U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Monday, September 22, 2014

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives


Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: July 2012

Lifestyle Therapy

Clinical Practice Recommendations

Diabetes Self-Management Education (DSME)

recommendations icon Recommendations for Diabetes Self-Management Education

  • Ensure that every person with diabetes receives individualized DSME at diagnosis and as needed thereafter to achieve treatment goals:

Diabetes self-management education (DSME) is an integral part of diabetes care to help patients achieve glycemic control and successful outcomes. DSME provides knowledge and builds skills and abilities needed for effective self-care through informed decision making, problem solving, and collaboration with the health care team. The goal of DSME is to improve clinical outcomes, health status, and quality of life for people with diabetes. Ongoing self-management support from the diabetes care team helps individuals sustain behavioral changes as they confront challenges due to aging, lifestyle changes, and progression of the disease process.

DSME services may be offered through a formal education program or through brief encounters that focus on the individual needs of the patient and/or family member/caregiver. The diabetes care team and the patient use the DSME process to assess needs, set self-management goals, develop an action plan, and foster active participation in health care decisions. DSME is a Medicare-reimbursable service when provided by an accredited program.

DSME programs are available in many AI/AN communities. Many of these programs use a comprehensive, AI/AN-specific DSME curriculum, Balancing Your Life and Diabetes.

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Medical Nutrition Therapy (MNT)

recommendations icon Recommendations for Medical Nutrition Therapy (MNT)

  • Refer every person with diabetes/prediabetes to a registered dietitian (RD), whenever possible, for individualized MNT at diagnosis and as needed thereafter to achieve treatment goals.
  • Lifestyle counseling by all clinicians needs to include these core messages: implement dietary modifications that reduce intakes of calories, saturated and trans fatty acids, and sodium, and increase physical activity to improve glycemia, dyslipidemia, and blood pressure.
  • Evaluate patients for food insecurity and accessibility and affordability of nutritious foods available to them; refer them as needed to food resources available in the community.

MNT includes individualized assessment, intervention, monitoring, and follow-up of nutrition interventions specific to the management and treatment of diabetes, other diseases, and other health conditions. Delivered by a RD who uses nationally recognized Academy of Nutrition and Dietetics protocols, MNT involves intensive nutrition counseling and therapy that relies heavily on follow-up and feedback to change behavior over a period of time.

There is good evidence that MNT is effective at any time in the disease process, but it appears to have its greatest effect in lowering A1C at initial diagnosis. MNT also has been shown to be cost-effective and is a Medicare-reimbursable service when provided by a RD.

A major factor that prevents many people with diabetes from adhering to MNT approaches is food insecurity. Nearly half of all households below the poverty level in the U.S. are food insecure, including AI/AN, who are overrepresented among low-income families. Food insecurity means these families are at risk of going hungry because of an inability to find or afford adequate food. In terms of diabetes, food insecurity creates a major barrier to managing and preventing diabetes effectively, and contributes to health disparities and disease burden.

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Physical Activity

recommendations icon Recommendations for Physical Activity

  • Document patients’ level of physical activity at diabetes visits and encourage individuals to set behavioral goals to begin or increase physical activity.
  • Assess patients for medical conditions that might affect the type, frequency, and intensity of physical activity in which they engage:
    • Some patients may require screening and additional testing before starting a physical activity program. See the American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription:
      Decision Tree Figure [PDF - 43KB]
  • When available, referral to a fitness specialist for supervision and coaching is highly recommended. There are fitness specialists and programs available in many AI/AN communities.

Physical activity is important for achieving glycemic control goals, and it is a core component of diabetes self-management. Physical activity improves strength and endurance, improves insulin action, lowers blood glucose levels, improves body mass index, and reduces depression. Any increase in physical activity – from daily living, occupational pursuits, and structured aerobic or resistance exercise – is beneficial for patients.

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Weight Management, Overweight and Obesity

recommendations icon Recommendations for Weight Management, Overweight, and Obesity

  • Assess weight and Body Mass Index (BMI) at diabetes visits.
  • Refer patients who are overweight (BMI 25.0-29.9 kg/m2) or obese (BMI ≥ 30 kg/m2) to structured community-based or clinic-based weight loss programs that emphasize goal setting, coaching, and motivational interviewing; education and skills development, physical activity, self-monitoring, problem solving, behavioral change, stress and stimulus control, the importance of social support, and the use of community resources.
  • Provide weight management counseling by a multidisciplinary team.
  • Providers may consider whether to discuss the option of bariatric surgery with diabetes patients who have a BMI ≥ 35 kg/m2, particularly when lifestyle therapy and pharmacotherapy fail to control diabetes or other comorbid conditions:
    • Ongoing lifestyle support and medical monitoring after surgery are needed for people with diabetes who undergo bariatric surgery.

Obesity and overweight, increasingly prevalent risk factors among AI/AN with diabetes, increase insulin resistance, and raise blood glucose levels. In turn, they exacerbate diabetes complications and make diabetes management more complex. Therapeutic lifestyle changes designed to achieve weight loss are the core components of weight management counseling, and are essential for managing diabetes and its comorbidities. See Table below for classification of weight and BMI.

Classification of Weight and Body Mass Index (BMI)

Classification BMI

Underweight < 18.4 kg/m2
Normal 18.5-24.9 kg/m2
Overweight 25-29.9 kg/m2
Obesity (Class 1) 30-34.9 kg/m2
Obesity (Class 2) 35-39.9 kg/m2
Extreme Obesity (Class 3) > 40 kg/m2

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Tobacco Use

recommendations icon Recommendations for Tobacco Screening and Cessation

  • Screen for non-ceremonial tobacco use (i.e., cigarette smoking and oral tobacco) at least annually and inquire periodically as to exposure to secondhand smoke.
  • Ask tobacco users at every diabetes visit about their willingness to quit, provide counseling, and offer tobacco dependence treatment.

Tobacco use rates among AI/AN people are the highest of any racial/ethnic group in the U.S., with 36% of adults, 18% of pregnant women, and 23% of youth reporting cigarette smoking in 2008. Tobacco use increases the already elevated risk of cardiovascular and microvascular complications in people with diabetes. Research shows that a brief tobacco dependence treatment intervention delivered by one provider can increase quit rates by as much as 80%.

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Resources

Tools for Clinicians and Educators

tools and resources icon Key Tools and Resources

Diabetes Self-Management Education (DSME)

IHS Division of Diabetes Treatment and Prevention. Indian Health Diabetes Best Practice Diabetes Self-Management Education (DSME) and Support, [PDF - 395KB] 2011.

American Association of Diabetes Educators. Setting Goals for AADE7 Self-Care Behaviors. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  2011.

Medical Nutrition Therapy (MNT)

IHS Division of Diabetes Treatment and Prevention.

American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes: A Position Statement of the American Diabetes Association. Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care. 2008 Jan;31 Suppl 1:S61-78.

Physical Activity

IHS Division of Diabetes Treatment and Prevention. Physical Activity and Diabetes Hub. Includes CME/CE online, quick guide cards, educational materials, best practices, and podcasts.

IHS Health Promotion/Disease Prevention and University of New Mexico. Physical Activity Kit (PAK): Staying on the Active Path in Native Communities…A Lifestyle Approach! This comprehensive audiovisual toolkit promotes age-appropriate physical activities across the lifespan of AI/AN people.

The American College of Sports Medicine and the American Diabetes Association. Joint Position Statement: Exercise and Type 2 Diabetes. Diabetes Care. 2010 Dec;33(12):2692–6.

University of Washington Health Promotion Research Center. Rapid Assessment of Physical Activity (RAPA). Exit Disclaimer: You Are Leaving www.ihs.gov 2006. The RAPA questionnaire enables clinicians to rapidly assess the level of physical activity of older adult patients.

Tobacco Use

Tobacco Use and Dependence Guidance Panel. U.S. Department of Health and Human Services. Rockville (MD). 2008.

U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Exit Disclaimer: You Are Leaving www.ihs.gov Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Office on Smoking and Health. 2010.

Weight Management, Overweight and Obesity

IHS Division of Diabetes Treatment and Prevention.

IHS. Healthy Weight for Life: A Vision for Healthy Weight Across the Lifespan of American Indians and Alaska Natives. 2011.

American Diabetes Association. Nutrition Recommendations and Interventions for Diabetes: A Position Statement of the American Diabetes Association. Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care. 2008 Jan;31 Suppl 1:S61-78.

additional resources icon Additional Resources

Diabetes Self-Management Education (DSME)

American Association of Diabetes Educators. Continuous Quality Improvement (CQI): A Step-by-Step Guide for Quality Improvement in Diabetes Education. 2nd Ed. Chicago (IL): American Association of Diabetes Educators. 2008.

American Association of Diabetes Educators Diabetes Education Accreditation Program (DEAP). Exit Disclaimer: You Are Leaving www.ihs.gov

  • Provides instructions, documents, guidance, and an accreditation process for DSME programs to achieve DEAP recognition that meets National Standards for DSME.

American Diabetes Association (ADA) Education Recognition Program. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Provides a mechanism for diabetes education programs and services to apply for ADA recognition that meets the National Standards for DSME.

Association of American Indian Physicians. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Website provides easy access to Native American-specific diabetes resources, such as diabetes tip sheets, public service announcements, posters, and more.

Healthy Interactions, Inc. in collaboration with the American Diabetes Association. US Diabetes Conversation Map® Kit. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Designed for providers to engage people with diabetes in conversations about diabetes and their self-care in small groups, kit includes a facilitator guide, five 3’ by 5’ colorful tabletop maps, and conversation cards. Providers need to attend a training session to obtain maps and facilitator kit.

Indian Health Service Division of Diabetes Treatment and Prevention.

Indian Health Service Healthcare Communications.

  • Website promotes improved communication between patients and providers, including “Ask Me 3,” “Patient Wellness Handout,” and goal setting document.

Learning About Diabetes, Inc. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Online database of free, easy-to-understand handouts that cover a wide array of diabetes topics.

National Diabetes Education Program. Making Systems Changes for Better Diabetes Care. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Web site provides information, models, links, resources and tools for health care professionals.

Wisconsin Diabetes Prevention and Control Program.

  • Follow-up Instruction Form for a Person with Diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  2011.
    Single page, low literacy demand form can be used to document post-visit follow-up plans. Space is provided to address two goals, five medicine changes, when to check blood glucose and when/how to share blood sugar results.

Medical Nutrition Therapy (MNT)

Indian Health Service Division of Diabetes Treatment and Prevention.

Envision New Mexico. University of New Mexico Health Sciences Center Department of Pediatrics. Pediatric Nutrition Telehealth (PNT). Exit Disclaimer: You Are Leaving www.ihs.gov

  • Web-based presentations help nutrition providers develop their skills in pediatric nutrition assessment, MNT, counseling, and working with individuals on treatment goals.

Physical Activity

Hansen D, Dendale P, Jonkers A, Beelan M, Manders RJF, Corluy L, et al. Continuous low- to moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training at lowering blood HbA(1c) in obese type 2 diabetes patients. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetologia. 2009 Sep;52(9):1789-97.

Topolski TD, LoGerfo J, Patrick DL, Williams B, Walwick J, Patrick MB. The Rapid Assessment of Physical Activity (RAPA) among older adults. Exit Disclaimer: You Are Leaving www.ihs.gov Prev Chronic Dis. [Internet]. 2006 Oct; [cited 2011 Nov 8]. Epub 2006 Sep 15.

Tobacco Use

Indian Health Service. IHS Tobacco Free Policy.

  • This circular establishes the IHS policy prohibiting the use of commercial tobacco in IHS-operated properties to protect the health, safety, and comfort of IHS employees, contractors, and visitors.

Centers for Disease Control and Prevention.

Tobacco Education Clearinghouse of California. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Offers over 500 low-cost educational materials covering tobacco use prevention, secondhand smoke exposure, and smoking cessation in a variety of formats for diverse audiences, including American Indian people youths and adults.

Weight Management, Overweight, and Obesity

National Diabetes Education Program. Small Steps. Big Rewards. Your Game Plan to Prevent Type 2 Diabetes. Healthcare Provider’s Toolkit. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 06-5334. 2006.

  • Based on the lifestyle modification strategies used in the Diabetes Prevention Program study, kit contains a decision pathway to diagnose and treat prediabetes, evidence-based strategies to motivate patients to lose weight, and copier-ready education materials.

National Heart, Lung, and Blood Institute. NHLBI Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Exit Disclaimer: You Are Leaving www.ihs.gov 1998.

  • Revision is being developed. Expected release is in 2012.

U.S. Department of Health and Human Services. The Surgeon General’s Vision for a Healthy and Fit Nation. Rockville, MD: Office of the Surgeon General. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  2010.

  • The recommendations identify opportunities for improving communities, encouraging healthy choices, and mobilizing medical communities.

Indian Health Service Division of Diabetes Treatment and Prevention and Division of Information Resource Management. Promoting a Healthy Weight in Children and Youth, Clinical Strategies: Recommendations and Best Practices. [PDF – 529 KB] 2008. 57 p.

  • Indian health specific guidelines, best practices, and resources for health care providers.

Weight-control Information Network (WIN). Exit Disclaimer: You Are Leaving www.ihs.gov National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health.

  • Resources for health professionals on nutrition, physical activity, weight control, and bariatric surgery.
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Patient Education Materials

Diabetes Self-Care

Indian Health Service Division of Diabetes Treatment and Prevention.

Indian Health Service and Partnership for Clear Health Communication at the National Patient Safety Foundation.

National Diabetes Education Program.

  • 4 Steps to Control Your Diabetes For Life. Exit Disclaimer: You Are Leaving www.ihs.gov NIH Publication No. 11-5492. 2011.
    Booklet reviews four steps that help people with diabetes understand, monitor, and manage their diabetes to help them stay healthy. Excellent for people newly diagnosed with diabetes or who just want to learn more about controlling the disease.
  • 2012 Diabetes Numbers at-a-Glance. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NDEP Publication No. 12. 2012.
    Based on American Diabetes Association 2012 clinical recommendations, this pocket guide provides a list of current recommendations to diagnose and manage prediabetes and diabetes.
  • Diabetes HealthSense. Exit Disclaimer: You Are Leaving www.ihs.gov
    Web site contains tools to help people with diabetes and those at risk make lifestyle and behavior changes. Includes videos and links to other web resources on lifestyle changes and behavioral strategies.

National Institute of Diabetes and Digestive and Kidney Diseases.

Nutrition

Indian Health Service Division of Diabetes Treatment and Prevention.

  • My Native Plate. 2012. Easy-to-understand nutrition and healthy eating tool. Front features a dinner plate. Back shows youth, breakfast, lunch and optional dinner plates. Based on the USDA My Plate and designed for American Indian/Alaska Native people. Best if printed as full-color 11 X 17.

Indian Health Service Nutrition Program. Strengthen the Family Circle. [PDF - 1.1MB]

  • This is an adaptation of the Dietary Guidelines for Americans for AI/AN people; it includes personal success stories and healthy eating posters. 2009.

American Diabetes Association

  • MyFoodAdvisor™ Exit Disclaimer: You Are Leaving www.ihs.gov is a free online calorie and carbohydrate counting tool that can help with diabetes management and nutrition. Tool includes over 5,000 food items, recipes, and meal planning tips.

National Institute of Diabetes and Digestive and Kidney Diseases. What I Need to Know About Eating and Diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 08–5043. 2007.

  • Easy-to-read illustrated booklet on nutrition and healthy eating for people with diabetes (available in large or standard format).

U.S. Department of Agriculture. ChooseMyPlate.gov. Exit Disclaimer: You Are Leaving www.ihs.gov

  • Interactive website on food and nutrition based on the 2010 Dietary Guidelines for Americans.

Physical Activity

National Institute of Diabetes and Digestive and Kidney Diseases. What I Need to Know About Physical Activity and Diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 08–5180. 2008.

  • Easy-to-read illustrated booklet on physical activity for people with diabetes.

Tobacco Use

U.S. Department of Health and Human Services. Smokefree.gov. Exit Disclaimer: You Are Leaving www.ihs.gov

  • The Smokefree.gov Web site has a step-by-step guide to quit smoking and other interactive tools, including opportunities for one-on-one help from an expert.

Weight Management, Overweight, and Obesity

Moyer VA; U.S. Preventive Services Task Force. Summaries for patients: screening for and management of obesity in adults: U.S. Preventive Services Task Force Recommendation. Exit Disclaimer: You Are Leaving www.ihs.gov Ann Intern Med. 2012 June 26.

Small Steps. Big Rewards. Your Game Plan to Prevent Type 2 Diabetes. Information for Patients. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 06-5334. 2006.

  • Booklet for individuals to develop their own game plan to prevent type 2 diabetes by setting goals and tracking their progress, and work with their health care team, family, and friends. Booklet based on the successful Diabetes Prevention Program study.

Small Steps. Big Rewards. Game Plan Fat and Calorie Counter. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 06-5334. 2006.

  • Tool for individuals for weight management and diabetes prevention to identify fat grams and calories for more than 1,500 commonly eaten foods.

Small Steps. Big Rewards. Game Plan Food and Activity Tracker. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  NIH Publication No. 06-5334. 2006.

  • Provides patients with the tools to help them begin making lifestyle changes, documenting their daily physical activity and dietary intake and the impact of reducing dietary fat grams and calories with this daily and one-week copier-ready tracker.
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Bibliography

Bariatric Surgery

Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122:248-56.

Dixon JB, Zimmet P, Alberti KGMM, Rubino F; IDF Taskforce on Epidemiology and Prevention. Bariatric surgery: an IDF statement for obese type 2 diabetes. Diabet Med. 2011;28(6):628-42.

Poirier P, Cornier M, Mazzone T, Stiles S, Cummings S, Klein S, et al. Bariatric surgery and cardiovascular risk factors: a scientific statement from the American Heart Association. Circulation. 2011. Epub 2011 Mar 14.

Diabetes Self-Management Education (DSME)

American Association of Diabetes Educators. AADE position statement: individualization of diabetes self-management education. Diabetes Educ. 2007 Jan-Feb;33(1):45-9.

American Association of Diabetes Educators. AADE7 self-care behaviors. Diabetes Educ. 2008;34:445-9.

American Association of Diabetes Educators. The art and science of diabetes self-management education desk reference. Mensing C, editor. 2nd ed. Chicago (IL): American Association of Diabetes Educators; 2010.

Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, et al. National standards for diabetes self-management education. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2012; 35 Suppl 1:S101-108.

Funnell MM, Tang TS, Anderson RM. From DSME to DSMS: developing empowerment-based diabetes self-management support. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Spectrum. 2007;20(4):221-6.

Medical Nutrition Therapy (MNT)

Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG, Franz MJ, et al. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2008;31 Suppl 1:S61-78.

Coleman-Jensen A, Nord M, Andrews M, Carlson S. Household food security in the United States in 2010: Economic Research Report 125, U.S. Department of Agriculture, Economic Research Service; Exit Disclaimer: You Are Leaving www.ihs.gov 2011 Sep. 29 p.

Coppell KJ, Kataoka M, Williams SM, Chisholm AW, Vorgers SM, Mann JI. Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatment—Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  BMJ. 2010;341;c3337.

Franz MJ, Powers A, Leontos C, Holzmeister LA, Kulkarni K, Monk A, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. Exit Disclaimer: You Are Leaving www.ihs.gov J Am Diet Assoc. 2010 Dec;110(12):1852-89.

O’Connell M, Buchwald DS, Duncan GE. Food access and cost in American Indian communities in Washington State. Exit Disclaimer: You Are Leaving www.ihs.gov J Am Diet Assoc. 2011 Sept;111(9):1375-9.

Paxton AE, Strycker LA, Toobert DJ, Ammerman A, Glasgow RE. Starting the conversation: performance of a brief dietary assessment and intervention tool for health professionals. Exit Disclaimer: You Are Leaving www.ihs.gov Am J Prev Med. 2011 Jan;40(1):67-71.

Salas-Salvadó J, Bulló M, Babio N, Martínez-González MA, Ibarrola-Jurado N, Basora J, et al. Reduction in the incidence of type 2 diabetes with the Mediterranean diet: results of the PREDIMED-Reus Nutrition Intervention Randomized Trial. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2011 Jan;34(1):14-9.

Seligman JL, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med. 2010 Jul;363:6-9.

Stang J. Improving health among American Indians through environmentally-focused nutrition interventions. J Am Diet Assoc. 2009 Sep;109(9):1528-31.

U.S. Department of Agriculture; U.S. Department of Health and Human Services. Dietary guidelines for Americans, 2010. Exit Disclaimer: You Are Leaving www.ihs.gov 7th ed. Washington (DC): U.S. Government Printing Office; December 2010. 95 p.

Van Horn L, McCoin M, Kris-Etherton PM, Burke F, Carson JA, Champagne CM, , et al. The evidence for dietary prevention and treatment of cardiovascular disease. Exit Disclaimer: You Are Leaving www.ihs.gov J Am Diet Assoc. 2008 Feb;108(2):287-331.

Wilson C, Brown T, Acton K, Gilliland S. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian Health Service. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2003;26(9):2500-4.

Physical Activity

American College of Sports Medicine. ACSM’s guidelines for exercise testing and prescription, 8th ed. Baltimore: Lippincott Williams & Wilkins; 2009 Apr. 400 p.

Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, et al. Exercise and type 2 diabetes. The American College of Sports Medicine and the American Diabetes Association: joint position statement. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2010 Dec;33(12):2692-6.

Donnelly J, Blair SN, Jackicic J, Manore MM, Rankin J, Smith BK, et al. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Exit Disclaimer: You Are Leaving www.ihs.gov Med Sci Sports Exerc. 2009 Feb;41(2):459-71.

Fretts AM, Howard BV, McKnight B, Duncan GE, Beresford SAA, Calhoun D, et al. Modest levels of physical activity are associated with a lower incidence of diabetes in a population with a high rate of obesity: the Strong Heart Family Study. Exit Disclaimer: You Are Leaving www.ihs.gov Diabetes Care. Published online before print June 20, 2012, doi: 10.2337/dc11-2321.

Hansen D, Dendale P, Jonkers A, Beelan M, Manders RJF, Corluy L, et al. Continuous low- to moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training at lowering blood HbA(1c) in obese type 2 diabetes patients. Diabetologia. 2009 Sep;52(9):1789-97.

Topolski TD, LoGerfo J, Patrick DL, Williams B, Walwick J, Patrick MB. The Rapid Assessment of Physical Activity (RAPA) among older adults. Exit Disclaimer: You Are Leaving www.ihs.gov Prev Chronic Dis. [Internet]. 2006 Oct; [cited 2011 Nov 8]. Epub 2006 Sep 15.

Tobacco Use

Asman K, O’Halloran A, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Quitting smoking among adults Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  — United States, 2001–2010. Morb Mortal Wkly Rep. 2011 Nov 11;60(44):38-45.

Caraballo RS, Yee SL, Pechacek TF, Henson R, Gfroerer JC. Tobacco use among racial and ethnic population subgroups of adolescents in the United States. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Prev Chron Dis. 2006 Apr;3(2):A39. Epub 2006 Mar 15.

Carson KV, Brinn MP, Peters M, Veale A, Esterman AJ, Smith BJ. Interventions for smoking cessation in Indigenous populations. Exit Disclaimer: You Are Leaving www.ihs.gov Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD009046. DOI: 10.1002/14651858.CD009046.pub2.

CDC. Smoking and tobacco use: trends in current cigarette smoking among high school students and adults, United States, 1965–2010. Exit Disclaimer: You Are Leaving www.ihs.gov Atlanta, GA: US Department of Health and Human Services, CDC; 2011.

Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 update: clinical practice guideline. Rockville (MD): Department of Health and Human Services (US), Public Health Service; 2008 May.

Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz N, Curry SJ, et al. Treating tobacco use and dependence: 2008 update: quick reference guide for clinicians. Rockville, MD: U.S. Department of Health and Human Services. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]   Public Health Service. April 2009.

Jamal A, Dube S, Malarcher AM, Shaw L, Engstrom MC. Tobacco use screening and counseling during physician office visits among adults — National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005 Exit Disclaimer: You Are Leaving www.ihs.gov – 2009 Supplements. Morb Mortal Wkly Rep. 2012 Jun 15;61(02):38-45.

Ranney L, Melvin C, Lux L, McClain E, Lohr KN. Systematic review: smoking cessation intervention strategies for adults and adults in special populations. Exit Disclaimer: You Are Leaving www.ihs.gov Ann Intern Med. 2006;145:845-56.

Sidransky D , Norman LA , McCarthy A , Taylor PL, editors. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Exit Disclaimer: You Are Leaving www.ihs.gov Atlanta (GA): Department of Health and Human Services (US), Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. 704 p.

Tahiri M, Mottillo S, Joseph L, Pilote L, Eisenberg MJ. Alternative smoking cessation aids: a meta-analysis of randomized controlled trials. Exit Disclaimer: You Are Leaving www.ihs.gov Am J Med. 2012 Jun;125:576-84.

Yeh HC, Duncan BB, Schmidt MI, Wang NY, Brancati FL. Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study. Exit Disclaimer: You Are Leaving www.ihs.gov Ann Intern Med. 2010 Jan 5;152(1):10-7.

U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Exit Disclaimer: You Are Leaving www.ihs.gov Atlanta, GA: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Office on Smoking and Health. 2010.

Weight Management, Overweight, and Obesity

Franz MJ, VanWormer JJ, Crain AL, Boucher JL, Histon T, Caplan W, et al. Weight-loss outcomes: a systematic review and meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up. Exit Disclaimer: You Are Leaving www.ihs.gov J Am Diet Assoc. 2007;107:1755-67.

Klein S, Sheard NF, Pi-Sunyer X, Daly A, Wylie-Rosett J, Kulkarni K, et al. Weight management through lifestyle modification for the prevention and management of type 2 diabetes: rationale and strategies: a statement of the American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2004;27(8):2067-73.

LeBlanc ES, O’Connor E, Whitlock EP, Patnode CD, Kapka T. Effectiveness of primary care–relevant treatments for obesity in adults: a systematic evidence review for the U.S. Preventive Services Task Force. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Ann Intern Med. 2011 Oct;155(7):434-7.

Moyer VA; U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Exit Disclaimer: You Are Leaving www.ihs.gov Ann Intern Med. 2012 Sep 4;157.

NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Exit Disclaimer: You Are Leaving www.ihs.gov Bethesda (MD): Department of Health and Human Services (US), Public Health Service, National Institutes of Health; 1998 Sep. (NIH Publication No. 98-4083).

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