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Managing Diabetes Hard for Homeless

Shelters struggle to meet needs of special population

TUESDAY, July 2, 2002 (HealthDayNews) --After eating two helpings of spaghetti and meatballs and stashing some chocolate-flavored marshmallow snack pies in a plastic shopping bag for tomorrow's breakfast and lunch, Andres disappears into the men's room of a New Jersey homeless shelter to give himself an insulin shot.

These days, Andres's blood sugar level is routinely above 300 milligrams per deciliter -- normal is in the 70 to 110 range -- so he self-administers three instead of the prescribed two insulin doses a day. Afterwards, he heads back out onto the street to find a place to sleep.

Andres, not his real name, is one of a number of homeless men and women struggling -- and often failing -- to control their diabetes.

"Nationally, Type II diabetes is at epidemic levels, and it is no different for the homeless population," says Pat Post, a health policy analyst for the National Health Care for the Homeless Council.

According to the National Institutes of Health, 17 million Americans have diabetes, almost 6 million of whom don't know it.

The disease, in which elevated blood sugar levels end up damaging different parts of the body, can often be managed with lifestyle modifications. Control your blood sugar now through diet and exercise, and you're far less likely to suffer complications, such as blindness, limb amputation and kidney failure later on.

However, this type of control is almost impossible when you're eating at soup kitchens and sleeping in city parks.

According to a survey of homeless individuals in Toronto published in a 2000 issue of the Canadian Medical Association Journal, about three-quarters of homeless people with diabetes reported difficulties managing their disease. Almost half of the people surveyed had inadequately controlled blood sugar levels.

"We found that the most commonly cited obstacle was their diet," says Dr. Stephen Hwang, study author and an assistant professor of health policy, management, and evaluation at the University of Toronto. "Homeless people have to eat what's served or they don't eat at all. That presents a real challenge."

In this study, 64 percent of homeless men and women surveyed reported problems with the food available at local shelters, pointing specifically to excessive amounts of sugar, starch and fat, as well as a lack of fresh fruits and vegetables.

Andres points to the same problem. "I eat whatever," he says. "I don't have no choice."

Needles are another problem: Many shelters do not permit them. "At some shelters, that possession of needles is not allowed because it's considered drug paraphernalia," Hwang says. Even where it is allowed, there was a fear that this would make the homeless individual a target for theft.

Because he is not staying overnight at the shelter, Andres can keep his needles with him (they're stored in his plastic shopping bag). People staying overnight must check their needles with the staff.

This protocol presents more scheduling and logistics problems. Some may need to take their insulin half an hour before eating, but may only gain access to their supplies 10 minutes before.

Eloise Crayton, managing director of nursing and community health at Grace Hill Neighborhood Services in St. Louis, feels shelters could address some of these problems by providing safe storage and ready access to diabetic medications and supplies, as well as establishing a secure place for people to self-administer insulin and use glucose-monitoring devices. One shelter agreed to set up space where homeless individuals living on the street could safely store their insulin and needles.

Grace Hill has been working on other remedies as well. "We were most concerned with diabetics being able to have some semblance of regular meals," Crayton says. "We were also concerned that most of the shelters relied on donated food and, as a result, maybe all the clients were getting were six doughnuts and some other pastries."

Grace Hill had its dietician meet with the cooks at the few shelters that actually have kitchens to provide instructions for healthier foods. Some of the tips were as simple as baking meat in the oven instead of frying it.

"Other changes were as simple as putting Sweet N' Low or NutraSweet out so they wouldn't have to put sugar in their coffee," adds Veronica Richardson, national director of the Institute of Healthcare Improvement in Boston, who was previously Grace Hill's director of chronic disease care management.

Grace Hill is also trying to set up programs to deal with long-term care issues. So often, diabetes management ends up at the bottom of the list of priorities when a person is worried about where the next meal is coming from.

"If their vision isn't too blurry, if everything seems to be OK, then diabetes becomes the least of their worries at this point," Richardson says. "It was a question of heightening their awareness to say, 'You may not be having problems now, but you're setting yourself up for worse things down the line.'"

Grace Hill set up what it calls "cluster visits" to try to meet all the standards of care in one fell swoop. The cluster visits were more successful in the winter months, Richardson says, because all the homeless were concentrated in one area.

Grace Hill also set up diabetic screenings at a local discount store during the summer, and arranged for the homeless to get shower shoes for free (these shoes help prevent against foot infections).

Andres believes that his diabetes, which was first diagnosed seven years ago, is starting to affect his vision -- but he doesn't have money to go to a doctor.

Does he worry about future complications? "Of course," he says. "Life is only once."

What To Do

For more information on homeless health-care concerns, visit National Health Care for the Homeless Council .

To learn more about diabetes, visit the American Diabetes Association or the Joslin Diabetes Center.

SOURCES: Pat Post, health policy analyst, National Health Care for the Homeless Council, Nashville, Tenn.; Stephen Hwang, M.D., assistant professor, health policy, management and evaluation, University of Toronto; Eloise Crayton, R.N., managing director, nursing and community health, Grace Hill Neighborhood Services, St. Louis; Veronica Richardson, R.N., national director, Institute of Healthcare Improvement, Boston; "Andres," homeless man; July 25, 2000, Canadian Medical Association Journal
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