: “I guess I should be very
thankful I’ve been so fortunate with my health. Before
seeing her, I just thought I was old and felt average for
my age.”
• Now rates health as “above-average” but recognizes
“room for improvement”

9. VS
“ [My health] is also taken care of
with medicine.

10. RISK FACTORS
• History of diabetes, hypertension, dyslipidemia, and
coronary artery disease
• Familial history of paternal hypertension and multiple
cerebrovascular accidents, paternal multiple falls with
resultant hip fractures; questionable maternal diabetes with
vascular disease, maternal myocardial infarction; sister with
ovarian cancer, hypertension, coronary artery disease with
three myocardial infarctions; brother with hypertension and
multiple stents secondary to coronary artery disease
• Lack of regular physical activity
• Lack of health-conscious diet
• Non-adherence to regular measurements of blood glucose
levels
• Mild obesity

11. DO
YOU
MONITOR?
“ Sometimes it’s just easier not to
know what my sugar is.
”

12. …time for change!
PLAN OF
ACTION
#1 Education
#2 Discussion

13. PART ONE:
Education

14. Education: PASS ON DESSERTS
Teach implications of less-than-optimal diet and
failure of self-monitoring blood glucose:
#1 Risk for fractures
#2 Diabetic complications, including worsening of
coronary artery disease (i.e. additional
PTCA/stents/possible bypass) as well as
cerebrovascular accident, vascular issues,
neuropathy, nephropathy, retinopathy and
subsequent diagnoses
(American Diabetes Association, 2008)

15. BLOOD IS THICKER
Education: THAN WATER
Correlate implications of history:
Correlate implications with particular emphasis on
diabetic complications with personal and familial
health histories to show relevancy

16. Education: LET’S GET PHYSICAL
Teach implications of physical inactivity:
Provide information regarding physical activity
improving current conditions, and delay and/or
prevention of others
(American Heart Association,
2008; National Institute of
Diabetes and Digestive and
Kidney Diseases, 2006)

17. Education: KEEP ON PRICKIN’
Teach implications of poor blood glucose monitoring:
Provide information regarding blood glucose control
and effects upon present diagnoses and possible
complications of poor control; show chart explaining
identical Hemoglobin A1c of 8.0% being not indicative
of good glucose control as chart proves can be great
daily variances during 30-day measurement period,
1/3 less than the required 90 days to determine A1c
value
(Kovatchev, 2007)

18. (American Diabetes Association, 2008)

19. Education: KEEP ON PRICKIN’
Teach implications of poor blood glucose monitoring:
Reinforce necessity of daily glucose checks as “HbA1c
levels increase steadily as the number of lipid
abnormalities increase . . . [with] low HDL [being] the
most common high-risk abnormality (59.8%) . . . and
women [being] much more likely to have multiple
lipid abnormalities”
(Brown, Nichols, Hayes, & Bowman, 2004)
Capitalize on “lifestyle changes” aspect to include
“glycemic control”

20. Education: IT’S NEVER TOO LATE
Teach value of physical activity:
Enforce research that has
determined “it’s never too late to
become physically active” and that
“even a small amount of activity can
result in better health”
(Agency for Healthcare
Research and Quality and the
Centers for Disease Control,
2002)

21. Education: PLAY “RATE YOUR PLATE”
Teach value of a well-balanced meal:
Play “Rate Your Plate”, available from the American
Diabetes Association on http://diabetes.org/all-about-
diabetes/chan_eng/i3/i3p4.htm; results were Lois’
plate often consisting entirely of carbohydrates, as
opposed to the ¼ recommendation; discussed
proportions of ½ non-starch vegetables and ¼ lean
protein
(American Diabetes Association, 2008)

22. PART TWO:
DISCUSSION

23. HEALTH
DISCUSSION:
BELIEFS
Although the Health Belief Model
is only appropriate for disease-
preventing behavior as opposed
to health-promoting, Lois
contends that,“nothing quite
motivates me like a threat”
(Pender, Murdaugh, & Parsons, 2006)

24. PERCEIVED
DISCUSSION: BENEFITS
+ Perceived benefits to action are verbalized as
“my health won’t deteriorate as quickly
without the changes”; “maybe I won’t have to
take as many pills”; and “since I have such an
addictive personality, maybe I can make this a
habit”

25. PERCEIVED
DISCUSSION: BARRIERS
-
Perceived barriers to action are verbalized as
“I find exercise boring”; “I have never
enjoyed sports”; and “I don’t want to hurt
myself . . . I can be so clumsy”

26. INCREASING
DISCUSSION: PHYSICAL
ACTIVITY
Emphasized benefits and addressed
barriers; discussed how regular
physical activity can increase
coordination as well as means of
finding enjoyable activities and Lois
decided upon walking: one 15-
minute session of walking either
outdoors or on the treadmill agreed
upon for the first week for 3 days,
increasing to 4 days the next, and 5
days the following; once 5 days of
activity is achieved weekly, the time
spent shall increase by 5 minute
increments weekly

27. FOOD &
DISCUSSION: BLOOD GLUCOSE
MONITORING
• Carbohydrates will be
decreased to ½ or less of the
plate for one month, then to
¼ the next month
• Blood glucose levels will be
checked daily for one month
then results to be discussed
with her endocrinologist to
determine any further
adjustments necessary

28. DISCUSSION: SUPPORT
Both the level of readiness and barriers
were evaluated to be relatively low,
necessitating high-intensity cues—e.g.
her “retail therapy” was dependent
upon adherence to physical activity
agreement; friends and family were
recruited as support; primary care
physician, cardiologist, and
endocrinologist were informed of plan

29. RESOURCES

30. AMERICAN
RESOURCES: DIABETES
ASSOCIATION
www.diabetes.org
• Founded in 1940, the mission is “to prevent and cure the lives of all people affected by
diabetes”
• Vision is “to make an everyday difference in the quality of life for all people with
diabetes”; core values are “integrity, leadership, ownership, inclusion, trust, [and]
passion for making a difference”
• ADA “funds research, publishes scientific findings, provides information and other
services to people with diabetes, their families, health health professionals, and the
public. [It] is also actively involved in advocating for scientific research and for the
rights of people with diabetes.”
• The agency reports to the board of directors whose Chair is R. Stewart Perry
• Senior management is overseen by CEO Larry Hausner
• Departments include accounting, administrative and clerical, communications,
community initiatives, customer service, finance, fund-raising, government relations and
advocacy, human resources, information systems, legal, marketing, publications, and
research

31. AMERICAN
RESOURCES: DIABETES
ASSOCIATION
www.diabetes.org
(continued)
• Funding is via corporate and private donations
• The National Office and Service Center in Alexandria, VA employs 302 people; other
offices are dispersed nationwide, with the majority in the eastern half of the United
States
• The vast array of information provides an invaluable resource to Lois; she has located a
support group at St. John Westshore Hospital; she was astounded during the
navigation of the site with the data available (e.g. diet, exercise, and solutions to
common questions; she feels she is “much more inclined to find answers since I always
forget while I’m in the doctor’s office. I also forget to bring the list of questions that
I’ve written down. I don’t want to call and bother anybody, and hopefully I won’t
forget by the time I reach the [ADA] website. Or forget the website. I tell ya, it’s you-
know-what getting old!” (The ADA was made Lois’ homepage in order address the
aforementioned.)
(American Diabetes Association, 2008)

32. RESOURCES: WEIGHT
WATCHERS
www.weightwatchers.com
• Founded in early 1960’s by Jean Nidetch by inviting a group of friends to her home
to discuss weight loss strategies; mission now is “to help people lose weight in a
sustainable way by helping them adapt a healthier lifestyle and a healthier relationship
with food and activity”
• The agency consults with a “Scientific Advisory Board” but ultimately defers
members to their own private healthcare provider
• David Kirchhoff is the president and CEO
• Funding is received by donations, sales, and membership fees
• Employees consist of leaders who conduct group meeting, weigh members, and
provide motivation and instruction on the Weight Watchers plan; and receptionists
who personally welcome, assist, encourage, and support members as well as collect
and tally all fees and sales, weigh members, and distribute materials; no figure is
available for number of employees

33. RESOURCES: WEIGHT
WATCHERS
www.weightwatchers.com
(continued)
• By supporting the recommendations of the American Diabetes Association, the
American Heart Association, the National Institute of Diabetes and Digestive and
Kidney Diseases, and the Agency for Healthcare Research and Quality and the
Centers for Disease Control, Weight Watchers aims to “help make healthy eating
decisions, and encourage [members] to enjoy [themselves] by becoming more
active.” (Weight Watchers, 2008).
• Lois admittedly attended her first meeting solely due to the interpersonal influence of
her daughter: “If it will help you”; however, she found the meetings to be enjoyable
and informative; by feeling “accountable every week to someone other than myself”
she is motivated to pay closer attention to her intake and activity

34. EVALUATION: FOLLOW-UP
• Lois has adhered to the plan in its entirety at the third week interval…
perhaps under the not-so-accurate-and-not-corrected-when-presumed
pretense that it affects the grade of the project.
• She has lost 9 lbs. and her glucose monitors have ranged from 72-148. She
has noticed a decrease in the blood glucose levels as her activity increases.
She has an appointment with her endocrinologist October 30th, 2008 to
review her medications and discuss the frequency of the glucose
monitoring as she states on every occasion that an audience is present
during her routine, “This [the fingersticks] is only because I love my
children.”
• Discussion with her primary care physician has led to repeat lipid profiles
during the first week of December with referral to her cardiologist, as
necessary.

35. EVALUATION: FOLLOW-UP
• Lois has verbalized feeling “less achy” and an ability to now “power-shop”
since she experiences less fatigue during the day “which I had never
realized that I had before.”
• Lois notes that it is at times difficult to initiate the physical activity, but
once she has started, she consistently “feels so much better that I did, both
physically and because I am honoring my commitment.” This positive
activity-related affect increases her perceived self-efficacy, thus enabling her
to continue the behavior with higher likelihood. She has also placed a
television in front of her treadmill to enhance the situational influence of
indoor walking.
• Lois states that reducing her carbohydrate intake to ½ of her plate was
“easier than I thought” because prior to her plan, she concedes to “never
really paying attention to the type of food that I was eating.” She states
that the ADA website and Weight Watchers meetings seem to compliment
each other in their teachings.

36. HEALTHY PEOPLE 2010 OBJECTIVES
Healthy People 2010 Objectives that have been addressed in this
project are:
• 5 -7 Reduce deaths from cardiovascular disease in persons with
diabetes by implementing lifestyle changes, Lois has the capability to
decrease her risk.
• 5-17 Increase the proportion of adults with diabetes who perform
self-blood-glucose-monitoring at least once daily. Lois has been
adherent to this objective for 3 weeks and verbalizes commitment
to the plan until speaking with her endocrinologist.
• 12-11 Increase the proportion of adults with high blood pressure
who are taking action (for example, losing weight, increasing
physical activity, or reducing sodium intake) to help control their
blood pressure.

37. HEALTHY PEOPLE 2010 OBJECTIVES
Healthy People 2010 Objectives that have been addressed in this
project are:
• 22-2 Increase the proportion of adults who engage regularly,
preferably daily, in moderate physical activity for at least 30 minutes
per day.
• 22-4 Increase the proportion of adults who perform physical
activities that enhance and maintain muscular strength and
endurance. Lois has increased her physical activity to walking 20
minutes 5 times weekly and has lost 9 lbs. in 3 weeks.
• 19-2 Reduce the proportion of adults who are obese. Lois states
she has a better understanding of the term obese as it relates to
body mass index values and has verbalized a goal of a BMI less than
30 before January 1, 2009.

38. ON THE PATH TO BETTER HEALTH
THE END

39. REFERENCES
• Agency for Healthcare Research and Quality and the Centers for Disease Control (2002). Physical activity and older Americans.
Retrieved October 7, 2008 from http://www.ahrq.gov/ppip/activity.htm.
• American Diabetes Association. (2008). The American Diabetes Association. Retrieved October 5, 2008 from
http://www.diabetes.org/aboutus.jsp?WTLPromo=HEADER_aboutus.
• American Diabetes Association. (2008). Complications of diabetes in the United States. Retrieved October 5, 2008 from
http://www.diabetes.org/diabetes-statistics/complications.jsp.
• American Diabetes Association. (2004). Dyslipidemia management in adults. Diabetes Care. Retrieved October 5, 2008 from
http://professional.diabetes.org/Multimedia_Display.aspx?TYP=8&CID=53336.
• American Heart Association. (2008). Older Americans and physical activity. Retrieved October 5, 2008 from
<http://www.americanheart.org/presenter.Jhtml?identifier=811>.
• Brown, J. B., Nichols, G. A., Hayes, R. P., & Bowman, L. (2004). Poorer glycemic control is associated with dyslipidemia in type 2
diabetes. Retrieved October 5, 2008 from http://professional.diabetes.org/Abstracts_Display.aspx?TYP=1&CID=44264.
• Jarvis, C. (2004). Physical examination and health assessment (5th ed.). St. Louis:Elsevier.
• Kovatchev, B. (2007). Continuous glucose monitoring reduces risks for hypoglycemia and hyperglycemia and glucose variability in
diabetics. [Webcast]. Retrieved October 6, 2008 from
<http://professional.diabetes.org:80/flashplayer/player.asp?idspk=322…inicial=../content/ADA2007/sync/CT-
OR01/&Speed=Modem&current_slide=1>.
• National Institute of Diabetes and Digestive and Kidney Diseases. (2006). Tips to help you get active. Weight-control Information
Network. Retrieved October 6, 2008 from http://win.niddk.nih.gov/publications/tips.htm.
• Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). New Jersey: Pearson.
• U. S. Department of Health and Human Services. (2008). Healthy people 2010. Retrieved October 8, 2008 from
http://www.healthypeople.gov/document/html/objectives.
• Weight Watchers. (2008). History and philosophy. About us. Retrieved October 9, 2008 from
http://www.weightwatchers.com/about/his/history.aspx.