Minnesota Health care News October 2012

October 2012 • Volume 10 Number 10

Childhood diabetesRenée Mijal, PhD

Indoor air qualityKathleen Norlien, MS

Should we tax pop?

Roger Feldman, PhD

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Advisory Board: Minnesota Medical Association (MMA), Minnesota Hospital Association (MHA), MinnesotaMedical Group Management Association (MMGMA), Buyers Health Care Action Group (BHCAG), MinnesotaBusiness Partnership (MBP), Minnesota Healthcare Network (MHN), Advocates for Marketplace Options forMainstreet (AMOM), Minnesota HomeCare Association (MHCA), Minnesota Physician-Patient Alliance (MPPA),Physicians Service Network (PSN), Minnesota Center for Rural Health, and Minnesota Council of Health Plans.

Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our addressis 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; [email protected]. We welcome the submission of manuscripts and letters for possible publication. All viewsand opinions expressed by authors of published articles are solely those of the authors and do notnecessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publica-tion. The contents herein are believed accurate but are not intended to replace medical, legal, tax,business, or other professional advice and counsel. No part of this publication may be reprinted orreproduced without written permission of the publisher. Annual subscriptions (12 copies) are$36.00. Individual copies are $4.00.

SEPTEMBER 2012 MINNESOTA HEALTH CARE NEWS 3

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PUBLISHER Mike Starnes [email protected]

EDITOR Donna Ahrens [email protected]

ASSOCIATE EDITOR Janet Cass [email protected]

ASSISTANT EDITOR Scott Wooldridge [email protected]

ART DIRECTOR Elaine Sarkela [email protected]

OFFICE ADMINISTRATOR MaryAnn Macedo [email protected]

BUSINESS DEVELOPMENT DIRECTOR Juline Birgersson [email protected]

ACCOUNT EXECUTIVE Iain Kane [email protected]

www.mppub.com

OCTOBER 2012 • Volume 10 Number 10

INTERVIEW Presidential mattersPresident Barack Obama and Gov. Mitt Romney

CALENDARNational breast cancer awareness month

SPECIAL FOCUS: DIABETES Rising type 2 diabetesamong youthBy Renée Mijal, PhD, MPH,Tammy Didion, RD, LD, andBrandon Nathan, MD

Research updateBy Steven A. Smith, MD, andElizabeth R. Seaquist, MD

Saving money on diabetesBy Laurel Reger, MBA

ENVIRONMENTALHEALTHIndoor air qualityBy Kathleen Norlien, MS, CPH

7 PEOPLE

NEWS4C O N T E N T S

Laura GilchristPT, PhD

St. CatherineUniversity

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PERSPECTIVE

10 QUESTIONS

BEHAVIORAL HEALTH Attention deficit hyperactivity disorderBy Elizabeth Reeve, MD

HOSPITALS Long-term acute care hospitalsBy Rahul Koranne, MD, MBA, FACP

Roger Feldman, PhD

University ofMinnesota

Exp. Date

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MINNESOTA HEALTH CARE ROUNDTABLE MINNESOTA HEALTH CARE ROUNDTABLE

Background and Focus:The recent Supreme Court ruling on the Affordable Care Actclears the way for implementationof health insurance exchanges.States have the option of creatingtheir own exchange by January2014 or joining one created by thefederal government. A health insur-ance exchange would provide con-sumers a place to compare andshop for health insurance cover-age. In Minnesota this idea wasfirst proposed as part of thePawlenty administration’s health-care reform task force, and Gov.Dayton is a strong supporter ofcreating a state-run program.Though simple and compelling atfirst brush, creating a consumer-accessible, “apples-to-apples” web-

site for comparing health insurance costs is challenging and very complex.

Objectives: We will define what a health care insurance exchange is and,considering the detailed and proprietary design of health insurance coverage,how it can be meaningful. Health insurance policies contain terms like “med-ically necessary,” “investigative,” “cosmetic,” “not medically necessary,” and“contract/benefit exclusion”—all terms that are defined differently by differentinsurers. This alone makes it virtually impossible for anyone to compare planseffectively. Further, networks of providers vary, depending on whether youchoose the “bronze,” “silver,” “gold,” or “platinum” option within a given insurer,as will access to hospital-based facilities, DME providers, and ancillary servic-es. Throw in features like “deductibles,” “co-insurance,” “maximum out-of-pocketexpenses,” “formulary design,” and “covered preventive services,” and you havea bewildering mathematical matrix. We will offer suggestions as to how aninsurance exchange can address these issues and provide a meaningful, consumer-friendly comparison service.

Panelists:� Peter Dehnel, MD, President, Twin Cities Medical Society;

Medical Director for Utilization Management, BC/BS MN

� Dan Maynard, President, Connecture

� Beth McMullen, Health Policy Director, Minnesota Business Partnership

� Manny Munson-Regala, JD, Deputy Director of the Health InsuranceExchange, Department of Commerce

� Charles Sawyer, DC, Senior Vice President, Northwestern HealthSciences University

� Dan Schuyler, Director, Leavitt Partners

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Survey Finds Seniors OptimisticAbout HealthA new survey cosponsored byUnitedHealthcare (UHC) finds thatmost older Americans feel opti-mistic about their health, saying their best years are yet to come.

The study, sponsored by the National Council on Aging,Minnetonka-based UHC, and USAToday, surveyed 2,250 U.S. citi-zens age 60 or older. It found thatnearly 70 percent of respondentssay their past year has been nor-mal or better than normal, andmore than 75 percent of seniorsages 60–69 say they expect theirquality of life to stay the same orimprove over the next decade.

A large majority of seniorsgive themselves high marks whenit comes to maintaining theirhealth: 92 percent say they man-age stress very well or somewhatwell, and 84 percent say they areconfident that they will be able todo what is needed to maintain

their health over the next five to10 years.

However, only 52 percent saythey exercise or are physicallyactive at least four days per week.Ten percent say their physicalactivity is limited to a few daysper month; 11 percent say theyare never physically active.

“It’s encouraging that somany of our survey respondentsfeel confident and empowered tomaintain their health as they age,but it’s important that this positivemindset doesn’t prevent themfrom taking the necessary steps tocounter the epidemic of obesityamong our senior population,such as exercising most days ofthe week to help maintain ahealthy weight,” says RhondaRandall, DO, chief medical officer,UHC Medicare and Retirement.

The survey also finds a signif-icant minority of seniors who facepossible financial hardship andare not prepared for long-termcare costs. Concerns about finan-cial instability are most pro-nounced among low- and moder-ate-income survey respondents.

U of M Enlists Help To Find ClinicalTrial VolunteersThe University of Minnesota hasenlisted a national research reg-istry to help find volunteers forclinical trials.

The partnership between TheUniversity of Minnesota Clinicaland Translational Science Institute(CTSI) and ResearchMatch, anational group funded by theNational Institutes of Health, willhelp U of M researchers connectwith volunteers interested in participating in research studies.ResearchMatch gives potentialparticipants information aboutclinical trails and other researchthey might be interested in, offi-cials say.

“Registering with Research-Match is an easy way for individu-als to make a difference throughresearch that is happening here atthe University of Minnesota andother academic institutions acrossthe country,” says Bruce Blazar,MD, a blood and marrow trans-

plant expert and director of theUniversity’s CTSI.

Minnesota ranks high amongstates in the amount of medicalresearch being done. However,shortages of volunteers are anongoing problem for researchersand clinical trials. Officials sayResearchMatch can be a usefulresource for all kinds of researchefforts.

“Although data have shownthat there are many individualswho want to join research studies,it can be hard to find the rightmatch for them or their familymembers,” said Blazar. “Theprocess of finding the right partici-pant for the right clinical trial canbe improved, and ResearchMatchis one way we’re improving thatprocess.”

Eden Prairie Passes CommunityHealth InitiativeEden Prairie passed a HealthyEating Active Living resolution onAug. 21, making it the second

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Minnesota city to announce a pol -icy of supporting healthy lifestylestrategies.

A coalition of health groupscalled the Twin Cities ObesityPrevention Coalition (TCOPC) hasbeen promoting Healthy EatingActive Living programs. TCOPC issponsored by the Twin CitiesMedical Society and funded byBlue Cross and Blue Shield ofMinnesota. The first communityresolution was passed by Eagan in March.

“I think I can speak for all ourphysician members whenapplauding the Eden Prairie CityCouncil and Mayor Nancy Tyra-Lukens for their leadership andforesight in laying down a founda-tion for the future health and well-ness of Eden Prairie residents,”says Peter Dehnel, MD, presidentof the Twin Cities Medical Society.

The city council of EdenPrairie approved a group of strate-gies as part of the resolution thatincludes an emphasis on greenspace in planning housing devel-opments; promotion of active liv-ing infrastructure, i.e., bike lanes,walking paths, and other activity-promoting community planning;and development of a healthyvending machine and concessionspolicy for city-owned facilities.

The council also approvedfurther development of commun -ity gardens, farmers’ markets, and“edible playgrounds,” which aregardens planted and tended byschool-age children, who learn thebenefits of gardening and healthyeating through the project.

“In June, Eden Prairie intro-duced its first edible playgroundto teach children how food is pro-duced and inspire kids to eathealthy and nutritious food,” saysEden Prairie Mayor Nancy Tyra-Lukens. “Passage of this resolu-tion furthers the city’s commit-ment to be a healthy eating andactive living community.”

Report CallsInactivity Cause of Poor HealthA Mayo Clinic physiologist saysthat lack of exercise should be

treated as a medical condition.Michael Joyner, MD, writes in theJournal of Physiology that physi-cal inactivity affects the health notonly of obese people but also peo-ple of normal weight.

Workers with desk jobs, patients immobilized for long peri-ods of time after injuries or sur-gery, and women on extendedbed rest can all experience seriousmedical conditions, such as atrophied bone or muscle, Joyner says.

“I would argue that physicalinactivity is the root cause ofmany of the common problemsthat we have,” Joyner says. “If wewere to medicalize it, we couldthen develop a way, just likewe've done for addiction … togive people treatments, and life-long treatments, that focus onbehavioral modifications andphysical activity. And then we cantake public health measures, likewe did for smoking, drunken driv-ing, and other things, to limitphysical inactivity and promotephysical activity.”

HealthPartners, ParkNicollet to CombineOrganizationsIn one of the largest consolida-tions seen in the Twin Cities health industry in decades,HealthPartners and Park NicolletHealth Services have agreed to amerger.

The move, announced Aug.30, will make the new organizationone of the largest health deliverysystems in the state. HealthPart -ners’ unique position as both ahealth insurer and a delivery sys-tem may result in added scrutinyfrom regulators, who mustapprove the new arrangement.

Bringing together two largeprovider groups in the metro areais historic, but not totally surpris-ing at a time when ruralMinnesota is seeing many smallhealth systems being consolidatedinto larger groups. Health carereform and market pressures havealready led metro-based systemssuch as HealthPartners, Allina

News to page 6OCTOBER 2012 MINNESOTA HEALTH CARE NEWS 5

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Health, and Fairview HealthServices to gobble up small tomid-size practices.

The new agreement will create a 1,500-physician multi-spe cialty group practice that istied to HealthPartners’ insurancearm, although the clinics and hos-pitals involved will continue towork with other insurers as well.Officials say the two groups willhave a combined, consumer-governed board of directors. Theoverall group will maintain theHealthPartners brand, but clinicsand hospitals will continue withtheir current names for the nearfuture.

“HealthPartners and ParkNicollet share the same mission:making people healthier, makinghealth care more affordable, andcreating the best possible experi-ence for our patients and mem-bers,” says Mary Brainerd, presi-dent and CEO of Bloomington-based HealthPartners, who will beCEO of the combined organiza-tion. “Separately, and in partner-ship, we’ve worked toward these

goals in the Twin Cities area fordecades. Together, we’ll be betterable to pursue this mission acrossour region for the benefit of thepeople we serve.”

David Abelson, MD, presidentand CEO of St. Louis Park-basedPark Nicollet, will lead the neworganization’s care delivery system, which will be named the Park Nicollet HealthPartnersCare Group.

“Park Nicollet andHealthPartners are two of thestrongest local collaborators insupport of our common goal ofimproving access to high-quality,compassionate care for people inthe Twin Cities,” Abelson says. “Bycombining our organizations, we’lltake that collaborative spirit muchfurther, creating new potential formeeting the changing needs ofour community at this importanttime in health care.”

The combined operations willinclude Park Nicollet MethodistHospital in St. Louis Park, fourHealthPartners hospitals—RegionsHospital in St. Paul, LakeviewHospital in Stillwater, Hudson

Hospital in Hudson, Wis., andWestfields Hospital in NewRichmond, Wis.—and a large sys-tem of medical and dental clinicsacross the Twin Cities and westernWisconsin.

Officials say they do not predict any layoffs or closures offacilities as a result of combiningthe two groups. The new agree-ment will be effective Jan. 1, 2013.

State CoalitionLaunches HealthyMinnesota 2020A statewide coalition to improvethe health of Minnesotans hasapproved a plan called HealthyMinnesota 2020.

The plan was created by theHealth Minnesota Partnership, astatewide initiative consisting ofbusiness, academic, nonprofit,and governmental leaders. Thecoalition has been looking at what factors contribute to healthand how to address health issuesin the state. The MinnesotaDepartment of Health (MDH)

sponsored the coalition, andHealth Commissioner Ed Ehlinger,MD, convened the group inJanuary of this year.

“Where we live, play, learn,and work has a huge impact onour health,” says Ehlinger.“Because of this, our goal is toimprove the social, economic, and physical environments of ourcommunities so that all Minne-sotans have the opportunity to behealthy and reach their fullestpotential.”

The Healthy Minnesota 2020plan will provide a framework forensuring that every Minnesotanhas a chance to be healthy, offi-cials say. The coalition explored arange of factors that contribute tohealth, including social, economic,and environmental conditions. Theframework it came up with recog-nizes that good health doesn’tcome simply from health careproviders or healthy eating, but isa result of many complex factors,including communities that pro-mote healthy workplaces andschools.

News from page 5


Call to get help with: Planning for long-term care Remaining independent in your community Arranging for in-home services Getting help from state agencies Becoming involved in your community

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Ruby Tam, MD, has joined Northwest Family Physicians and will see

patients at its office in Crystal. Tam received a master’s degree in

chemistry at San Jose (Calif.) State University and worked for nine

years as a process/project development scientist before going to

medical school at Des Moines (Ia.) University. She completed her

residency at Methodist Hospital in St. Louis Park.

Jocelin Huang, MD, has joined Minnesota

Oncology and began practicing at its clinics in

Edina and Waconia in August. Huang received

her medical degree from the University of

Chicago Pritzker School of Medicine, and com-

pleted her fellowship in medical oncology and

hematology at Mayo Clinic in Rochester. Huang’s

areas of special interest include the treatment of

colorectal, pancreatic, and hepatobiliary cancers;

breast cancer; multiple myeloma; and lymphoma.

Sue Sendelbach, PhD, RN, of Allina Health, has been appointed

by Gov. Mark Dayton to the Minnesota Board of Nursing. Sendelbach

is the director of nursing research at Abbott Northwestern Hospital in

Minneapolis and has been a clinical nurse specialist in critical care

there for more than 20 years. Sendelbach is active in local and

na tional organizations dedicated to critical care, clinical nurse special-

ist issues, and care of patients with cardiovascular disease. Her four-

year board term began in June.

The Minnesota Alliance for Patient Safety (MAPS) has named

Marie Dotseth as its new executive director. Dotseth brings an exten-

sive background in health care and health care policy to her new role

in advancing MAPS’ safety agenda and providing education to

Minnesota’s health care providers. She has worked with the National

Institute of Health Policy at the University of St. Thomas, Children’s

Hospitals and Clinics, Minnesota Department of Health, and Allina

Health System, among others. Dotseth held an instrumental leader-

ship role when MAPS was founded in 2000, serving as co-chair.

Jewelia Wagner, MD, has joined the staff of

Clinic Sofia, a women’s health care provider in

the Twin Cities. She will be based at the clinic’s

Edina location. Wagner received her medical

degree from the University of Nebraska and

completed her obstetrics and gynecology resi-

dency at the University of Kansas.

Shoreview-based Chiropractic Care of

Minnesota (ChiroCare) has named Vivi-Ann

Fischer, DC, chief clinical officer. Fischer founded Plymouth Grove

Chiropractic, PA in 1988 and previously practiced in Duluth.

Saravana Balaraman, MD, has joined RiverView Health and will

practice on the main campus in Crookston. He will specialize in family

medicine, with some obstetric duties as well. Balaraman previously

was chief resident of family medicine at Stamford (Conn.) Hospital.

Balaraman received his medical degree at JJM Medical College in

Davangere, India. He did his postgraduate training in ear, nose and

throat at Command Hospital in Bangalore, India.

St. Croix Orthopaedics, PA, has added two physicians: Nicholas

Holmes, MD, and Eric Kirksson, MD. Holmes, a primary-care sports

medicine physician, will provide care for patients at the practice’s new

urgent care clinic in Lake Elmo. Kirksson, a physical medicine and

rehabilitation physician, will treat patients at the Lake Elmo, Fairview

Lakes, and Stillwater clinics.

P E O P L E

OCTOBER 2012 MINNESOTA HEALTH CARE NEWS 7

Jocelin Huang, MD

Jewelia Wagner, MD

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Roger Feldman, PhD

University of Minnesota

Roger Feldman, PhD,

is the Blue Cross

Professor of Health

Insurance in the

University of

Minnesota’s Division

of Health Policy

and Management.

He was a Marshall

Scholar at the

London School of

Economics, served

as a senior staff

member of the

President’s Council

of Economic

Advisers, and has

served on the Panel

of Health Advisers for

the Congressional

Budget Office.

Consumption of sugar-sweetened drinksis a major contributor to the current U.S.obesity and diabetes epidemics. In a

recent issue of Health Affairs, a research team ledby Columbia University’s Y. Claire Wang reportedthese stark facts:

• The average American consumes almost 45 gallons of sugar-sweetened beverages annually.

• Consumption of sugar-sweetened beverageshas been linked to weight gain and diabetes.

• Women who consume at least one sugar-sweet-ened beverage daily havean 83 percent to 98 per-cent increased risk ofdeveloping diabetes.

• A 20-ounce bottle of popcontains nearly 17 tea-spoons of sugar.

Diabetes: deadly and rampant

That’s right: three 20-ounce bottles of pop containalmost as much sugar as a chocolate cake. Nowonder diabetes affects 25.8 million people of allages in the U.S., according to the NationalInstitutes of Health. And it’s increasing by almost2 million people each year. Diabetes is a majorcause of heart disease and stroke, and, accordingto the National Institutes of Health, is the seventh-leading cause of death in the U.S. Diabetes is par-ticularly rampant among the elderly and non-Hispanic black adults, with prevalence rates of26.9 percent and 18.7 percent, respectively.

One way to reduce obesity

The Centers for Disease Control and Preventionlists reducing the intake of sugar-sweetened bev-erages as a major obesity-prevention strategy.One way reduction could be accomplished wouldbe by taxing such drinks. I estimate that a smalltax, such as two cents per bottle, would reducepop consumption by 5 percent. In Minnesota, thatwould represent 85 million fewer 12-ounce cans ofpop consumed each year. Think of that as saving2,550 calories per person each year.

Short-term benefit

Wang and her colleagues noted that some of thecut in calories from drinking less pop would be replaced by increased intake of nutritiousdrinks such as milk and juice. Even after allowingfor calories obtained from milk and juice, an esti-mated 60 calories of every 100 pop-calories wouldnot be replaced. Over the course of one year, thiswould represent almost one-half pound of bodyweight lost per person.

Long-term benefit

And benefits from reducing calories would con -tinue. Over 10 years, a penny-per-ounce tax wouldresult, nationwide, in 95,000 fewer cases of coro-nary heart disease; 8,000 fewer strokes; 26,000fewer premature deaths; and $17 billion dollarsnot spent on medical expenditures. (Those sav-ings in medical expenditures are “discounted,”meaning that future savings are expressed in anequivalent amount of today’s money.)These would not be the only healthy conse-quences of taxing pop. People who drink two or

more sugary soft drinks perweek are twice as likely todevelop pancreatic cancer asnondrinkers, according toUniversity of Minnesota epi-demiologist Mark Pereira.

Pros and cons of sanctions

Pop taxes have been criticized because they areregressive, meaning they fall more heavily on thepoor, who consume more pop. But, according to aleading expert on obesity and nutrition, YaleUniversity’s Kelly Brownell, the poor are dispro-portionately affected by diet-related diseases andwould benefit most from reduced consumption ofunhealthy food. Furthermore, a tax is among theleast coercive methods of changing behavior.Rather than banning pop or restricting access to it,a pop tax nudges consumers to drink less pop.

New York City Mayor Michael Bloomberg caused astir earlier this year by proposing to ban the saleof large sugary drinks in certain settings. His pro-posal was criticized by some as an intrusion onpersonal freedom. Another criticism of the pro-posed ban was that it would be hard to enforceand easy to evade. For example, people couldavoid the ban by buying two regular-size drinks.

Instead of banning large sodas, why not tax allsugar-sweetened soft drinks? A poll of New YorkCity residents found that 72 percent would sup-port a pop tax if the revenue were used for obe sityprevention. Subsidizing healthy alternatives topop would build support for a pop tax, especiallyif subsidies brought healthy foods into neighbor-hoods where they are not available.

Worth considering

A pop tax is not a silver-bullet cure for our obe sityand diabetes epidemics. They have multiple causes, including the fact that many Americanswork in sedentary jobs and have little time to shopfor and prepare healthy food. Nevertheless, weneed to use every weapon in our arsenal to fightthese epidemics. A pop tax should be amongthose weapons.

Obesity, diabetes, and a tax on popCould economic sanctions on sugary drinks help curb disease?

P E R S P E C T I V E

A

A 20-ounce bottle of popcontains nearly

17 teaspoons of sugar.

A philosophy of caring is good. A history of it is better.Caring. It would be nice if you could see it, like an amenity. Or tour it, like an apartment. But you can’t. All we can do is give you our definition: Caring is believing that everyone is someone who deserves to feel loved and valued, and be treated with dignity.

That’s not just something we say. As the nation’s largest not-for-profit provider of senior care and services, it’s what we’ve been doing for almost 90 years.

To learn more about our communities in Minnesota, call 1-888-GSS-CARE.

The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, sex, disability, familial status, national origin or other protected statuses according to federal, state and local laws. All faiths or beliefs are welcome. Copyright © 2010 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 10-G2016

www.good-sam.com

Dr. Laura Gilchrist is a professor in the Doctor of Physical Therapy (DPT) program at St. Catherine University, Minneapolis, and a clinical research scientist in the hematologyand oncology program at Children’s Hospitals and Clinics of Minnesota. She specializes in the study of physical function in pediatric cancer patients.

Not many people have professional expertise in both neuroscience andphysical therapy. What led you to specialize in both fields? I started my professional career in basic neuroscience research, studying modulation of simple motor patterns like walking. I loved researching how the nervous system worked, but missed see-ing the direct impact of my work. So, after completing a PhD in neuroscience, I looked for away to apply my knowledge of the nervous system to patients. Physical therapy can directlyim prove someone’s function and quality of life by using neuroplasticity, the brain’s ability

to form new pathways for sending messages to body parts.

What kinds of medical conditions do you treat? Physical therapists treatpatients who have movement disorders. Previously, I worked primarily with

acute neurologic and cardiac disorders; currently, I work with children receiv-ing cancer treatment.

You are one of the few physical therapists in North America whostudies nerve damage in children receiving chemotherapy. What

can you tell us about this relatively new research area? This damage iscalled chemotherapy-induced peripheral neuropathy (CIPN). CIPN can produce weak-

ness, shooting pains, numbness, lack of sensitivity to temperature, and/or tingling in thehands and feet that spreads to arms and legs. In children, it usually shows up during treat-ment, but in rare cases can appear months after chemotherapy is finished.

These symptoms are serious in their own right and also because they may make it diffi-cult for a patient to continue chemotherapy. CIPN is getting attention because for somepediatric cancers, survival rates now exceed 85 percent to 90 percent, which means that sideeffects of cancer treatment are more important than ever.

Please tell us about the research you do at Children’s Hospitals and Clinicsof Minnesota. My research addresses minimizing cancer treatment’s damage to the nerv-ous and musculoskeletal systems. This includes determining which medications and treat-ment parameters minimize CIPN, plus rehabilitation techniques that improve function inpatients who do develop CIPN. Currently, among children treated at Children’s Hospitalsand Clinics of Minnesota, nerve damage is being recognized in more patients and earlierduring chemotherapy, so that it can be appropriately addressed.

A grant from the American Cancer Society supports our search for clinical indicators ofpersistent neuropathy in children whose cancer is cured. Ultimately, we aim to providephysicians and nurses with simple clinical indicators of CIPN symptoms that indicate aworse functional prognosis for children receiving cancer treatment.

How do you interact with other medical professionals to care for patients?Physicians ask my research collaborators who are physical therapists to evaluate childrenwhen treatment decisions need to be made. For example, if a patient appears to be espe -cially sensitive to [chemotherapy drug] vincristine’s side effects, the physician may have atherapist evaluate that patient’s neuropathy before determining the next dose. If the thera-pist can inform the physician that neuropathy is no worse than before the previous dose, thepatient may be able to receive a full dose of chemotherapy.


Laura Gilchrist PT, PhD

1 0 Q U E S T I O N S

Photo credit: Bruce Silcox

Researching nerve damage, improving cancer treatment

By interacting with physical therapists, physicians and nurseshave learned more about gait and movement patterns that are worri-some, and are more likely to ask a therapist for an evaluation or torefer a patient for physical therapy.

Does teaching physical therapy influence the way youprovide patient care? Teaching in the DPT program forces me tomake my clinical decisions explicit for students. That and exploringcases with students allow me to reflect on my clinical practice.

What are some recent advances in physi-cal therapy? It’s an exciting time. Therapists areusing principles of neuroplasticity more than everin rehabilitation strategies. Researchers are investi-gating ways to incorporate these principles intonew treatment modalities, including robotics, virtual reality, and transcranial magnetic stimula-tion. Also, the field of regenerative medicine will change the way wetreat patients in the future. For example, it may become possible toregrow damaged nerves in the spinal cord.

How do you motivate pediatric patients to continueworking hard to achieve their rehabilitation goals?I’ve learned so much from my therapist collaborators, who havegreat skill at adapting what could be a routine exercise into a game.For example, to strengthen ankle dorsiflexion (flexing the footupward), a child might play tug of war with a sibling or therapist by using elastic tubing looped around the top of the child’s foot. By making exercises fun, therapists gain greater compliance.

Sometimes, though, therapists need to recommend something thatjust isn’t fun, like the use of an orthotic or assistive device. Eventhen, the therapists are skilled at educating the patient and family onthe reasons for the device, and help the child have a choice of coloror decorations to make the device more tolerable.

Please share a success story about your patients. It’s verysatisfying to see a child or young adult who had a difficult time withneuropathy during treatment return to normal activities of life. I get

to hear stories about how they are returning tonormal activities such as playing soccer, competingin track, and going off to college.

How do you anticipate this work willchange in the next 10 years? More patientswill become involved with rehabilitation duringcancer treatment. So often, patients are referred

to physical therapy several years after treatment because they havepersistent neuropathy and pain. By that time, the biomechanics of,say, the foot may have been damaged and they have suffered need-lessly. Suppor tive care during chemotherapy, such as exercises tomaintain mobility of the joint and the use of supportive orthotics,could prevent some of this suffering.

Additionally, physicians will become more adept at determiningwhich patients are at high risk of developing neuropathy fromchemo therapy. There is fascinating ongoing research into determininggenetic markers of susceptibility for specific side effects. A geneticprofile could be done for each new patient, and his or her chemother-apy tailored to decrease side effects while still ensuring a cure.


By making exercises fun, therapists gain

greater compliance.

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Susan arrived at my office withthree kids in tow, talking onher cell phone. I glanced at the

clock: She was 45 minutes early forher appointment, which meant shemust have forgotten what time to behere. Her 15-year-old, Sam, was herefor his routine six-month visit forattention deficit hyperactivity disor-der (ADHD). When they came in,the two youngest kids immediatelystarted bickering over who wasgoing to play with which toy. Sambusied himself on his cell phone,managing to send several text mes-sages before he even sat down.

Susan quickly pulled out Sam’srecent report card and expressed herdismay: three A’s, a C, and a D. Samwas bright, but his report card did not always show it. Sam chimed inthat his poor grades were “becausethe class is boring and I don’t like the teacher.”

Susan wondered if changing Sam’s medication would “solve theproblem.” I wondered if she had fol-lowed up on my previous sugges-

tions to have her own symptomsevaluated. This family’s visit is atextbook example of ADHD acrossthe lifespan.

Affecting children and adults

ADHD has historically been thought of as a childhood disorder.We know now that 40 percent to 60 percent of ADHD children growup to be ADHD adults. Unfortu-nately, only 5 percent to 10 percentof adults receive treatment for their symptoms.

Treatment is worthwhile, however. Statistically, people withADHD are at risk for additionalmental health conditions, de creasedincome, underemployment, lowereducational achievement, greaterinterpersonal conflict, and higherrates of substance abuse. In somestudies, substance abuse is as high as70 percent among adults withADHD. During childhood and ado-lescence, ADHD increases the riskfor early-age smoking, substanceabuse, lower high school graduation

B E H A V I O R A L H E A L T H

Attention deficithyperactivity disorder

A lifetime condition that responds to treatment

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rates, and increased teenpregnancy.

ADHD’s personalimpact changes familylife. Parents of childrenwith ADHD are morelikely to miss work, oftendue to the need to go toschool to pick up a childafter a crisis. Childrenwith ADHD have morefrequent visits to theemergency room, morebike accidents, and, inlater teen years, moremotor vehicle accidents.On a day-to-day basis,family conflict in homeswith ADHD children can be significant and disruptive.

What is ADHD?

ADHD is best describedas a disorder of attentionregulation rather than adisorder of inattention.Frus trated parents maylament the fact that theirchild (or perhaps theirspouse) can focus “when they want to.” How can impaired atten-tion, they ask, allow someone to play four hours of video gamesnonstop?

The ability to focus and attend turns out to be a delicate bal-ance among environment, motivation, and neurotransmission.Placed in different environments or given certain motivators, we

all have variations in our attention spans.This explains why it takes us days toorganize and complete our tax forms every April—and only a few minutes toget ready to go out when offered freemovie tickets.

Proper attention relies on three areasof brain function: arousal and alertness,processing, and memory. Typically, a per-son with ADHD has impairment in morethan one of these areas, although ADHDmay be an accurate diagnosis if one ofthese functions is significantly impaired.

Diagnosis

An ADHD diagnosis depends on clinical data obtained during aphysician’s visit. Testing by a psychologist or neuropsychologist maybe helpful, but is not always necessary. Supplemental data from reli-able resources is essential to confirm symptoms. This can come from


Attention deficit hyperactivity disorder to page 23

Symptoms and subtypes

Symptom category A. Six or more of the following symptoms of inattention have beenpresent for at least six months to an extentthat is inappropriate for developmental level:

Inattention

• Doesn’t pay close attention to details/makescareless mistakes in schoolwork, work, orother activities.

• Difficulty keeping attention on tasks or play activities.

• Doesn’t seem to listen when spoken todirectly.

• Doesn’t follow through on instructions;doesn’t finish schoolwork, chores, or work-place duties (not due to oppositional behav-ior or failure to understand instructions).

• Difficulty organizing activities.• Avoids/dislikes activities requiring

sustained mental effort (schoolwork, homework).

• Loses things needed for tasks and activities(toys, homework, pencils, tools).

• Easily distracted.• Forgets to do daily activities.

Symptom category B. Six or more of the fol-lowing symptoms of hyperactivity-impulsi vityhave been present for at least six months toan extent that is disruptive and inappropriatefor developmental level:

Hyperactivity

• Fidgets with hands or feet or squirms in seat when sitting still is expected.

• Often gets up from seat when remaining inseat is expected.

• Excessively runs around or climbswhen/where it is inappropriate (adolescentsor adults may feel very restless).

• Difficulty playing or doing leisure activitiesquietly.

• Is often “on the go” or acts as if “driven by a motor.”

• Often talks excessively.

Impulsivity

• Blurts out answers before questions are finished.

• Difficulty waiting for a turn.• Often interrupts.

ADHD subtypes

Combined. Six symptoms from category Aand six symptoms from category B have beenpresent for the past six months.Inattentive. Six symptoms have been presentfor the past six months from category A butnot from category B.Hyperactive-Impulsive. Six symptoms havebeen present for the past six months fromcategory B but not from category A.

Forty percentto 60 percent

of ADHDchildren grow up

to beADHD adults.


From 2000 to 2005, I lived in Starbuck, Minn.,and worked in a 20-bed hospital. Thereweren’t many options available there for the

sickest of the sick among our rural population. If apatient needed an intensive care unit (ICU), ourteam would occasionally need to send that individual to the TwinCities. Once that patient was well enough to leave the ICU, optionswere limited if he or she still needed skilled medical care.

Now, there is another option: along-term acute care hospital

(LTACH). Bethesda Hospital, inSt. Paul, is one of two LTACHsin the state. (The other isRegency Hospital, in GoldenValley.) LTACHs may be theleast well-known type ofhealth care facility. Whatexactly is an LTACH?

Specialty hospital

LTACHs are licensed specialtyhospitals that provide acute

medical care over an extendedperiod of time to criti cally ill patients

who have complex medical conditions.Currently, there are approximately 430

LTACHs in the United States. They are accredit-ed by the Joint Commission, an independent non-

profit organization that accredits and certifies morethan 19,000 health care organizations and programsin the United States.

LTACHs were created in the 1980s to enablemedically complex patients to be discharged fromhospital ICUs. This was done in part as a way to

control Medicare spending on high-utilization, critically ill patients.Such patients are the people that LTACHs are designed to serve.Medicare data indicate that LTACH patients are “the sickest of the sick.”

Patients don’t live permanently at an LTACH; the averagelength of stay for LTACH patients on Medicare is 25 days, althoughpatients may stay for longer or shorter periods. This specialty hospi-tal focuses on preparing a patient to 1) live independently and ulti-mately return to his or her home community or to 2) achieve thehighest level of wellness possible before transferring to a less inten-sive level of care such as a skilled nursing facility, transitional careunit, or private home with home care services.

Admissions criteria

LTACH patients require constant medical management by a physi-cian and advanced nursing staff. Their conditions can include, butare not limited to, multi-organ or multisystem failure, including res-piratory and cardiac complications; postsurgical or organ transplantcomplications; complex wounds; multiple injuries; traumatic braininjury; and acquired brain injury due to such causes as strokes,tumors, and infections.

More than 40 percent of our patients need help being weanedfrom a ventilator; some require inpatient dialysis. Our patients areoften referred directly from a hospital ICU by intensivists (physi-cians specializing in ICU care) or by hospitalists, physicians who seepatients only in the hospital and help coordinate a patient’s transi-tion away from the hospital ICU. Patients undergo a clinical assess-ment before being admitted to our LTACH, since they must meetcertain criteria that confirm they need ongoing acute care.

The top four criteria indicating a patient is ill enough to requireLTACH services are:

• The patient needs ongoing care at an acute hospital level.

H O S P I T A L S

Long-term acute care hospitalsYou’ve left the hospital intensive care unit—now what?

By Rahul Koranne, MD, MBA, FACP

• The patient requires daily physician visits to monitor and changethe care plan.

• The patient has already been at a short-term hospital for morethan five days.

• A lower level of care has been unsuccessful, and the patient hasbeen readmitted to the original hospital.

Wide range of services

LTACHs offer comprehensive, personalizedmedical treatment and therapies designed toimprove outcomes for medically complexpatients. They also provide a variety of medicaland rehabilitation services that are not routinelyoffered at other types of post-acute facilities,such as care of complex wounds and injuries, and inpatient dialysis.

In addition, they offer comprehensive laboratory and radiologyservices on-site, medical specialists, and subspecialists. Our staff, forexample, includes pulmonologists, neurologists, psychiatrists, psy-chologists, nephrologists, pathologists, geriatricians, physiatrists,palliative care specialists, infectious disease physicians, and generaland plastic surgeons. The hospital also has in-house respiratorytherapy, pharmacy, laboratory, radiology, case management, andsocial service expertise.

One of the core competencies offered by LTACHs is know-howin weaning a patient off a ventilator. (A ventilator is a machine thatassists a person’s breathing during surgery and often is needed aftersurgery by critically ill patients.) Helping patients to no longer needa ventilator is important for multiple reasons, including the fact that

the longer a ventilator tube stays inserted in a patient’s airway, thegreater that patient’s risk of developing a subsequent lung infection,called pneumonia.

Ventilator weaning results in patients who are less likely to bereadmitted to the hospital after LTACH discharge and who will beable to regain personal mobility. Ventilator weaning allows patients

to travel to physical therapy; free themselves from heavy, restrictiveventilator equipment; regain the ability to speak so they can clearlyindicate their needs; heal more quickly; and, hopefully, have morechoice when it comes to choosing a less care-intensive facility whenthey are ready to transition out of the LTACH.

When a hospital’s rate of ventilator-associated pneumonia islower than national benchmarks, patients and families have a betteroverall experience. Bethesda Hospital reported zero cases of ventila-tor-associated pneumonia in calendar year 2011 and has receivednational recognition for its ventilator-weaning protocol.

A few LTACHs, including ours, also offer neurological specialtycare that includes both brain injury services and medical behavioralcare. Medical behavioral care is appropriate when various dement-


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Long-term acute care hospitals to page 16

LTACH patients are

“the sickest of the sick.”

ing illnesses are complicated by acutemedical problems so that both condi-tions must be treated simultaneously.Brain injury services include teamworkbetween neurologists, psychiatrists, psy-chologists, and all the various therapists,with the goal of bringing the patient tothe highest possible functional outcome.

Benefits

LTACHs have been shown to reducehealth care costs in several ways. First,care pro vided at an LTACH costs lessthan care in a hospital ICU. For exam-ple, among patients with tracheostomies—an incision in the front of the neckthrough which a tube is inserted to facilitate breathing—Medicarespending for care is typically less when care is delivered in anLTACH than in a hospital ICU. Second, superior quality outcomes,such as lower rates of ventilator-associated pneumonia, mean that patients’ length of stay is shorter in an LTACH than in a standard ICU.

Studies also show that LTACH patients aremore likely to be discharged to their home than areindividuals discharged from a short-term acute carefacility like a hospital ICU.

In addition, patients treated atLTACHs tend to be readmitted to short-term acute care hospitals less often thanpatients treated in other post-acute caresettings. A 2004 report to Congressnoted that LTACH patients were read-mitted to short-term acute care hospitals26 percent less often than patients withsimilar conditions who were being caredfor at skilled nursing facilities.

Finally, a patient’s relatively longerlength of stay at an LTACH allowspatients and their families time to devel-op meaningful, lasting relationships withstaff. This helps to build a strong senseof community within the LTACH.

Cost-effective safety net

As the health care system continues to work toward reducing costsand improving patient outcomes, LTACHs have emerged as a cost-effective safety net for post-ICU patients with complex medical conditions.

Rahul Koranne, MD, MBA, FACP (Fellow of theAmerican College of Physicians), is board-certified ininternal medicine and geriatrics and is the medical direc-tor for Bethesda Hospital, HealthEast Care System HomeCare, and HealthEast Care Navigation Strategy.

Long-term acute care hospitals from page 15


LTACHs have emerged as a cost-effective safety net

for post-ICU patients.

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PRESIDENT BARACK OBAMA

Position on the ACA“The Affordable Care Act will make health caremore affordable for families and small businesses

and brings much-neededtransparency to the insur-ance industry.

“When fully imple -mented, the Affordable CareAct will keep insurance com-panies from taking advan-tage of consumers—includ-ing denying coverage to

people with preexisting conditions and cancelingcoverage when someone gets sick.

“Because of the new law, 34 million moreAmericans will gain coverage—many who willbe able to afford insurance for the first time.Once the law is fully implemented, about 95 percent of Americans under age 65 will haveinsurance.”

How the ACA helps individuals and businesses“The ACA promotes better value through pre-ventive and coordinated care, and eliminateswaste and abuses.

“The ACA also helps keep insurance premi-ums down. Insurance companies must publiclyjustify excessive rate hikes and provide rebates ifthey don’t spend at least 80 percent of premiums on care insteadof overhead, marketing, and profits. As many as 9 million con-sumers are expected to get up to $1.4 billion in rebates becausethe President passed the ACA.

“Millions of small businesses are now eligible for a tax creditto help pay for their health care premiums. The credit willincrease to cover 50 percent of premium costs in 2014.

“Under the ACA, help for small businesses—including thenew insurance exchanges—will reduce small business health carespending by nearly 9 percent, according to independent esti-mates.”

Expanding coverageStarting in 2014, all Americans will have access to affordablehealth insurance no matter their circumstances—whether theychange jobs, lose their job, decide to start a business, or retireearly. Purchasing private insurance in the new state-based healthinsurance exchanges could save middle-class families who can’tget employer-provided insurance thousands of dollars.

Young adults are now eligible to stay on their parents’ healthinsurance plans as they enter the workforce, until they turn 26.Since the health care law passed, 3.1 million young adults—tradi-tionally the group least likely to be insured—gained insurancebecause of the ACA.

Presidential mattersA discussion of health care with the two presidential campaigns

I N T E R V I E W

GOV. MITT ROMNEY

Position on the ACA“The transformation in American health care setin motion by Obamacare will take us in preciselythe wrong direction. The bill,itself more than 2,400 pageslong, relies on a dense webof regulations, fees, subsi-dies, excise taxes, exchanges,and rule-setting boards togive the federal governmentextraordinary control overevery corner of the healthcare system. The costs are commensurate:Obamacare added a trillion dollars in new healthcare spending. To pay for it, the law raised taxesby $500 billion on everyone from middle-classfamilies to innovative medical device makers, andthen slashed $500 billion from Medicare.

“Obamacare was unpopular when passed,and remains unpopular today, because theAmerican people recognize that a governmenttakeover is the wrong approach. WhileObamacare may create a new health insuranceentitlement, it will only worsen the system’sexisting problems. Obamacare will violate thatcrucial first principle of medicine: ‘do no harm.’It will make America a less attractive place topractice medicine, discourage innovators from

investing in life-saving technology, and restrict consumer choice.”

Repealing and replacing the ACA“On his first day in office, Mitt Romney will issue an executiveorder that paves the way for the federal government to issueObamacare waivers to all 50 states. He will then work withCongress to repeal the full legislation as quickly as possible.

“In place of Obamacare, Mitt will pursue policies that giveeach state the power to craft a health-care reform plan that isbest for its own citizens. The federal government’s role will be to help markets work by creating a level playing field for com -petition.

“Mitt will begin by returning states to their proper place incharge of regulating local insurance markets and caring for thepoor, uninsured, and chronically ill. States will have both theincentive and the flexibility to experiment, learn from one another, and craft the approaches best suited to their own citi-zens.”

The Romney campaign says it will ease regulations on privateinsurers, promote high-risk pools, enact tort reform, and enablesmall businesses to form purchasing pools for insurance coverage.

The campaign also gives a nod to the consumer-driven caremodel that employs health savings accounts (HSAs) for groupplans by saying that Romney will “end tax discrimination againstthe individual purchase of insurance; unshackle HSAs by allowing

With the Affordable Care Act’s(ACA) emergence as one of

President Barack Obama’s sig-nature accomplishments duringhis first term, health care wasdestined to be front and centerin this year’s presidential race.Although the old axiom that

the economy is always the firstthing on voters’ minds remains

true, in this election healthcare issues are also making animpact. And with the selection

of Rep. Paul Ryan asRepublican Mitt Romney’s

running mate, the future ofMedicare has become a major

point of debate.With this in mind, Minnesota

Health Care News has examined the two campaigns’health-care policy positions.

Here is a list of the candidates’positions on top issues. Allanswers are taken from theofficial campaign websites

unless otherwise noted.

Birth control and women’s health “As part of the ACA … many insurance plans will be required tofully cover birth control without copays or deductibles as part ofwomen’s preventive care. This step will help more women makehealth care decisions based on what’s best for them—not theirinsurance company—and could save them hundreds of dollarsevery year.

“Certain religious organi-zations, including churches,will be exempt from the rules,and other religious organiza-tions will not have to pay fortheir insurers to cover birthcontrol.

“Thanks to unprecedented new guidelines in the ACA,women will have access to a wide range of preventive health serv-ices—mammograms, cervical cancer screenings, and birth con-trol—without a copay or deductible. The Affordable Care Actwill also prevent insurance companies from discriminating againstwomen so that being a woman is no longer considered a pre-existing condition.”

The future of Medicare[From the President’s weekly address, Aug. 25]“Thanks to the health care law we passed, nearly 5.4 million sen-iors with Medicare have saved over $4.1 billion on prescriptiondrugs. That’s an average of more than $700 per person. And thisyear alone, 18 million seniors with Medicare have taken advan-tage of preventive care benefits like mammograms or other cancerscreenings that now come at no extra cost.

“Growing up as the son of a single mother, I was raised withthe help of my grandparents. I saw how important things likeMedicare and Social Security were in their lives. And I saw thepeace of mind it gave them. That’s why, as President, my goal hasbeen to strengthen these programs now, and preserve them forfuture generations.

“That’s why, as part of the Affordable Care Act, we gave sen-iors deeper discounts on prescription drugs, and made sure pre-ventive care like mammograms are free without a copay. We’veextended the life of Medicare by almost a decade. And I’ve pro-posed reforms that will save Medicare money by getting rid ofwasteful spending in the health care system and reining in insur-ance companies—reforms that won’t touch your guaranteedMedicare benefits.

“Republicans in Congress have put forward a very differentplan. They want to turn Medicare into a voucher program. Thatmeans that instead of being guaranteed Medicare, seniors wouldget a voucher to buy insurance, but it wouldn’t keep up withcosts. As a result, one plan would force seniors to pay an extra$6,400 a year for the same benefits they get now. And it wouldeffectively end Medicare as we know it.”

“I’m willing to work with anyone to keep improving the cur-rent system, but I refuse to do anything that undermines the basicidea of Medicare as a guarantee for seniors who get sick.”


funds to be used for insurance premiums; and promote ‘co-insur-ance’ products.”

Abortion and women’s health“Mitt believes that life begins at conception and wishes that thelaws of our nation reflected that view. But while the nationremains so divided, he believes that the right next step is for theSupreme Court to overturn Roe v. Wade—a case of blatant judi-cial activism that took a decision that should be left to the peopleand placed it in the hands of unelected judges.

“With Roe overturned, states will be empowered through thedemocratic process to determine their own abortion laws and nothave them dictated by judicial mandate.

“Mitt supports the Hyde Amendment, which broadly barsthe use of federal funds for abortions. As president, he will endfederal funding for abortion advocates like Planned Parenthood.He will protect the right of health care workers to follow theirconscience in their work. And he will nominate judges who knowthe difference between personalopinion and the law.”

Free market reforms“Competition drives improve-ments in efficiency and effec-tiveness, offering consumershigher quality goods and serv-ices at lower cost. It can have the same effect in the health caresystem, if given the chance to work.”

The Romney campaign says other steps to improve the freemarket for health care include: capping non-economic damages inmedical malpractice lawsuits; empowering individuals and smallbusinesses to form purchasing pools; preventing discriminationagainst individuals with preexisting conditions who maintain con-tinuous coverage; and improving medical information technologysystems.

The future of Medicare“President Obama has had three years in office, during whichtime he has attacked every serious proposal to preserve andstrengthen America’s entitlement programs while enacting cuts toMedicare and putting in place a bureaucratic board that one daymay ration the care available through the program.

“Mitt Romney … proposes that tomorrow’s Medicare shouldgive beneficiaries a generous defined contribution, or ‘premiumsupport,’ and allow them to choose between private plans andtraditional Medicare.

“Mitt’s plan honors commitments to current seniors whilegiving the next generation an improved program that offers thefreedom to choose what their coverage under Medicare shouldlook like. Instead of paying providers directly for medical ser -vices, the government’s role will be to help future seniors pay foran insurance option that provides coverage at least as good astoday’s Medicare, and to offer traditional Medicare as one of theinsurance options that seniors can choose.

“With insurers competing against each other to provide thebest value to customers, efficiency and quality will improve andcosts will decline. Seniors will be allowed to keep the savingsfrom less expensive options or choose to pay more for costlierplans.”

We’ve extended the life of Medicareby almost a decade.

Mitt believes that life begins at

conception.

10 Flu ClinicMinnesota Visiting Nurse Agency (MVNA)will offer flu shots for adults and childrenage 3 and older. No appointment needed;bring your insurance card. Contact 612-617-4600 or www.mvna.org for moreinformation. Wednesday, Oct. 10, 5–7 p.m., Fairmount Ave. United Methodist Church,1523 Fairmount Ave., St. Paul

11 Aging Eye ForumPhillips Eye Institute eye specialists will discuss age-related vision issues and treat-ment options. Free parking. No charge forforum. To register, call (612) 775-8964 oremail [email protected]. Thursday, Oct. 11, 6–8 p.m., Phillips EyeInstitute, 2215 Park Ave., Minneapolis

13 American Diabetes Association ExpoAsk health care professionals your dia-betes questions one-on-one, and takeadvantage of free health screenings. Checkout the Bookstore, Family Fun Zone, andHealthy Eating Area, and pick up aHealthy Passport and pedometer. To regis-ter, call Molly at 763-593-5333 x6652, or email [email protected]. Saturday, Oct. 13, 9 a.m.–3 p.m.,Minneapolis Convention Center, 1301 2nd Ave. S., Minneapolis

15 National Latino AIDS Awareness Day In 2003, the Latino Commission on AIDSand the Hispanic Federation joined forcesto create National Latino AIDS AwarenessDay, which initially involved just 100 cities.Minnesota joined the tradition in 2004.Further information about NLAAD can befound on the Minnesota Department ofHealth website, www.health.state.mn.us/.

17 Women’s HeartAdvantage ScreeningHelp stop the most common cause of deathin women—heart disease. Participate in afree heart screening hosted by HealthEast.There is no need to fast for this screening.Call 651-326-2273 for more information.Wednesday, Oct. 17, 10 a.m.–12 p.m.,Keystone Senior Program, 2000 St. Anthony Ave., St. Paul

17 Hip Replacement SeminarIf you are suffering from hip pain or having difficulty with lost mobility, thisseminar may be for you. Dr. KristofferBreien will discuss recent advances in hipreplacement surgery, including reduction inrecovery time. Free. To register, call (651)232-6704, or visit www.healtheast.org/orthorsvp. Wednesday, Oct. 17, 6–7:30 p.m.,Orthopaedic Specialty Ctr., 1925 Woodwinds Dr., Woodbury

23–24 Food Day 2012Come to a two-day event designed tobuild awareness of healthy, affordable,sustainably produced food. Oct. 23 willinclude a free food expo and panel discus-sions; Oct. 24 will feature an all-day filmseries. Free. Visit [email protected] formore information.Tuesday, Oct. 23, 10 a.m.–3 p.m. andWednesday, Oct. 24, 9 a.m.–8 p.m.,Coffman Memorial Union, 300 Washington Ave. S.E., Minneapolis

Nov. 3 Brain Injury Consumer ConferenceThe Minnesota Brain Injury Alliance presents a conference for individuals withbrain injury and their loved ones. Therewill be workshops and sessions focusingon innovations in brain injury care, ther -apy, and rehabilitation. Free. To register,call (612) 378-2789 or visit www.braininjurymn.org. Saturday, Nov. 3, 1 p.m.–4 p.m., North Como Presbyterian Church, 965 Larpenteur Ave. W., Roseville

Send us your news:We welcome your input. If you have an event youwould like to submit for our calendar, please sendyour submission to MPP/Calendar, 2812 E. 26thSt., Minne apolis, MN 55406. Fax submissions to612-728-8601 or email them to [email protected]. Please note: We cannot guaranteethat all submissions will be used. CME, CE, andsymposium listings will not be published.

America's leading source of health

information online

Did you know that there are more than 2.5 million breast cancer survivors in theUnited States? Although the chances of awoman contracting breast cancer in herlifetime are one in eight, death rates for thisdisease have been going down steadily, 2.7 percent annually in Minnesota alone.The key lies in early detection and smartlifestyle choices.

Many risk factors for breast cancer aregenetic and therefore not preventable, butsome factors are avoidable lifestyle choices:• Drinking alcohol—More than two drinks

per day will put a woman at 1.5 times therisk for cancer as a woman who drinksno alcohol.

• Being overweight/obesity—While the linksbetween weight and cancer are complex,women who carry most of their extraweight around their waist are at higherrisk for cancer.

• Lack of exercise—Studies have repeatedlyshown that exercise can reduce the risk of breast cancer, and even exercise asmoderate as brisk walking can make adifference.

In addition to a healthy lifestyle, regu-lar breast self-exams are encouraged.Women ages 20–39 should have a clinicalbreast exam (CBE) as part of a regularexam by a health expert at least every threeyears. After age 40, women should have abreast exam and a mammogram performedby a health expert every year.

If you should feel anything unusualduring a breast self-exam, contact a healthprofessional right away. With early detec-tion, your doctor can determine the mostappropriate treatment for you, and the per-centage of breast cancer survival can onlyincrease. For further information aboutbreast cancer, visitwww.cancer.org/Cancer/BreastCancer/

Oct. 22 Breast Cancer Support GroupThis group meets the third Monday of eachmonth to discuss survivorship skills andreduce stress through mutual support. Free.No registration needed—come when youcan. Call 763-236-6060 for information.Monday, Oct. 22, 7–9 p.m., Mercy HeartCtr., 4040 Coon Rapids Blvd., Ste. 120, LL Conference Rm. 1, Coon Rapids

October CalendarNational Breast Cancer Awareness Month

20 MINNESOTA HEALTH CARE NEWS SEPTEMBER 2012

Victoza® helped me take my blood sugar down…

Model is used for illustrative purposes only.

and changed how I manage my type 2 diabetes.Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells.

While not a weight-loss product, Victoza® may help you lose some weight.

And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

If you’re ready for a change, talk to your doctor about Victoza® today.

FOR TYPE 2 DIABETES

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

Non-insulin • Once-daily

Indications and Usage:Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the first medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children.

Important Safety Information:In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer.Inflammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis.Before using Victoza®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of fluids may reduce your chance of dehydration.The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when first starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies.

Please see Brief Summary of Important Patient Information on next page.

If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW.You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088.Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

Important Patient Information

This is a BRIEF SUMMARY of important information about Victoza®. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Victoza®, ask your doctor. Only your doctor can determine if Victoza® is right for you.

WARNING

During the drug testing process, the medicine in Victoza® caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if Victoza® will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take Victoza® if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body.

What is Victoza® used for?

• Victoza®isaglucagon-like-peptide-1(GLP-1)receptoragonistusedtoimprovebloodsugar(glucose)controlinadultswithtype2diabetesmellitus,whenusedwithadietandexerciseprogram.

• Victoza®shouldnotbeusedasthefirstchoiceofmedicinefortreatingdiabetes.

• Victoza®hasnotbeenstudiedinenoughpeoplewithahistoryofpancreatitis(inflammationofthepancreas).Therefore,itshouldbeusedwithcareinthesepatients.

• Victoza®isnotforuseinpeoplewithtype1diabetesmellitusorpeoplewithdiabeticketoacidosis.

• ItisnotknownifVictoza®issafeandeffectivewhenusedwithinsulin.

Who should not use Victoza®?

• Victoza®shouldnotbeusedinpeoplewithapersonalorfamilyhistoryofMTCorinpatientswithMEN2.

What is the most important information I should know about Victoza®?

• Inanimalstudies,Victoza®causedthyroidtumors.Theeffectsinhumansareunknown.PeoplewhouseVictoza®shouldbecounseledontheriskofMTCandsymptomsofthyroidcancer.

• Inclinicaltrials,thereweremorecasesofpancreatitisinpeopletreatedwithVictoza®comparedtopeopletreatedwithotherdiabetesdrugs.Ifpancreatitisissuspected,Victoza®andotherpotentiallysuspectdrugsshouldbediscontinued.Victoza®shouldnotberestartedifpancreatitisisconfirmed.Victoza®shouldbeusedwithcautioninpeoplewithahistoryofpancreatitis.

• Seriouslowbloodsugar(hypoglycemia)mayoccurwhenVictoza®isusedwithotherdiabetesmedicationscalledsulfonylureas.Thisriskcanbereducedbyloweringthedoseofthesulfonylurea.

• Victoza®maycausenausea,vomiting,ordiarrhealeadingtothelossoffluids(dehydration).Dehydrationmaycausekidneyfailure.Thiscanhappeninpeoplewhomayhaveneverhadkidneyproblemsbefore.Drinkingplentyoffluidsmayreduceyourchanceofdehydration.

• Likeallotherdiabetesmedications,Victoza®hasnotbeenshowntodecreasetheriskoflargebloodvesseldisease(i.e.heartattacksandstrokes).

What are the side effects of Victoza®?

• Tellyourhealthcareproviderifyougetalumporswellinginyourneck,hoarseness,troubleswallowing,orshortnessofbreathwhiletakingVictoza®.Thesemaybesymptomsofthyroidcancer.

• Themostcommonsideeffects,reportedinatleast5%ofpeopletreatedwithVictoza®andoccurringmorecommonlythanpeopletreatedwithaplacebo(anon-activeinjectionusedtostudydrugsinclinicaltrials)areheadache,nausea,anddiarrhea.

• Immunesystemrelatedreactions,includinghives,weremorecommoninpeopletreatedwithVictoza®(0.8%)comparedtopeopletreatedwithotherdiabetesdrugs(0.4%)inclinicaltrials.

• Thislistingofsideeffectsisnotcomplete.YourhealthcareprofessionalcandiscusswithyouamorecompletelistofsideeffectsthatmayoccurwhenusingVictoza®.

What should I know about taking Victoza® with other medications?

• Victoza®slowsemptyingofyourstomach.Thismayimpacthowyourbodyabsorbsotherdrugsthataretakenbymouthatthesametime.

Can Victoza® be used in children?

• Victoza®hasnotbeenstudiedinpeoplebelow18yearsofage.

Can Victoza® be used in people with kidney or liver problems?

• Victoza®shouldbeusedwithcautioninthesetypesofpeople.

Still have questions?

Thisisonlyasummaryofimportantinformation.Askyourdoctorformorecompleteproductinformation,or

• call1-877-4VICTOZA(1-877-484-2869)

• visitvictoza.com

Victoza® is a registered trademark of Novo Nordisk A/S.

DateofIssue:May2011Version3

©2011NovoNordisk140517-R3June2011

school report cards and from communication with teachers or a significant other.

There are three types of ADHD: the inattentive subtype, thehyperactive/impulsive subtype, and the combined subtype. The par-ticular subtype depends on which combination of symptoms some-one has. Symptoms used to diagnose ADHD are adapted from theCenters for Disease Control and Prevention and are grouped intotwo categories, shown in the sidebar on page 13.

Diagnostic standards require individuals to havesix symptoms in one category to meet criteria for theinattentive or hyperactive subtypes, and six symptomsin each category to meet criteria for the combined sub-type. Symptoms must be present before the age of 7and cause day-to-day functional impairment.

In addition, a diagnosis of ADHD requires thatsymptoms cannot be better explained by another con-dition. For example, children with autism often strug-gle with focus and inattention. Since these symptomscan be accounted for by autism, they do not counttoward a separate diagnosis of ADHD.

Treatment

Treatment is in two primary categories: pharmaceuticaland nonpharmaceutical. Evidence suggests greater effi-cacy for pharmaceutical interventions, but nonpharma-ceutical approaches are beneficial and should be incor-porated into overall treatment strategy for all patients.

Particularly useful are behavioral approaches that help the patientdevelop skills in time management, organization, impulse control,and prioritizing.

Pharmaceutical treatments for ADHD focus on medicationsfrom two major groups, stimulants and nonstimulants.

Stimulants. Potential side effects include appetite suppression,weight loss, height suppression, bodily or vocal tics, mild increase inheart rate (tachycardia) and blood pressure, headaches, insomnia,irritability, and stomach upset.

Nonstimulants. Unlike stimulants, which can bestopped and started abruptly without effecting effica-cy, nonstimulants need to be taken daily and takeweeks before they work at full efficacy.

Patients who respond only partially to either classof medication may be prescribed both a stimulant anda nonstimulant, a common medical practice that iswell tolerated by most patients.

Responds to treatment

ADHD is a common but often undertreated disorderthat should be recognized as a lifetime condition.Untreated, its long-term outcome can impact work,home, and family. Symptoms may show themselvesdifferently as a patient ages, but continue to need, andrespond to, treatment.

Elizabeth Reeve, MD, practices child and adolescent psychi-atry at Regions Hospital’s Child and Adolescent PsychiatricClinic in St. Paul. She was named 2012 Psychiatrist of theYear by the Minnesota Psychiatric Association.

Attention deficit hyperactivity disorder from page 13

ADHD is best describedas a disorderof attention.


Read usonlinewherever you are!

www.mppub.com


There are two main forms of diabetes: type 1, formerlycalled juvenile diabetes, and the more common type 2,formerly called adult-onset diabetes. In type 1 dia-

betes, the body’s immune system attacks and destroys cells inthe pancreas called beta cells. Beta cells produce insulin, ahormone that allows the body to use carbohydrates and helpsto regulate the amount of sugar in the blood. Because theinsulin-producing beta cells are destroyed, people with type 1must take insulin for the rest of their lives to regulate bloodsugar. In people with type 2 diabetes, the pancreas still pro-duces insulin, but the cells in the body stop responding to itand do not use blood sugar appropriately. Over time, peoplewith type 2 diabetes may have problems producing insulinand require supplemental insulin for the rest of their lives.Both types of diabetes result in high blood sugar levels andcan be associated with lifelong complications such as kidney,eye, and heart disease.

S P E C I A L F O C U S : D I A B E T E S

Rising type 2 diabetesamong youth

An alarming trend By Renée Mijal, PhD, MPH, Tammy Didion, RD, LD,

and Brandon Nathan, MD

Our fully trained and professional staff mem-bers ensure specialized care of diabetic feet.We take the time to determine the best planof treatment for your unique conditions.

By using an on-site fabrication lab for diabetic inserts, patients receive a truly custom product. Evaluation and follow-upadjustments are provided at no additionalcost. We also offer a wide range of diabeticshoes from leading manufacturers including:

• Dr. Comfort• Drew• Brooks

• New Balance• Orthofeet• Many more

If you are eligible for Medicare, Diabeticshoes and Inserts are covered from 80 to100% and we will bill Medicare for you.Coverage for non-Medicare members variesby plan. We can help you ask the rightquestions to determine your benefits.

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We serve the portion of the diabetic community with low income and limited access to care.

You may be in a position to help us help them.

Do you ever have too many test strips?Do you ever end up throwing them away?

We can take your unexpired & factory sealed boxes of test strips and even offer up to $20 per box of 100.

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Attention Diabetics

For more information, please call

763-229-2795Minnesota Diabetic Test Strips

How many kids have it?Historically, children diagnosed with diabetestypically had type 1 and almost never got type2. However, during the past 30 years, the number of young children and youth with type 2 diabetes has increased. Research findingspresented at the 2012 American DiabetesAssociation Scientific Sessions showed that the number of type 2 diabetes cases among 10- to 19-year-olds increased 21 percentbetween 2001 and 2009.

The exact number of young children andyouth in Minnesota with either type 1 or type2 diabetes is unknown. However, using 2001 national study data, we estimate that 2,600 of the 1.4 million Minnesotans 20 years oryounger have diabetes (approximately 18 in10,000). Of those, we estimate that most type2 cases occur among the state’s 720,000 10- to 19-year-olds, withapproximately four of every 10,000 youth affected.

Risk factors Age, ethnicity, family history, and obesity are risk factors for type 2diabetes.

Age. Adolescents are the most likely age group to develop type2 diabetes.

Ethnicity. Native American, Asian/Pacific Islander, Latino, orAfrican American youth aged 10 to 19 are more likely to have type 2 than similar-aged Caucasians.

Family history. Nearly 100 percent of youth that develop type 2diabetes have a biological mother, father, sister, or brother who alsohas type 2 diabetes.

Obesity. Being obese increases the risk of developing type 2 dia-betes. Data from the 2010 Minnesota Student Survey, a survey ofpublic school students, indicates that 9 percent of ninth and 12thgraders meet the criteria for being obese.

Impact Type 2 diabetes affects youth during ado-lescence and into adulthood. Since type 2diabetes in youth has only recently begunto be seen in larger numbers, its conse-quences and lifelong burden are not fullyunderstood. However, its burden duringchildhood and adolescence includes:

Physical impact• By the time youth are diagnosed with

type 2 diabetes, they frequently haveprotein in their urine. This can be anearly sign of kidney disease.

• Youth with type 2 diabetes tend to develop diabetes-related kidneydisease more rapidly than do adults with diabetes.

• Youth with type 2 diabetes are more likely to have high bloodpressure, higher cholesterol and triglyceride levels, and other indi-cators of poor heart health as compared with peers in the generalpopulation, those with type 1 diabetes, and obese youth withoutdiabetes.

Social impact

• Managing diabetes, including activities like checking blood glu-cose levels during school, can make youth feel different from theirpeers and complicate delivery of care.

• Children who are obese (most youth with type 2 diabetes areobese) are more likely to report lower social functioning thanhealthy children.

Emotional impact

• Boys with type 2 diabetes are more likely to be moderately or


Leg Pain StudyDo your legs hurt when you walk?Does it go away when you rest?

Or, have you been diagnosed with PAD?You may have claudication, caused by lack

of blood supply to the leg musclesThe University of Minnesota is seeking volunteers

to take part in an exercise-training program,funded by the National Institutes of Health

To see if you qualify,contact the

EXERT Research Team at

612-624-7614or email [email protected] visit EXERTstudy.org

EXERTstudy.org

Rising type 2 diabetes among youth to page 34

More resources for parentsChildren and Diabetes: (from the Centers for Disease Control andPrevention): www.cdc.gov/diabetes/projects/cda2.htm

Tips for Teens: Lower Your Risk for Type 2 Diabetes: (from the National Diabetes Education Program):www.ndep.nih.gov/teens/LowerYourRisk.aspx

Children & Adolescent Overweight (From the Minnesota Department of Health): www.health.state.mn.us/divs/hpcd/chp/cdrr/obesity/pdfdocs/childrenoverwightfactsheet.pdf

Take Action Now to Prevent Diabetes Later (from the National DiabetesEducation Program): Information for mothers who had diabetes duringpregnancy about how to prevent diabetes in themselves and in their families. www.ndep.nih.gov/am-i-at-risk/gdm/take-action.aspx

Youth Physical Activity Toolkit (from Centers for Disease Prevention and Control): Information for families, schools, and other groups to helpchildren and youth keep physically active www.cdc.gov/Healthyyouth/physicalactivity/guidelines.htm#1

Many peoplewith type 2

diabetes are not

aware thatthey have diabetes.


Diabetes is a disease with significantand devastating physical, eco -nomic, and social impact on indi-

viduals and society. It is the No. 1 cause ofblindness and kidney failure, and the sev-enth-leading cause of death in the UnitedStates. More than 25 million Americanshave diabetes, and recent projections fromthe Centers for Disease Control and Prevention estimate that one inthree American adults may have diabetes by 2050.

Medical expenses for people with diabetes are typically morethan twice those for people without the disease. One in threeMedicare dollars is spent on diabetes, and in 2007, the most recent

year for which this information is available,the estimated cost of diabetes-related medical expenses in the U.S. totaled $174billion a year. Closer to home, diabetescosts Minnesotans $2.68 billion per year.

An estimated one in three adults andone in six youth in the state have diabetesor prediabetes. Prediabetes adversely

affects health whether or not it progresses to diabetes, which in onefederal study was shown to occur in 10 percent of participants peryear over a three-year period. This means that 30 percent of predia-betics were diagnosed with type 2 diabetes within three years afterbeing diagnosed with prediabetes. Diabetes is a growing—and serious—epidemic.

Three-pronged approach

In addition to research into diabetes that is being conducted inde-pendently at the University of Minnesota and at Mayo Clinic, bothinstitutions are collaborating on research to address the growingdiabetes epidemic. In 2010, the two institutions launched theDecade of Discovery: A Minnesota Partnership to ConquerDiabetes, with the goal of making substantial progress by 2020.This partnership’s three-pronged approach aims to prevent, opti -mally treat, and ultimately cure type 1 and type 2 diabetes, relatedconditions in which levels of the sugar glucose within the body arenot regulated appropriately. To accomplish this, more than $2 mil-lion has been invested in 10 research projects thus far. Projectsinclude basic science research to discover previously unknown scien-tific information and refine current understanding of existing infor-mation, as well as applied research that takes information discov-ered and translates it into devices, medicine, and best practices toachieve prevention, treatment, cure, and optimal delivery of care.

Improving treatment

Two projects aim to advance the development of an artificial pan-creas for improved treatment of both type 1 and type 2 diabetes. An artificial pancreas is a device that automatically administers thecorrect amount of insulin to a patient. For such a device to work, it must operate 24/7 to automatically and continuously measure theamount of glucose in a person’s blood, use that measurement todetermine how much insulin is needed minute by minute, and de -liver the correct amount of insulin to the bloodstream on a minute-by-minute basis. Current technology is limited by the types of


The Minnesota Diabetes and Heart Health Collaborative: Working together to keep you informed

Visit www.heart.org

for more information about

cholesterol and heart health Minnesota Diabetes &Heart Health Collaborative

www.mn-dc.org

The Good = HDL Cholesterol: Keep it highThe Bad = LDL Cholesterol: Keep it low

The Ugly = too much cholesterol can lead to heart attack and stroke

Cholesterol Do you know your numbers?

h d

Ask your doctor

U of M and Mayo Clinic—working together to

conquer diabetesBy Steven A. Smith, MD,

and Elizabeth R. Seaquist, MD

Research update

glucose sensors that are available and the abil-ity to couple information those sensors collectabout changes in a person’s blood glucose levels with changes in the rate of insulinadministration.

In one project, Dr. Yogish Kudva (MayoClinic) and Dr. Steven Koester (University ofMinnesota) are developing a specialized elec-tronic chip to improve glucose sensors.

Currently available sensors in insulin pumps require a patient toinsert the catheter of an insulin pump in a different location underhis or her skin every three to seven days. The chip under develop-ment is intended to be inserted under the skin in a minor surgicalprocedure every few months. This should provide diabetic patientswith a more sensitive and reliable form of blood glucose monitoringas well as decreasing the amount of time they spend maintainingtheir insulin pumps.

In a second project, Mayo Clinic researchers Drs. Andy andRita Basu are working with Dr. Kudva to learn more about howchanges in blood glucose are reflected in changes in tissue glucose.Current technology measures the level of glucose that is in fluidwithin tissue under the skin. However, this is only an approximatemeasure of glucose levels in tissue because many factors affect how

quickly glucose moves from blood to tissue,including diet, stress, and exercise.

Since knowing how much glucose is inthe blood is necessary to calculate an accu-rate insulin dose, we need to know moreabout how we can use the measurement of tissue glucose as a surrogate for bloodglucose in the delivery of insulin. In thisproject, investigators will change blood glu-cose levels to see how quickly these changesappear in tissue glucose. Results of thisresearch will be used to automate theinsulin delivery system within an artificialpancreas.

Understanding the cause

In a project that may help treat type 2 diabetes and may one day prevent it, Dr.Alessandro Bartolomucci (University ofMinnesota) and Dr. John Miles (MayoClinic) are investigating a newly discoverednaturally occurring peptide that increases

fat breakdown and enhances weight loss. (A peptide is a moleculethat that conveys messages within and between cells.) In addition,Dr. Brian Fife (University of Minnesota) and Dr. GovindarajanRajagopalan (Mayo Clinic) are altering the immune system of amouse to resemble that of a human in order to identify what trig-gers the destruction of the insulin-producing cells that occurs in type 1 diabetes.

Assessing success

To determine the success of future strategies to prevent andtreat diabetes, Decade of Discovery investigators compiled theMinnesota Health Atlas (www.mnhealthatlas.org), a compre-hensive database that includes information about the health

of those Minnesotans who have diabetes and those who are at riskfor it. This collection of data provides insight into the preventionand treatment of diabetes across the state on a county-by-countybasis. The Atlas project, led by Mayo Clinic’s Jeanette Ziegenfuss,PhD, and her team, in cooperation with public heath organizations,health care providers, and pharmacies, created a baseline snapshotof diabetes in the state that can be compared against future healthstatistics to assess the success of future interventions designed toimprove diabetes prevention and care delivery.

Potential health benefit

Decade of Discovery research and other research efforts at theUniversity of Minnesota and Mayo Clinic have the potential to pro-vide enormous individual and public health benefit by helping peo-ple with diabetes live healthier lives. In so doing, this research isexpected to ultimately reduce the cost of health care for employers,the state, and, therefore, for taxpayers.

Steven A. Smith, MD, is a professor of medicine in the Division ofEndocrinology, Diabetes, Nutrition, and Metabolism at the Mayo Clinic.Elizabeth R. Seaquist, MD, is a professor of medicine in the Division ofEndocrinology and Diabetes at the University of Minnesota, where sheholds the Pennock Family Chair in Diabetes Research. The authors areDecade of Discovery collaborators.


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Foot Solutions is a Medicare approvedsupplier for this program. Please stop by

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Diabetes is the No. 1 cause ofblindness and kidney failure.

Diabetescosts

Minnesotans$2.68

billion peryear.


Don’t cut back on medicinePeople with diabetes who have trouble affordingmedical supplies should not reduce the amount ofmedicine they take, the frequency with whichthey take it, or how often they test their bloodsugar (based on their doctor’s instructions).Instead, they may be pleasantly surprised to learnthat their pharmacist or other members of theirhealth care team can suggest ways to lowerexpenses. Here are cost-saving ideas to explore.

• There are multiple treatments for diabetes. Askif your treatment can be adjusted to cost less.

• Request prescriptions for generic drugs andthose covered by your insurer.

• Ask your doctor or pharmacist if it would beappropriate and cheaper to get 90-day prescrip-tion refills, or higher dosage pills that you couldcut in half. Also ask if a combo-med (two medi-cines in one pill) would work for you.

• Ask your clinic for free samples or manu-facturers’ coupons for diabetesmedicines and supplies.

• Approximately 700 prescription drug discountprograms are available. Some haverestrictions and some may require peoplewith diabetes to apply separately for each


Saving money on diabetesDiabetes is expensive. According to the American Diabetes Association (ADA),people with diabetes typically spend more than $13,000 annually on their healthcare—three times the amount spent by people without the disease. Fortunately,there are many ways to cut the cost of managing diabetes.

Reduce cost, not medicineBy Laurel Reger, MBA

Did you know?• Diabetic retinopathy can be controlled and

diabetic patients need regular eye exams to

maintain vision and good eye health.

• Diabetes Type ll can also cause vision changes.

• Glaucoma must be diagnosed in early stages in

order to prevent vision loss.

• All children entering school need a comprehen-

sive eye exam, because vision screenings do not

detect a number of eye disorders.

• To maintain eye health, everybody from babies

to boomers to older adults needs a regular eye

exam by a family eye doctor.

To locate an optometrist near you and find comprehensive information about eye health visit

http://Minnesota.aoa.org

Minnesota Optometric Association

Doctors on the frontline of eye and vision care

Diabetic? You may have PAD and not even know it.

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Peripheral Arterial Disease (PAD) affects 1 in 3 people over 50 with diabetes. 9 of 10 cases go untreated which can lead to leg amputation.

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medication they take. Ask your doctor to find the right pro-grams for you.

If you have health insurance• Call your insurer (there’s a phone number on the back of an

insurance card) to ask which diabetes supplies and equipmentare covered. Most insurers cover at least some of the cost of dis-posable supplies, diabetic shoes or inserts, wheelchairs, liftchairs, and other items prescribed by your doctor. Certain items,including wheelchairs, are available free on short-term loan fromGoodwill.

• If you are eligible for Medicare Part D, compare plans carefully toselect the best coverage for your diabetes medicines. Free helpunderstanding your options is available by calling the MinnesotaSenior LinkAge Line at (800) 333-2433 or by emailing [email protected].

If you have Medicare Medicare covers the following, but some limitations

apply; check with www.medicare.gov for details.

• Diabetes screening

• Diabetes self-management training by an accredited educa-tion center

• Medical nutrition therapy by a dietitian or nutrition team

• Diabetes supplies

• Free flu and pneumococcal shots

• Foot exams

• Therapeutic shoes prescribed by your doctor

• Insulin, medicines, and some supplies under Medicare Part D

If you don’t have health insurance• See if you qualify for programs providing lower cost prescription

drugs, supplies, and services, at www.benefitscheckup.org.

• Check www.MinnesotaHelp.info for local health care and prescrip-tion drug resources.

• Most Minnesota counties have their own health-care discount pro-grams. Contact your county social services or local public healthagency to see what it offers.

• “Financial Help for Diabetes Care” listsresources for diabetes products, services,and insurance: www.diabetes.niddk.nih.gov/dm/pubs/financialhelp

• Join a diabetes research study. Study partic-ipants may receive free medicines and serv-ices, incentive awards, or payment. Searchwww.clinicaltrials.gov to find research tri-als that may accept you.

• Shop around for the best prices; the cost of prescription medicationcan vary between pharmacies. Online tools like www.Medtipster.com help you find the lowest price at pharmacies inyour area. Mail order pharmacies and those offering discount cardsmay also save you money.

If you cannot afford to see a doctor, visit a free or low-cost clinic.

• Find a local community health center at http://findahealthcenter.hrsa.gov/ for free or low-cost services that may include dental care,

mental health services, and more.

• In the metro area, St. Mary’s Health Clinics offer free health care,medicines, and help acquiring other health services. Call (651) 287-7777 to see if you are eligible.

• United Way 2-1-1 is a free, confidential way to find health care,transportation, and additional services. Call 2-1-1, or (651) 291-0211 from a cell phone, 24/7. Help is available in more than 100 languages, including Spanish, Hmong, Somali, and Russian.

Whether you have health insurance or not, discount programsare available.

• Contact the ADA for discount programs for diabetes medicines andblood glucose meters at www.diabetes.org (search “prescriptionassistance”) or call (800) DIABETES (342-2383).

• UnitedWay has a drug discount program for everyone: go to www.familywize.org.

• Many large pharmacies such as Walgreens and WalMart have dis-count cards and offer certain prescription drugs for $4 per refill.

• Ask your employee benefits office, union, co-op, or membershiporganization (such as AARP) if it offers prescription drug discounts.

Ask if yourtreatmentcan beadjusted tocost less.

Prescription assistance programs • Minnesota RxConnect helpline (800) 333-2433

• Partnership for Prescription Assistance, www.PPARx.org

• PhRMA, www.RxHope.com

• Volunteers in Health Care, www.rxassist.org

Saving money on diabetes to page 33

In the next issue...

• Plantar fasciitis• Pacemakers for pain• Seasonal affective

disorder



E N V I R O N M E N T A L H E A L T H

In 1644, English jurist Sir Edward Coke (1552–1634) was quotedas saying, “For a man’s house is his castle, et domus sua cuiquetutissimum refugium” (and one’s home is the safest refuge for all).

But this may no longer be true. Today’s homes can be plagued byindoor pollutants that include off-gassed chemicals from carpet and

other manufactured home furnishings; cigarette smokeand other byproducts of combustion; and naturally occur-ring pollutants such as mold and radon. The quality ofthe air we breathe inside may worsen when homes aretightened up to save energy and in winter when windowsstay shut and ventilation decreases.

In fact, the Environmental Protection Agency(EPA) ranks indoor air as the fourth biggest source of exposure to contaminants, in part because peoplespend up to 90 percent of their time inside. The goodnews is that people can take steps to improve theirindoor air qual ity, with even small changes resultingin improved health.

Indoor air qualityKeeping it healthyBy Kathleen Norlien, MS, CPH

WHO’S A BIGGER BASEBALLFAN, YOU OR ME?You’ll find that people with Down syndromehave a passion for knowledge and learningthat can rival anyone you’ve met before.To learn more about the rewards of knowing orraising someone with Down syndrome, contactyour local Down syndrome organization.Or visit www.dsamn.org today.

©2007 NationalDown SyndromeCongress

It is the mission of the Down Syndrome Association ofMinnesota to provide information, resources and support toindividuals with Down syndrome, their families and theircommunities. We offer a wide range of services, programs andmaterials at no charge. If you are interested in receiving oneof our information packets for new or expectant parents,please email [email protected] or

For more information please call:

(651) 603-0720 • (800) 511-3696

Pollution sourcesIndoor air pollutants are radiological,chemical, or biological in nature.Biological pollutants include mold,pets, and pests. Chemical pollutantsinclude formaldehyde and volatileorganic hydrocarbons emitted by carpet, paint, furniture, and textiles;scented products such as air freshen-ers, cleaning products, and personalcare products; asbestos; lead; andbyproducts of combustion. Com -bustion byproducts include carbon monoxide (CO); nitro-gen dioxide (NO2); and particulates from wood smoke,gas-burning appliances, and tobacco smoke. A radiologicalpollutant in Minnesota is most likely to be radon, a natu -rally occurring radioactive gas in the ground.

Radiological. Radon typically seeps into ahome through cracks and drains in the base-ment floor. It is the leading cause of lung cancerin nonsmokers, so it is prudent to performthe simple and relatively inexpensive test forit. If radon is found to be at an unsafe level,a radon-mitigation professional can install equipmentthat reduces the amount of the gas entering thehome. More information on radon and how totest for it is at: www.health.state.mn.us/divs/eh/indoorair/radon/radontestresults.html

Biological. To prevent mold growth, keepyour house dry; maintaining a relative humidity below 50 percentgenerally keeps mold from growing. Watch for leaks in the buildingenvelope—roof leaks, wet basements, and leaking pipes under sinks—and fix them within 24 to 48 hours. Make sure that your home iswell ventilated and use ventilation fans in bathrooms and kitchens.

These fans should vent to the outdoors, notinto an attic or other interior area, and canbe wired to operate by timer to ensure reg-ular use. Use carpet-free flooring in mois-ture-prone areas such as kitchens, baths,and basements. Dehumidifiers are helpfulin areas that become damp when it rains orwhen humidity is high, such as basements.Maintain them with regular cleaning andby emptying reservoirs that collect waterand changing filters as necessary. Refer tothe owner’s manuals for more detailedinstructions on how to operate and main-tain all your appliances so they functioneffectively and don’t become breedinggrounds for mold or other microbiologicalhazards.

Pets can be problematic for people allergic to them, but keepingpets out of the bedroom and off furniture helps. Regular house clean-ing helps too, by reducing the amount of pet hair in the home.Maintaining a clean house is also important because it reduces house-hold dust, which can contain lead from lead paint that may be pres-

ent in the home; pesti-cides and other outdoor

contaminants tracked insideon shoes; pollen; and other

allergens such as dust mites. Dust mites breed in warm,

moist environments and are typical-ly found in greatest numbers inbedrooms. Someone allergic to dustmites could consider investing inmite-proof covers for the mattressand pillow in addition to regularly

vacuuming, damp dusting, and washing bed linens in hot water anddrying them on high heat. Keep clutter to aminimum for easier cleaning.

Chemical. Minimize the use of chemicalswithin your home. Used improperly—

without carefully following direc-tions or when mixed with

other chemicals—they maybe hazardous to your health. If

you must work with harsh chemi-cals, use the correct type of protective gloves, eyewear, andother protective equipment. Always work with chemicals inwell-ventilated areas. Avoid disturbing floor tiles or other

home-building materials that may contain asbestos, as thatreleases fibers into the air that can cause lung cancer and


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Indoor air quality to page 32

Asthma and air qualityFor the estimated 392,000 children and adultsin Minnesota who currently have asthma,maintaining a healthy home can be a crucialpart of asthma control. Indoor sources of airpollution may trigger asthma attacks and con-tribute to hospitalizations, unplanned doctorvisits, and absences from school and work.Therefore, it is of utmost importance that homesbe made healthy for people with asthma, especially if their asthma triggers are linked tocontaminants in the environment.

The EPA ranksindoor air as thefourth biggest

source of exposure to

contaminants.

other diseases if inhaled in sufficient quantity.Instead of buying scented household cleaning

products, clean with vinegar and baking soda.Unscented personal care products support indoor airquality better than scented ones. If you plan to buypaint or home furnishings, request they be manufactured oflow-emitting materials, or purchase floor-model items thathave already off-gassed in the store. Outside the home, off-gassed chemicals responsible for that “new car smell” maycontaminate air inside a new car or one parked inthe sun. Ventilate the car’s interior as soon asyou enter it or beforehand, if possible.

Combustion byproductsFinally, be mindful of the potential for tinyparticles and other pollutants emitted intoindoor air by sources of combustion.Byproducts of combustion can contain additionalharmful chemicals that can be irritating or toxic.

All combustion appliances, such as gas waterheaters, driers, stoves, and fireplaces, should vent out-

doors. Be sure to have working alarmsfor CO and smoke in your home as

well as in atypical living spaces such ascabins, campers, and ice-fishing houses.

Wood and gas stoves used in homes should be inspect-ed and cleaned annually, and old stovesreplaced with EPA-certified models. Woodburned in a wood stove, fireplace, or even out-doors should be clean, dry, and not from achemically treated source such as broken furni-ture. This is because heat from the fire releasesharmful chemicals into the surrounding air. Andsince smoking is a known health hazard that

contaminates the air around it, it should be done outdoors.

Breathe easily The most efficient way to maintain healthy indoor air is tokeep pollutants out of it. Do that by keeping your homedry, clean, and well maintained, and by minimizing com-bustion byproducts and the indoor use of chemicals.Checklists are available to help you identify air pollutants.Many of these checklists also provide low-cost solutionsfor getting rid of air pollutants, making your home ahealthier place to live and a refuge where you can breathe

easily.

Kathleen Norlien, MS, CPH (Certified in Public Health), is a researchscientist with the Minnesota Department of Health asthma program.

Indoor air quality from page 31


Healthy homes checklistswww.surgeongeneral.gov/library/calls/healthyhomes/checklist.pdfwww.extension.iastate.edu/publications/pm1622.pdfwww.mngreencommunities.org/publications/download/HealthyHome_checklist.pdf

Maintaining ahealthy home can

be a crucial part ofasthma control.

Health Care ConsumerAssociation

Minnesota

Each month, members of the Minnesota HealthCare Consumer Association are invited to participate in a survey that measures opinionsaround topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the September survey.

Pe

rce

nta

ge

of

tota

l re

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s

Yes No0

20

40

60

80

100100%

0%

Pe

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nta

ge

of

tota

l re

spo

nse

s

Very

satisfied

Does not

apply

Satisfied Unsatisfied Very

unsatisfied

0

10

20

30

40

50

60

70

80

13.5%

2.7%

16.2%

0.0%

67.6%

2. How satisfied were you with your understandingof the information you received at discharge forfollow-up care?

1. Have you or a member of your family ever beendischarged from a hospital?

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Very

useful

Does not

apply

Useful Barely

useful

Useless0

10

20

30

40

50

8.1%

40.5%

21.6%24.3%

5.4%

Pe

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ge

of

tota

l re

spo

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s

100% Does not

apply

Very

related

Somewhat

related

Unrelated0

10

20

30

40

50

60

70

80

2.7%

10.8%

2.7%

10.8%

73.0%

5. If readmission to the hospital occurred, how much do you feel a lack of clear information about follow-up care contributed?

Pe

rce

nta

ge

of

tota

l re

spo

nse

s

Very

satisfied

Does not

apply

Satisfied Unsatisfied Very

unsatisfied

0

10

20

30

40

50

60

10.8%

2.7%

18.9%

13.5%

54.1%

3. How satisfied were you that other care providers understood and integrated the dis-charge information into your follow-up care?

September survey results ...

4. How useful was the follow-up care you receivedfrom the hospital after you got home?

How health care reform will affect costsParts of the Affordable Care Act could benefit your diabetes care andlower what you spend to stay healthy. Here are a few examples:

• Having diabetes no longer excludes you from getting health insur-ance. A preexisting condition insurance plan is now available thatlimits annual out-of-pocket expenses (www.pcip.gov/). In addition,insurance companies will no longer be able to drop people who getsick and start filing claims. In 2014, everyone will be allowed tobuy private health insurance regardless of his or herhealth status.

• Most people without access to health insurance will beable to comparison shop for insurance options on cen-tralized exchanges.

• People age 65 and older on the Medicare Part D pre-scription drug plan will receive a discount on somedrugs and will have their annual checkup, vaccina-tions, and screening tests fully covered.

• Lifetime and annual limits on benefits will be droppedcompletely.

• Deductibles and copayments for many preventive serv-ices and screenings will be eliminated.

• Medicaid will be expanded to cover more people.

Certain health care costs will increase under theAffordable Care Act. For instance:

• Government subsidies to Medicare Advantage

(known as gap insurance) will decrease, which could increase pre-miums or reduce benefits.

• Individuals earning at least $200,000 and families earning morethan $250,000 will see their Medicare payroll taxes increase.

• Starting in 2014, people who do not buy health insurance as man-dated by law will face a penalty of $95 or 1 percent of income.This increases to $695 or 2.5 percent of income by 2016.

Biggest savings Exercise regularly, eat healthfully, lose as little as

10 pounds if you are overweight, and don’t smoke. A healthy lifestyle can prevent diabetes complica-tions and may even reduce your need for medicines,supplies, and services.

Don’t endanger your health by not followingyour treatment plan because of its cost. Talk to yourdoctor, pharmacist, diabetes educator, or anyone onyour health care team—they’ll help you find solu-tions in these tough financial times.

Laurel Reger, MBA, is a planner with the MinnesotaDepartment of Health (MDH) and co-chairs theMinnesota Diabetes and Heart Health Collaborative, avoluntary group of organizations within the state thatdevelops educational resources and advances best prac-tices to support healthy behaviors.

Saving money on diabetes from page 29

Diabetes is expensive.


We want to hear from you!

Join now.

SM

Welcome to your opportunity to be heardin debates and discussions that shape thefuture of health care policy. There is nocost to join and all you need to becomea member is access to the Internet. Yourprivacy is completely assured; we won’teven ask your name.

Members receive a free monthly electronicnewsletter and the opportunity toparticipate in consumer opinion surveys.

www.mnhcca.org

Health Care ConsumerAssociation

Minnesota

severely depressed than are boys with type 1.

• Binge eating is a frequent behavior among youth of both genderswho have type 2 diabetes and appears to be associated withdepression and lower reported quality of life.

Symptoms to monitorMany people with type 2 diabetes, includingyouth, are not aware that they have diabetes.That’s because early in the course of the disease,few if any symptoms may be present. However,one risk factor for type 2 diabetes that can bedetected easily is the presence of dark, velvety skin on the neck or inthe armpits or groin. This can be a sign of insulin resistance (anearly sign of/precursor to type 2 diabetes), as are high blood pres-sure and high cholesterol, both of which can be detected by a healthcare provider. If your child has any of these symptoms, talk withyour health care provider about whether or not a screening test fordiabetes is appropriate.

As type 2 diabetes progresses, additional symptoms may appearand can progress to potentially life-threatening complications. Ifyour child develops any of the following symptoms, contact yourhealth care provider immediately:

• Extreme thirst

• Frequent urination

• Unexplained weight loss

Preventive steps for parentsThe Minnesota Department of Health’s Office of Statewide HealthImprovement Initiatives recommends these simple lifestyle changesto help reduce your child’s risk of developing diabetes:

• Offer your child a variety of fruits and vegetables every day.

• Limit your family’s consumption of fast food.

• Limit your family’s consumption of sugary beverages such as popand juice; encourage your child to drink water.

• Encourage your child to engage in physical activity for at least onehour daily.

• Limit the TV your child watches to between one and two hoursper day.

These lifestyle changes will not only help younger children andyouth reduce their risk of developing type 2 diabetes, but will alsohelp those already diagnosed with either type 1 or type 2 diabetesachieve optimal control of their blood sugar so they can live health -ier, happier lives.

Renée Mijal, PhD, MPH, is an epidemiologist and Tammy Didion, RD, LD,is a diabetes prevention planner. Both are with the diabetes unit at theMinnesota Department of Health. Brandon Nathan, MD, is an assistantprofessor of pediatrics at the University of Minnesota.

Rising type 2 diabetes among youth from page 25


Binge eating is a frequent behavior among youth of both genders who have type 2 diabetes.

Elizabeth Klodas, M.D.,F.A.S.C.C is a preventive

cardiologist. She isthe founding Editor inChief of CardioSmartfor the American

College of Cardiologywww.cardiosmart.org,a published author

and medical editor forwebMD. She is a member

of several nationalcommittees on improving

cardiac health and afrequent lecturer on

the topic.

Preventive Cardiology Consultants isfounded on the fundamental belief thatmuch of heart disease can be avoidedin the vast majority of patients, andsignificantly delayed in the rest, by prudentmodification of risk factors and attainablelifestyle measures.

We are dedicated to creating a true part-nership between doctor and patient workingtogether to maximize heart health. Wespend time getting to know each patientindividually, learning about their lives andlifestyles before customizing treatmentprograms to maximize their health.

Whether you have experienced any typeof cardiac event, are at risk for one, or

are interested in learning how to preventone, we can design a set of just-for-yousolutions.

Among the services we provide

• One-on-one consultations withcardiologists

• In-depth evaluation of nutrition andlifestyle factors

• Advanced and routine blood analysis

• Cardiac imaging including (as required)stress testing, stress echocardiography,stress nuclear imaging, coronary calciumscreening, CT coronary angiography

• Vascular screening

• Dietary counseling/Exercise prescriptions

Now accepting new patients

A unique perspective on cardiac care

To schedule an appointment or to learn more about becominga patient, please contact:

Preventive Cardiology Consultants6545 France Avenue, Suite 125, Edina, MN 55435

phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

A Medicare plan that lets youkeep the doctor who knows your history, medications and the names of all your grandkids.

Switch your Medicare plan. Not your doctor.With a HealthPartners Freedom plan, you stick with your doctor; whether he or she is at Park Nicollet, Fairview, Allina Health, HealthPartners or hundreds of other clinics. So go ahead, make the switch. Shop and compare plans online. Or call us at 952-883-5601 or 800-247-7015, 8 a.m. to 8 p.m., seven days a week. TTY users call 952-883-6060 or 800-443-0156.

H2462_57148_CMS Accepted 8/19/12 HealthPartners is a health plan with a Medicare contract. ©2012 HealthPartners

healthpartners.com/medicare

INFORMATION

Job Number 245-11845 Trim 9.5” x 12.625” Modification Date August 27, 2012 11:15 AM

Client HealthPartners Bleed 10” x 13.125” Output Date 08/27/12

Description Print Ad Live 8.5” x 11.625” Page # 1

File Name 245-11845_MedicarePrint2012_MN-Health-Care r3

SIGN-OFF

[ ] CD Peter Tressel

[ ] AD Melissa Tresidder

[ ] CW

[ ] AS Mark Jenson

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[ ] PM Krista Kraabel

Notes

3

Diabetes and Hearing Loss by the Numbers

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*Our hearing test and video otoscopic inspection are always free. Hearing test is an audiometric test to determine proper amplificationneeds only. These are not medical exams or diagnoses nor are they intended to replace a physician’s care. If you suspect a medicalproblem, please seek treatment from your doctor. **ME200 not included. †According to The Better Hearing Institute.

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Call 888-667-1821 to schedule your FREE hearing test!

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If you’ve answered “Yes” to any one of these questions, Miracle-Ear can help!

IN QUIET ENVIRONMENTS...Do you turn the TV up louder than others need to?Do you have trouble hearing others over the phone?

IN NOISY ENVIRONMENTS...At get-togethers, are you reluctant to participate for fear of saying something wrong because you’ve misheard something?Does it require a lot of concentration to listen to a conversation, especially with background noise?

IN EVERYDAY ENVIRONMENTS...Do family or loved ones comment on your inability to hear properly?Do you sometimes feel that people are leaving you out of conversations because it’s a nuisance for them to speakslowly or more loudly for your sake?

©2012 Miracle-Ear, Inc. 14347DMPM

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Prove that age is just a number.enroll in a meDiCare Plan toDay.

Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.H2425_002_083012_N01 CMS Accepted 09/04/2012H2461_083012_N02 CMS Accepted 09/04/2012S5743_083012_K01_MN CMS Accepted 09/04/2012

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Minnesota Health care News October 2012

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Transcript of Minnesota Health care News October 2012