Major Health Issues and Chronic Disease Management of Adults Across the Life Span
abuse, p. 677
adult day health, p. 691
advanced medical directives, p. 677
Americans with Disabilities Act (ADA), p. 676
anorexia, p. 684
assisted living, p. 692
body mass index, p. 684
bulimia, p. 684
cancer, p. 682
cardiovascular disease, p. 681
caregiver, p. 677
caregiver burden, p. 677
Chronic Care Model (CCM), p. 680
chronic disease, p. 680
community-based model, p. 691
cultural and linguistic competence, p. 691
diabetes, p. 682
do-not-resuscitate order, p. 677
durable medical power of attorney, p. 677
erectile dysfunction, p. 688
Family and Medical Leave Act (FMLA), p. 677
financial exploitation, p. 677
frail elderly, p. 691
gay, p. 690
gestational diabetes mellitus (GDM), p. 685
health, p. 676
health screenings, p. 687
health status indicators, p. 678
heart disease, p. 681
home health, p. 691
hospice, p. 692
hypertension, p. 681
injury, p. 677
impoverished, p. 690
lesbian, p. 690
life expectancy, p. 678
living will, p. 677
long-term care, p. 692
menopause, p. 685
men’s health, p. 687
mental health, p. 676
neglect, p. 677
obesity, p. 684
Office of Men’s Health, p. 677
Office on Women’s Health, p. 677
Older Americans Act (OAA), p. 676
osteoporosis, p. 686
Patient Self-Determination Act, p. 677
Personal Responsibility and Work Opportunity Reconciliation Act, p. 677
physical activity, p. 681
preconceptual counseling, p. 685
prostate cancer, p. 688
rehabilitation, p. 692
reproductive health, p. 685
respite care, p. 691
sexually transmitted disease, p. 683
sexually transmitted infection, p. 683
stroke, p. 681
Temporary Assistance for Needy Families (TANF), p. 677
testicular cancer, p. 688
unintended pregnancy, p. 685
weight control, p. 684
women’s health, p. 676
—See Glossary for definitions
Monty Gross, PhD, RN, CNE
Dr. Monty Gross is Associate Professor of Nursing at James Madison University in Harrisonburg, Virginia. As a Certified Nurse Educator, he teaches in the bachelor’s and master’s programs. He holds a BS in communications from Clarion University of Pennsylvania and a BSN and MSN in community health from the University of Virginia. Since 1999 he has taught various nursing courses. In 2006 he completed his PhD from Virginia Tech. He has experience in both acute and critical care and continues to practice at the University of Virginia Medical Center, Charlottesville, Virginia.
Linda Hulton, PhD, RN
Dr. Linda Hulton is Professor of Nursing at James Madison University (JMU). She received her BSN in Nursing from Roberts Wesleyan College and her Masters and PhD in nursing from the University of Virginia. Prior to coming to JMU, she had over 20 years of clinical experience in community health. Her area of research interest is adolescent health promotion and unintended pregnancy. She has received grants for evaluation of school-based health programs and teen pregnancy prevention programs. She has served as a consultant to the Virginia State Public Health Department regarding school-based teen pregnancy prevention programs. She was named the JMU Mosier Fellow 2002-2003 for her work, “Strengthening the Safety Net: A Health Education Program for an Alternative High School.” She currently serves as Project Evaluator for the Federal Office on Adolescent Pregnancy Programs grant awarded to the Office on Children and Youth. She has had her scholarly work published in Issues in Comprehensive Pediatric Nursing, Sigma Theta Tau’s Online Journal of Knowledge Synthesis in Nursing, the Journal of Gynecological and Neonatal Nursing, The Journal of School Nursing, and the Journal for Specialists in Pediatric Nursing. At JMU, she teaches undergraduate courses in community health nursing and graduate courses in research and technology in nursing education.
Sharon Strang, RN, DNP, APRN, FNP-BC
Dr. Sharon Strang is an Assistant Professor of Nursing and an Assistant Professor in the Graduate School at James Madison University. She is a Board Certified Family Nurse Practitioner who practices at a free clinic. She received her BSN from Duquesne University in Pittsburgh, PA and her Masters of Science in Nursing from the University of Pennsylvania at Edinboro. Sharon completed a Post Masters Nurse Practitioner Certificate Program at Old Dominion University and received her DNP from the University of Virginia. The focus of her doctoral studies and grant writing is chronic disease. She has presented at national nursing and education conferences and published in nursing education and nurse practitioner journals. In 2005 she received the Virginia Council of Nurse Practitioner’s nurse practitioner in education award.
This chapter provides an overview of major health issues of adults that occur at various stages of life. Nurses struggle with these numerous and complex topics. As the Baby Boomers age, the health care system will be faced with large numbers of people needing care for chronic disease (Robine, Michel, and Herrmann, 2007). Unhealthy lifestyles, environmental pollution, and politics are a sample of factors a nurse will need to consider in population-centered health care. Descriptive statistics are frequently provided to help illustrate the significance of a disease or condition. There is strong evidence that community interventions, such as those designed for disadvantaged populations to improve diabetes care, can improve health through political involvement and strategies such as implementing well-planned programs (Glazier et al, 2006; Brownson, Chriqui, and Stamatakis, 2009). Significant changes are rapidly occurring in health care and in the communities through policy changes and research. Nurses will be better prepared to practice by having a better understanding of these major health issues.
Historical Perspectives on Adult Men and Women’s Health
Men and women have always faced a wide array of health issues that transition over time to impact their lives and the community. Gender inequalities span throughout time and all societies, damaging the health of both genders (WHO, 2007). Social and political climates influence research and funding agendas that ultimately affect how health care is delivered in the community. A gender gap has existed where the emphasis on health issues and community focus has given priority to one gender over the other through research, policies, and funding. This has resulted in the focus of prevention and treatment being on one or the other gender, depending on social and political time period. Gender disparities are an ongoing global problem (Holdcroft, 2007).
Historically men have dominated the medical and research professions because of cultural and societal norms. Because of this, health researchers focused on issues predominately oriented toward men with the exception of mental health (Riska, 2009). At the beginning of the twentieth century, discussions of women’s health focused primarily on reproduction and women’s roles as mothers. In the 1920s, with the birth control movement in its initial stages, women’s health expanded to address family planning and reproductive health. Women began to be empowered by the suffragette movement, winning the right to vote in 1920. As the women’s rights movement gained momentum, women’s health issues and the research of those issues displaced many issues of men. In the 1980s recommendations were made by the U.S. Public Health Services Task Force on Women’s Health Issues to increase gender equity in biomedical research and the establishment of guidelines for including women in federally sponsored studies (Alexander et al, 2007). In 1990 the Society for Women’s Research was founded. Through political action of the National Institute of Health (NIH), legislation once again included women and other minorities in research studies (NIH Revitalization Act of 1993).
As the United States prospered and scientific knowledge grew, illness and death rates from infectious diseases decreased and those of chronic diseases increased for men and women. Primary infections, for example, involving diarrhea and pneumonia shifted to chronic illnesses, such as cardiovascular disease and cancers (WHO, 2009). This transition occurred because vaccines were developed, living standards improved, and health policies and programs were implemented to reduce the spread of infections and increase life span.
Health Policy and Legislation
Health policy is action taken by public and private agencies to promote health. It is a reflection of the values held in society and can greatly influence the health of the citizens overall. Legislation consists of laws that regulate health care and promote health. Nursing practice and the care provided is impacted by policy and legislation. To be fully engaged in improving the health care from the bedside to the community level, nurses must understand how policy and legislation, along with other system factors such as social, cultural, and economic forces, can be incorporated into planning care for clients (Smith-Campbell, 2009).
The following are four examples of important federal legislation that has influenced the health of adults and their lives in communities: The Older Americans Act of 1965, the Americans with Disabilities Act of 1990, the Family and Medical Leave Act of 1993, and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.
The Older Americans Act (OAA), originally passed in 1965, established the Administration on Aging (AOA) and state agencies to provide for the social service needs of older people. The mission of the AOA is to help older adults maintain dignity and live independently in their communities through a comprehensive and coordinated network across the United States (AOA, 2010). In 2008, of the $1.9 billion funding allotted to the AOA, two thirds supported state and community grants for multiple social and nutritional service programs. Title III of the OAA authorizes funding for non-profit area agencies on aging to coordinate social services that provide supportive and nutritional services, family caregiver support, and disease prevention and health promotion activities. The services are available to all people age 60 or over, specifically targeted to those with the greatest economic or social need.
In 1990, the Americans with Disabilities Act (ADA) was passed, providing protection against discrimination to millions of Americans with disabilities. This legislation requires government and businesses to provide disabled individuals with equal opportunities for jobs, education, access to transportation and public buildings, and other accommodations for both physical and mental limitations. Although some business owners voiced concerns about the economic burden the required accommodations would cost, Travis (2009) points out that modification generally does not cost a lot of money in comparison to economic gain. Not only did the disabled, but the non-disabled and businesses themselves benefited from the changes.
The Family and Medical Leave Act (FMLA), initially passed in 1993, provides job protection and continuous health benefits where applicable for eligible employees who need extended leave for their own illness or to care for a family member. Frequently caregivers provide unpaid care for their family members, including aging parents, children, grandchildren, and partners. Often adults find themselves struggling to balance work and caring for a family member. More families find themselves in this struggle as more women enter the work force and work full time. Caregivers’ multiple roles and responsibilities are frequently coupled with financial strain, which can lead them to experience caregiver burden. In 2008 the Act was amended to increase military family entitlements (Rogers et al, 2009).
In 1996 Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act, commonly known as “welfare reform.” This law targeted women who received public assistance and changed the previous Aid to Families with Dependent Children (AFDC) to Temporary Assistance for Needy Families (TANF)—a work program that mandates that women heads-of-household find employment to retain their benefits. The Administration for Children and Families (ACF), within the Department of Health and Human Services (USDHHS) is responsible for federal programs such as TANF that promote the economic and social well-being of families, children, individuals, and communities (ACF, n.d.).
The nurse serves in a unique position for advocacy and support of health legislation and policy that supports the physical, mental, and social well-being of adults. Advocacy can be accomplished in a variety of ways such as lobbying, public speaking, participating in grass roots activities, and staying abreast of proposed legislation that influences the health of men and women, their families, and communities.
Ethical and Legal Issues and Legislation for Older Adults
Ethical issues regarding the care and treatment of older adults arise regularly. As the population continues to age and technological advances continue to be developed, complex ethical and legal questions will continue to increase. The most common of these issues involve decision making—assessment of the ability of the client to make decisions, the appropriate surrogate decision maker, disclosure of information to make informed decisions, level of care needed on the basis of function, and termination of treatment at the end of life. One often-overlooked concern of older persons is that of abuse. The National Center on Elder Abuse (NCEA), within the Administration on Aging, notes that abuse encompasses physical, emotional, and sexual abuse, as well as exploitation, neglect, and abandonment. Identification of abuse consists of recognizing the following: (a) The willful infliction of physical pain or injury, (b) infliction of debilitating mental anguish and fear, (c) theft or mismanagement of money or resources, and (d) unreasonable confinement or the depriving of services.
Only one in six cases of elder abuse are reported, although nearly all states have enacted mandatory reporting laws and have services available to provide assistance (Halphen and Sadowsky, 2009). Although legal definitions vary from state to state, the NCEA defines neglect as “the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Neglect may also occur if the person who has fiduciary responsibilities fails to pay for items or necessary home care services or, on the part of the in-home service provider, to provide the necessary care (NCEA, n.d., p 2). Older persons can make independent choices with which others may disagree. Their right to self-determination can be taken from them if they are declared incompetent. According to the Older Americans Act, financial exploitation is the “illegal or improper act or process of an individual, including a caregiver, using the resources of an older individual for monetary or personal benefit, profit or gain” (Area Agency on Aging, n.d., p 1).
During the assessment process, nurses will want to be aware of contradictions between injuries and the explanation of their cause, co-dependency issues between client and caregiver, and substance abuse by the caregiver. The local social services agency or area agency on aging can help with information on reporting requirements. Nurses can play a key role in reducing elder abuse.
The Patient Self-Determination Act of 1991 requires those providers receiving Medicare and Medicaid funds to give clients written information regarding their legal options for treatment choices if they become incapacitated. A routine discussion of advanced medical directives can help ease the difficult discussions faced by health care professionals, families, and clients (Emanuel, 2008). The nurse can help an individual complete a values’ history instrument. These instruments ask questions about specific wishes regarding different medical situations (Messinger-Rapport, Baum, and Smith, 2009). “Your Life Your Choices: Planning for Future Medical Decisions: How to Prepare a Personalized Living Will” (Pearlman et al, n.d.) is a valuable resource to help people by using scenarios and information to guide people through the process of developing advance medical directives. There are two parts to the advanced directives. The living will allows the client to express wishes regarding the use of medical treatments in the event of a terminal illness. A durable medical power of attorney is the legal way for the client to designate someone else to make health care decisions when he or she is unable to do so. A do-not-resuscitate order (DNR) is a specific order from a physician not to use cardiopulmonary resuscitation. State laws vary widely regarding the implementation of these tools, so it is important to consult a knowledgeable source for information. It is also important to involve the family, and especially the designated decision maker or agent, in these discussions so that everyone is clear about the client’s choices (Emanuel, 2008).
The environmental impact of an unhealthy environment adds significantly to the burden of disease for men and women. Men and women are often exposed to different environmental factors because of upbringing, employment, cultural, or tradition variations.
It is important to understand that the hosts (men and women) may respond differently to environmental factors. For example, Clougherty (2010) reports that women and girls are affected more than men and boys by air pollution. Both gender (a social construct) and sex (a biological construct) are factors that make identification of the impact of environmental hazards on men and women more complex. Social and environmental factors influence adults’ choices of health behaviors. Understanding how these factors impact health outcomes will require additional research and policy analysis (Angel and Angel, 2006; USDHHS, Healthy People 2020, 2010). Conducting gender analysis as part of research would help clarify if environment is influencing separate social and biological differences between men and women.
Governmental programs are in place to improve environmental health. The Centers for Disease Control and Prevention (CDC) Environmental Hazards and Effects Program (EHEP) is designed to prevent and control disease or death and to promote health and quality of life that result from interactions between people and their environments. The program uses indicators that can be used to assess and monitor progress on goals to improve the environmental health. It is incumbent on community health nurses to decrease the burden of disease resulting from an unhealthy environment (Levin P et al, 2008).
Health Status Indicators
Health status indicators are the quantitative or qualitative measures used to describe the level of well-being or illness present in a defined population or to describe related attributes or risk factors. They can be represented in the form of rates, such as mortality and morbidity, or proportions, such as percentages of a given population that receive immunizations (Community Health Status Indicators, 2008).
Over the past decade, efforts to reduce chronic disease risk factors have resulted in less-than-expected improvements. The CDC developed the Future Initiative (2005) as part of a major strategic planning process and developed a set of Health Protection Goals to track measure of mortality and morbidity by life stages. The goals were categorized by four themes, each with an overarching goal: Healthy People in Every Stage of Life, Healthy People in Healthy Places, People Prepared for Emerging Health Threats, and Healthy People in a Healthy World. Improvements were noted among all life stages with the exception of adults. Adults reported continued declining trends in perceived health status and dramatic declines in healthy weight indicators (Roy et al, 2009).
Life expectancy is a measure that is often used to gauge the overall health of a population. Although the United States spends more money per capita on health than any other country, other developed countries have a longer life expectancy for both genders. As illustrated in Figure 30-1, in the United States, life expectancy for men (75.2 years) ranked 25th out of 37 countries and territories and 23rd for women (80.4 years) (MMWR, 2008).
In 2007, both American men and women could expect to live longer than they did in 1990. Overall, American men gained 3.5 years of life and women could expect to live 1.6 years longer. Mortality from heart disease, stroke, and cancer has continued to decline in recent years and was substantially lower in 2006 than in 1950, decreasing overall by 46%. Specifically, the age-adjusted rates for heart disease declined by 66%, cerebrovascular disease by 75%, and the overall death rates for cancer declined 16% (NCHS, 2009). However, mortality from chronic respiratory disease and unintentional injury has not seen this decline (Miniño et al, 2009; NCHS, 2009).
Life expectancy and mortality rates also vary among ethnic/racial groups in the United States. The gap in life expectancy between white adults and African-American adults persists but has narrowed since 1990 (NCHS, 2009). The age-adjusted death rate was 1.3 times greater, infant mortality rate 2.4 times greater, and maternal mortality rate 3.4 times greater for the African-American population than for the white population. Life expectancy for the white population exceeded that for the African-American population by 5.0 years (Heron et al, 2009).
When healthy years of life are increased, longer life spans are generally considered desirable. However, increasing prevalence of chronic diseases and other conditions associated with aging can increase functional limitations and affect quality of life. Moreover, being male or female leads to different socialization, expectations, and lifestyles that affect and interact with health in very complex ways (Azad and Nashtar, 2005; Chandra and Minkovitz, 2006; Chang et al, 2006; Brittle and Bird, 2007).
Of particular concern is the high prevalence of adults with risk factors such as tobacco use, high cholesterol, obesity, and insufficient exercise habits, which are associated with chronic disease. Cholesterol levels have been dropping, in particular for
the older adults, because of a large increase of drug therapies. However, obesity rates remain high with more than one third of adults classified as obese in 2005 to 2006. Obesity rates among women vary by race and ethnicity; 53% of all non-Hispanic African-American women 20 years and over were obese in 2003 to 2006, compared with 42% of women of Mexican origin and 32% of non-Hispanic white women (NCHS, 2009).
The prevalence of diabetes, serious heart conditions, and hypertension among adults 45 to 64 years of age is strongly associated with poverty status. In lower-income populations, modifiable risk factors for these diseases are more common. The number of poor adults 45 to 64 with hypertension was similar to the percentage of higher income persons who were 65 to 74 years of age (NCHS, 2009).
Although women live longer than men, by about 5 years, they do not necessarily live those extra years in good physical and mental health. Women are more likely to use health services and report greater rates of disability. For instance, men have higher blood pressure levels than women through middle age. However, after menopause, women may be more affected by increased blood pressure. Some women experience changes in systolic blood pressure (Kim et al, 2006). Women also present with different risk factors and symptoms for cardiac-related conditions. Women often report more jaw/neck pain, dyspnea, back pain, fatigue, paroxysmal nocturnal dyspnea, and palpitations. Men and women were equally likely to report midsternal chest pain or pressure (Shin, Martin, and Howren, 2009).
Adult Health Concerns
In 1988 the CDC created the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). Chronic illness has become a public health problem of great proportions. The most common and costly chronic diseases are heart disease, diabetes, stroke, cancer, and arthritis. Chronic disease is the leading cause of preventable deaths, disability, and decreased quality of life. The costs accounted for more than 75% of the nation’s $1.4 trillion medical care spending in 2007 (NCCDPHP, 2007). Many models have been developed to guide the delivery of care to people with chronic illness. A complex health care system and community model was developed with the funding of the Robert Wood Johnson Foundation. This model is Wagner’s Chronic Care Model (CCM).
The CCM identifies the essential elements of a health care system that encourages high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. Evidence-based change concepts under each element, in combination, foster productive interactions between informed clients who take an active part in their care and providers with resources and expertise (Model Elements, 2007). The CCM continues to be implemented and evaluated today. Using electronic health records, provider reminders for key evidence-based care components, interprofessional teams communicating regularly, and community health classes to educate people with chronic diseases are ways the CCM is being implemented.
Family remains an important source of support for people with chronic disease. A recent review of programs whose purpose was to increase effective family support showed that programs that train families in supportive communication techniques have improved both health behaviors and client symptom management (Rosland and Piette, 2010).
More than one in three, or an estimated 81.1 million, American adults have one or more types of cardiovascular disease (CVD). The leading cause of death for African Americans, American Indians or Alaska Natives, Hispanics, and whites in the United States is heart disease. It is the leading cause of death for both men and women. Heart disease was responsible for 26% of deaths in 2006 (Heron, 2007). In 2010 the cost of heart disease to the United States was estimated to be $316.4 billion (Lloyd-Jones et al, 2010). In response to the high incidence and mortality rates of heart disease, the American Heart Association (AHA) has the following goal: “By 2020, to improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent” (AHA, 2010a).
Approximately 23 of the Healthy People 2020 objectives focus on cardiovascular disease. Reaching these objectives means intervening with all ethnicities in the United States. However, there continues to be gaps in knowledge and awareness for heart disease, particularly in women. In a 2009 survey of 2300 women age 25 or older, 60% of white women were aware that heart disease was the leading cause of death for women. However, only 43% of African-American women, 44% of Hispanic women, and 34% of Asian women knew the major cause of death for their gender. Knowledge of heart attack signs and symptoms have not increased since 1997 among all women surveyed, and only 53% of the women surveyed said they would call 911 if they thought they were having a heart attack (Mosca et al, 2010).
High blood pressure, or hypertension, is estimated to occur in one in three U.S. adults and, because hypertension does not have symptoms, one third of these people do not know they have the disease. Uncontrolled hypertension leads to heart attack, stroke, kidney damage, and a host of other complications. Only 77.6% of people with hypertension are aware they have the disease. Hypertension is controlled in 44.1% of people with the disease, 67.9% are under current treatment, and 55.9% do not have it controlled (AHA, 2010b). Although these numbers are not optimal, blood pressure control improved significantly from 1999 to 2006; however, racial, ethnic, and socioeconomic differences have not shown significant improvement (McWilliams et al, 2009). Both men and women have racial and ethnic differences in hypertension. Of non-Hispanic white males, 34.3% have hypertension compared with 43% of African-American males and 25.9% of Mexican-American men. Of African-American females, 44.8% have hypertension while 31.6% of Mexican-American women and 31.1% of non-Hispanic white women have hypertension (AHA, 2010). In a study conducted in New York City, the single most important factor for lack of blood pressure control was lack of a routine place of medical care (Angell et al, 2008).
Pazoki et al (2007) conducted a study on an intervention that focused on increasing physical activity in women in a community-based healthy heart program. This study included 335 healthy women from 25 to 64 years old and showed that a community-based lifestyle modification program significantly increased time spent in either moderate or vigorous physical activity, significant decreases in systolic blood pressure, and a significant increase in post-test healthy heart knowledge over the control group.
Strokes have decreased in the United States since the 1950s. However, the estimated prevalence of stroke in 2006 was 6.4 million (about 2.5 million males and 3.9 million females). This has decreased from 7 million in 2002. African Americans have almost twice the risk of first-time strokes as whites. Mexican Americans also have an increased incidence of stroke over non-Hispanic whites. Stroke is responsible for about 1 in 18 deaths. Since women live longer than men and strokes increase with age, more women are likely to die from stroke than men. In 2011, 60.6% of the stroke deaths were women (AHA, 2011).
Healthy People 2020 retained Objective 12-7 from Healthy People 2010 to reduce stroke deaths to 48 in 100,000. Community-based programs and policy regarding stroke care from initial signs and symptoms to after treatment have been developed by the AHA (Jones et al, 2008). Collaboration between health care institutions, community leaders, emergency medical services, and support groups within the community is needed for programs to be effective. Nurses can direct efforts toward smoking, since the incidence of ischemic stroke is twice as high in smokers as in adults who do not smoke (AHA, 2010).
Diabetes is a serious public health challenge for the United States. Of the 23.6 million people with diabetes, 12 million, or 11.2% of all men 20 years and older, have diabetes. Of all U.S. women more than 20 years old, 11.5 million, or 10.2%, have diabetes (CDC, 2008). In the United States, diabetes is an epidemic with 1 in 12 to 13 adults reportedly having diabetes, costing the nation approximately $174 billion each year. It is also estimated that for every three people who have diabetes, there is another who does not know he or she has it. Age-adjusted diabetes was diagnosed in 6.6% of non-Hispanic, 7.5% of Asian Americans, 10.4% of Hispanics, and 11.8% of non-Hispanic African Americans (CDC, 2008). The many complications associated with diabetes include heart disease, stroke, hypertension, retinopathy, kidney disease, neuropathies, amputations, and dental disease (NIDDK, National Diabetes Information Clearinghouse, 2008).
At least 18 of the goals of Healthy People 2020 are related to diabetes. There is a tremendous need in the community to strive to limit the toll this disease takes on the person and the community. Social and economic factors related to health and well-being need to be addressed.
Primary prevention includes educating adults about nutrition and the risks of obesity, smoking, and physical inactivity. Community interventions addressing healthy eating, exercise, and weight reduction can also benefit adults at risk for diabetes. Secondary prevention includes screening for diabetes with finger-stick blood glucose tests or glucose tolerance tests. Screening is also accomplished by thorough history and physical examination. Tertiary prevention targets activities aimed to reduce the complications of the disease.