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Articles 691 - 720 of 1117
Full-Text Articles in Entire DC Network
Interprofessional Collaboration To Support Children With Diabetes, Katie M. Polo, Susan M. Cahill
Interprofessional Collaboration To Support Children With Diabetes, Katie M. Polo, Susan M. Cahill
The Open Journal of Occupational Therapy
Background: The purpose of this study was to investigate school nurses’ perspectives related to interprofessional collaboration to support health promotion and development of self-management skills of students with diabetes.
Method: A link to an on-line survey was sent to 312 school nurses. The survey included 11 items pertaining to the nurses’ perceptions.
Results: The majority of the respondents (91.8%, n = 56) reported that instruction and maintenance of diabetes self-management skills would benefit from an interprofessional team. Few of the respondents (20.8%, n = 11) identified occupational therapy practitioners as possible collaborators. Nearly two-thirds (62.7%, n = 37) of the …
Sex After Gray Hair? Association Between Sexual Activity, Hugging, And Health Among Older Adults?, Chantelle Sharpe
Sex After Gray Hair? Association Between Sexual Activity, Hugging, And Health Among Older Adults?, Chantelle Sharpe
USF Tampa Graduate Theses and Dissertations
Research on sexual behavior in late life is limited but is growing. Despite ageist stereotypes associating old age with asexuality, older adults continue to desire and engage in sexual behavior. Previous studies have examined the relationship between health and the ability to engage in sexual behavior, sexual satisfaction, desire, or interest in sex. Research has yet to examine the potential reverse of this relationship, where sexual behavior may serve as a protective factor against health outcomes.
This dissertation examined three research questions to test the relationship between sexual activity or hugging and self-reported health outcomes (e.g., arthritis and diabetes) and …
Occupational Stress And Increased Risk For Type 2-Diabetes: A Narrative Review, Harrynauth Persaud, Shawn Williams
Occupational Stress And Increased Risk For Type 2-Diabetes: A Narrative Review, Harrynauth Persaud, Shawn Williams
Publications and Research
Diabetes is a significant health problem in the United States. There is a large body of research that explains the biological and pathoetiological cause(s) of this increasingly prevalent disease. There is also an increasing body of research that explores the psychosocial causes of diabetes mellitus type 2. The association between stressful work organization and diabetes has been established as a significant precursor and causative agent of diabetes mellitus - type 2. The objective of this narrative review is to discuss the impact of work stress as it applies to the rising incidence of diabetes - type 2, and to propose …
Cebp/Α Increases Functional Β-Cell Mass, Jason Ray, Jeffery Tessem
Cebp/Α Increases Functional Β-Cell Mass, Jason Ray, Jeffery Tessem
Journal of Undergraduate Research
Type 1 and Type 2 diabetes are major global health concerns. Diabetes is characterized by impaired management of glucose in the bloodstream, which is due to decreased pancreatic functional β-cell mass. Functional β-cell mass is determined from the insulin secretion rate and the number of β-cells, which is determined from cellular proliferation and death rates. Increasing functional β-cell mass could cure diabetes either by enhancing pancreatic islets prior to transplantation, or by strengthening endogenous cells. Although β-cells stop proliferating around adolescence, β-cell proliferation resumes during conditions such as pregnancy and obesity (1), demonstrating that the molecular pathways necessary for replication …
Diabetes Screening And Prevention In A High-Risk, Medically Isolated Border Community, Ann V. Millard, Margaret A. Graham, Nelda Mier, Jesus Moralez, Maria Perez-Patron, Brian Wickwire, Marlynn L. May, Marcia G. Ory
Diabetes Screening And Prevention In A High-Risk, Medically Isolated Border Community, Ann V. Millard, Margaret A. Graham, Nelda Mier, Jesus Moralez, Maria Perez-Patron, Brian Wickwire, Marlynn L. May, Marcia G. Ory
Anthropology Faculty Publications
Introduction: A project in a Texas border community setting, Prevention Organized against Diabetes and Dialysis with Education and Resources (POD2ER), offered diabetes prevention information, screening, and medical referrals. The setting was a large, longstanding flea market that functions as a shopping mall for low-income people. The priority population included medically underserved urban and rural Mexican Americans. Components of the program addressed those with diabetes, prediabetes, and accompanying relatives and friends.
Background: People living in the Lower Rio Grande Valley (LRGV) face challenges of high rates of type 2 diabetes, lack of knowledge about prevention, and inadequate access to medical care. …
Evaluation Of Community-Based Program On Health Indicators In Food Insecure Population, Mark Wilkinson
Evaluation Of Community-Based Program On Health Indicators In Food Insecure Population, Mark Wilkinson
International Nursing Research Congress (INRC)
Purpose: The purpose of this project is to improve the health outcomes of a food insecure population through health interventions of health screenings, health education, dietary education, and increased physical activity.
Methods: The intervention of health screenings of weight, BMI, dyastolic/systolic blood pressure, and blood glucose readings in conjuction with health education and increased physical activity will be initiated within a food insecure population.
Results: The research is ongoing.
Conclusion: The research is ongoing
The evaluation of a community based program on health indicators in a food insecure population
Food insecurity is defined as not having enough quantity or quality …
Addressing Nutritional Literacy In Preschool Learning Environments, Cynthia Warren
Addressing Nutritional Literacy In Preschool Learning Environments, Cynthia Warren
Journal of Family Strengths
INTRODUCTION: Obesity among preschool children is more common among lower-income families. Prevalence of type 2 diabetes in U.S. Mexican and African American populations has steadily increased and is associated with modifiable risk factors, such as poor dietary habits.
AIM: The purpose of this study was to conduct an assessment of the preschool Bienestar/NEEMA Health Program, focusing on: students’ knowledge increase, teacher input on the classroom materials used, parental feedback on take-home activities, and input on the program's food service training by the school district's nutrition coordinator.
SAMPLE: Curriculum was implemented and assessed in one Head Start school over …
The Turnover Of Succinated Proteins In The Adipocyte For The Treatment Of Diabetes, Dominique Jacobs
The Turnover Of Succinated Proteins In The Adipocyte For The Treatment Of Diabetes, Dominique Jacobs
Senior Theses
In the United States 29.1 million people have diabetes, or 1 out of every 11 people. The rate of new cases of diagnosed diabetes has begun to fall, but the numbers are still very high. 86 million people are living with prediabetes, a serious health condition that increases a person’s risk of developing type 2 diabetes mellitus (T2DM) and other chronic diseases (1). Unfortunately, 90% of those 86 million people are unaware that they are at risk. The health and economic costs for both types of diabetes are enormous: more than 20% of health care spending is committed to people …
Food Security Status, Dietary Behaviors And Health Outcomes In Cambodian Americans With Depression And At High-Risk For Diabetes, Living In New England, Chelsey Hahn
Master's Theses
Background:
Refugee survivors of starvation and trauma during the Khmer Rouge rule of Cambodia suffer myriad poor health outcomes, 30 years after the genocide. Having high rates of food insecurity, depression, and the highest rate of type 2 diabetes mellitus for an Asian subgroup complicates nutritional health outcomes.
Objectives:
(1) To document household food insecurity of Cambodian Americans who were alive during the Pol Pot era, with depression and elevated diabetes risk in New England; (2) To document the dietary behaviors of Cambodian Americans; and (3) To explore preliminary associations between household food insecurity, dietary behaviors and diabetes risk …
Latinos With Diabetes: How Do Social, Psychological, And Cultural Factors Affect Health Outcomes?, Erika Ruiz
Latinos With Diabetes: How Do Social, Psychological, And Cultural Factors Affect Health Outcomes?, Erika Ruiz
Social Work Dissertations - Archive
Diabetes has become one of the most common, costly, and preventable health problems diagnosed among all Americans (Centers for Disease Control [CDC], 2015a). Twenty-nine million individuals (9.3% of the population) have diabetes; this figure includes both diagnosed and undiagnosed diabetes cases (American Diabetes Association, 2014a,b). Diabetes is highly prevalent among Latinos in the United States; it is the fifth leading cause of death among this population (National Center for Health Statistics, 2011a). Yet, most people with diabetes do not die from diabetes per se; most people with diabetes die from cardiovascular disease. Given the large number of Latinos in the …
A1c Reduction And Weight Loss In A Veteran Population Using Glp-1-Ras, Shelby L. Beutel Darrow
A1c Reduction And Weight Loss In A Veteran Population Using Glp-1-Ras, Shelby L. Beutel Darrow
Undergraduate Honors Thesis Collection
Background: Diabetes mellitus is a metabolic disorder defined by high blood glucose. Glucagon-like peptide-1 receptor agonists (GLP-1-RAs) are a newer class of medications that offer potential 2 to 3 kg weight loss and a 1% to 1.5% decrease in A1c. At the Indianapolis Veterans Affairs Medical Center (VAMC), GLP-1-RAs are non-formulary.
Objectives: Primary outcomes included mean change in weight, body mass index (BMI) and A1c in VAMC patients. Secondary outcomes included the comparison to published values, analysis of insulin needs, and analysis of GLP-1-RA discontinuation reasons.
Methods: Indianapolis VAMC patients ages 18-80 with type 2 diabetes who started a GLP-1-RA …
The Effects Of An Acute Bout Of Exercise On Hunger Hormones In Individuals At Risk For Type 2 Diabetes, Sydney Spoon
The Effects Of An Acute Bout Of Exercise On Hunger Hormones In Individuals At Risk For Type 2 Diabetes, Sydney Spoon
UNLV Theses, Dissertations, Professional Papers, and Capstones
Background: Hunger hormone levels are typically dysregulated in obese and diabetic
populations, however; postprandial exercise has been shown to influence hunger hormone levels. Purpose: To determine if hunger hormones including acylated ghrelin and GLP-1 levels are altered in response to an acute bout (15 minutes) of walking in individuals at risk for type 2 diabetes mellitus (T2DM).
Methods: Ten subjects at risk for prediabetes (fasting blood glucose 100–125mg/dL) participated in this randomized crossover design trial. Subjects arrived at the laboratory following an overnight fast and underwent one of two conditions: 1) Test meal with no walking (CON) or 2) Test …
Health & Kinesiology News, Georgia Southern University
Health & Kinesiology News, Georgia Southern University
Health Sciences & Kinesiology: News & Publications (2015-2023)
- Students provide Healthy and Diabetes Friendly Food Demonstrations
Diabetes, Cardiovascular Disease, And Chronic Kidney Disease In South Asia: Current Status And Future Directions, Anoop Misra, Nikhil Tandon, Shah Ebrahim, Naveed Sattar, Dewan Alam, Usha Shrivastava, K M Venkat Narayan, Tazeen H. Jafar
Diabetes, Cardiovascular Disease, And Chronic Kidney Disease In South Asia: Current Status And Future Directions, Anoop Misra, Nikhil Tandon, Shah Ebrahim, Naveed Sattar, Dewan Alam, Usha Shrivastava, K M Venkat Narayan, Tazeen H. Jafar
Section of Pulmonary & Critical Care
No abstract provided.
The Effect Of Acute Hyperglycemia On Muscular Strength, Power And Endurance, Franklin Lime-Ma, Joshua A. Cotter, Evan E. Schick
The Effect Of Acute Hyperglycemia On Muscular Strength, Power And Endurance, Franklin Lime-Ma, Joshua A. Cotter, Evan E. Schick
International Journal of Exercise Science
International Journal of Exercise Science 10(3): 390-396, 2017. The purpose of this study was to elucidate the impact of acute hyperglycemia on skeletal muscle strength, power, and endurance. Ten male collegiate athletes (age 21.5 ± 1.5 years, height 186 ± 2.03 cm, body mass 108.8 ± 7.6 kg) participated in 2 testing sessions, separated by 7 days and randomized for either high glucose (HG) or control (C) treatment conditions. HG consumed a high glucose drink (2 g glucose/kg body weight) while controls consumed an isocaloric nutrition bar (40% protein, 30% fat, and 30% carbohydrate). Blood glucose (BC) levels for HG …
Clinical Significance Of A False Positive Glucose Challenge Test In Patients With A High Body Mass Index, A Borja, M Moretti, Nisha Lakhi
Clinical Significance Of A False Positive Glucose Challenge Test In Patients With A High Body Mass Index, A Borja, M Moretti, Nisha Lakhi
NYMC Faculty Publications
OBJECTIVE: To determine if there is an increased maternal or neonatal morbidity in overweight and obese patients with a false positive glucose challenge test (GCT). METHODS: Patients with a body mass index (BMI) >/=25.0 at registration were included in this prospective 36-month study. The study cohort consisted of patients with a false positive (FP) GCT, with two comparison cohorts: those with a (1) screen negative (SN) GCT result and (2) true positive (TP) GCT result. Risks were reported as odd ratios with 95% confidence intervals, with a P/=4000 g in the FP cohort, but this fell short of reaching statistical …
Comparison Of Multiple Obesity Indices For Cardiovascular Disease Risk Classification In South Asian Adults: The Carrs Study., Shivani A. Patel, Mohan Deepa, Roopa Shivashankar, Mohammed K. Ali, Deksha Kapoor, Ruby Gupta, Dorothy Lall, Nikhil Tandon, Viswanathan Mohan, Muhammad Masood Kadir, Zafar Fatmi, Dorairaj Prabhakaran, K. M. Venkat Narayan
Comparison Of Multiple Obesity Indices For Cardiovascular Disease Risk Classification In South Asian Adults: The Carrs Study., Shivani A. Patel, Mohan Deepa, Roopa Shivashankar, Mohammed K. Ali, Deksha Kapoor, Ruby Gupta, Dorothy Lall, Nikhil Tandon, Viswanathan Mohan, Muhammad Masood Kadir, Zafar Fatmi, Dorairaj Prabhakaran, K. M. Venkat Narayan
Community Health Sciences
BACKGROUND:
We comparatively assessed the performance of six simple obesity indices to identify adults with cardiovascular disease (CVD) risk factors in a diverse and contemporary South Asian population.
METHODS:
8,892 participants aged 20-60 years in 2010-2011 were analyzed. Six obesity indices were examined: body mass index (BMI), waist circumference (WC), waist-height ratio (WHtR), waist-hip ratio (WHR), log of the sum of triceps and subscapular skin fold thickness (LTS), and percent body fat derived from bioelectric impedance analysis (BIA). We estimated models with obesity indices specified as deciles and as continuous linear variables to predict prevalent hypertension, diabetes, and high cholesterol …
Sex-Dependent Effects Of Ho-1 Deletion From Adipocytes In Mice, Peter Hosick, Mary Frances Weeks, Michael W. Hankins, Kyle H. Moore, David E. Stec
Sex-Dependent Effects Of Ho-1 Deletion From Adipocytes In Mice, Peter Hosick, Mary Frances Weeks, Michael W. Hankins, Kyle H. Moore, David E. Stec
Department of Exercise Science and Physical Education Scholarship and Creative Works
Induction of heme oxygenase-1 (HO-1) has been demonstrated to decrease body weight and improve insulin sensitivity in several models of obesity in rodents. To further study the role of HO-1 in adipose tissue, we created an adipose-specific HO-1 knockout mouse model. Male and female mice were fed either a control or a high-fat diet for 30 weeks. Body weights were measured weekly and body composition, fasting blood glucose and insulin levels were determined every six weeks. Adipocyte-specific knockout of HO-1 had no significant effect on body weight in mice fed a high-fat diet but increased body weight in female mice …
High Fat Diet Induced Obesity Impairs Skeletal Muscle Glycogen And Lipid Preservation After Adiponectin Incubation, Cesar Meza, Cynthia Montenegro, Catalina De La Peña, Lannie O'Keefe, Shaan Naughton, Anna Simcocks, Deanne Hryciw, Michael Mathai, Andrew Mcainch, Sudip Bajpeyi
High Fat Diet Induced Obesity Impairs Skeletal Muscle Glycogen And Lipid Preservation After Adiponectin Incubation, Cesar Meza, Cynthia Montenegro, Catalina De La Peña, Lannie O'Keefe, Shaan Naughton, Anna Simcocks, Deanne Hryciw, Michael Mathai, Andrew Mcainch, Sudip Bajpeyi
International Journal of Exercise Science: Conference Proceedings
High fat diets have been attributed as critical factors contributing to obesity and type 2 diabetes, characterized by increased lipid accumulation, impaired glucose uptake, and defects in glycogen storage in skeletal muscle. Adiponectin, an adipokine, has been shown to have antidiabetic effects by improving fat oxidation and glucose uptake. PURPOSE: To investigate the effects of adiponectin incubation, in high fat diet induced obese rats, on measures of skeletal muscle substrate metabolism including glycogen, glucose transporter 4 (GLUT4), lipid, and mitochondrial contents. METHODS: Male Sprague Dawley rats were fed a Western-style (21% fat by weight; 41% total energy) high …
Tennessee Diabetes Action Report, February 2017, Tennessee. Department Of Health.
Tennessee Diabetes Action Report, February 2017, Tennessee. Department Of Health.
Diabetes Action Report
No abstract provided.
Use Of Grounded Theory In Cardiovascular Research, Patrick J. Dunn, Vasileios Margaritis, Cheryl Anderson
Use Of Grounded Theory In Cardiovascular Research, Patrick J. Dunn, Vasileios Margaritis, Cheryl Anderson
The Qualitative Report
While grounded theory is often cited in the qualitative literature as the methodology, there are few good examples of publications that follow the principles of grounded theory and result in an actual theory. The purpose of this paper is to demonstrate how the Corbin and Strauss (2015) method of grounded theory was used in a study looking at how patients with cardiovascular disease and diabetes develop health literacy skills that are used to manage their condition. The key principles of grounded theory include theoretical sampling, constant comparison, open, axial, and selective coding, the use of memoing, and theoretical saturation. Data …
Understanding Health Literacy Skills In Patients With Cardiovascular Disease And Diabetes, Patrick J. Dunn, Vasileios Margaritis, Cheryl L. Anderson
Understanding Health Literacy Skills In Patients With Cardiovascular Disease And Diabetes, Patrick J. Dunn, Vasileios Margaritis, Cheryl L. Anderson
The Qualitative Report
Health literacy is the ability to understand and act on health information and is linked to health outcomes. It is unclear how health literacy skills are developed in patients with complex conditions, such as cardiovascular disease and diabetes. The purpose of this grounded theory study was to gain perspectives of both patients and healthcare professionals on how health literacy skills were developed in patients with cardiovascular disease or diabetes. The research questions addressed how knowledge and skills were acquired, the role of digital tools, instructional strategies used by healthcare professionals, and how the instructional strategies of the healthcare professionals matched …
Diabetes Mellitus: Concerns, Treatment Options, And The Future, Ryan Curry
Diabetes Mellitus: Concerns, Treatment Options, And The Future, Ryan Curry
Biology: Student Scholarship & Creative Works
Diabetes is a serious disease that is becoming very serious worldwide. This review will discuss some of the treatment options that are available for type two diabetes with a comparison to insulin management. It will discuss the history, genetics, economics, and also the future of diabetes management.
Correlation Between Self-Appraisal And Measured Risk For Prediabetes, Amanda Sowell
Correlation Between Self-Appraisal And Measured Risk For Prediabetes, Amanda Sowell
Nursing Theses and Capstone Projects
One-third of adults in the United States have prediabetes and 90% of those individuals are unaware they have the disease. Prediabetes is a disease where blood sugar levels are higher than normal, but not high enough to be diagnosed as prediabetes. The purpose of this thesis was to identify adults at risk for prediabetes in a rural community setting, and explore the relationship between adults’ perceived risk for prediabetes and actual measured risk for prediabetes as determined by the Centers for Disease Control (CDC) Prediabetes Screening Test. The organizing framework was based on Betty Neuman’s systems model. The participants of …
Engagement And Outcomes In A Digital Diabetes Prevention Program: 3-Year Update., S Cameron Sepah, Luohua Jiang, Robert J. Ellis, Kelly Mcdermott, Anne L. Peters
Engagement And Outcomes In A Digital Diabetes Prevention Program: 3-Year Update., S Cameron Sepah, Luohua Jiang, Robert J. Ellis, Kelly Mcdermott, Anne L. Peters
Global Public Health | Faculty Scholarship
OBJECTIVE: Translations of the Diabetes Prevention Program (DPP) have proliferated in recent years, with increasing expansion to digital formats. Although these DPP translations have consistently shown favorable clinical outcomes, long-term data for digital formats are limited. This study's objective was to examine clinical outcomes up to 3 years post-baseline and the relationship between program engagement and clinical outcomes in a digital DPP.
RESEARCH DESIGN AND METHODS: In a single-arm, non-randomized trial, 220 patients previously diagnosed with prediabetes were enrolled in the Omada Health Program, a commercially available, 16-week DPP-based weight loss intervention followed by an ongoing weight maintenance intervention. Changes …
Identifying Factors Associated With Participation In T1d Support Program For Young Adults, Taylor L. Neher, Samuel D. Towne Jr., Sarah E. Toevs
Identifying Factors Associated With Participation In T1d Support Program For Young Adults, Taylor L. Neher, Samuel D. Towne Jr., Sarah E. Toevs
Public and Population Health Faculty Publications and Presentations
Objective: Type 1 diabetes (T1D) has been shown to have a significant and stressful impact on an individual’s transition into young adulthood. Young adults are often experiencing new levels of independence and decision-making at this time. Insufficient research has been conducted on the use and impact of T1D support programs tailored to young adults in relation to the emotional impacts of the disease, access to programming, and desired outcomes of programs. his study assesses awareness, utilization, and emotional needs of T1D support programs tailored to young adults.
Research Design and Methods: A cross-sectional analysis was performed on surveys collected through …
Two Approaches, One Problem: Cultural Constructions Of Type Ii Diabetes In An Indigenous Community In Yucatán, Mexico, Elizabeth Durden
Two Approaches, One Problem: Cultural Constructions Of Type Ii Diabetes In An Indigenous Community In Yucatán, Mexico, Elizabeth Durden
Faculty Journal Articles
The emerging epidemic of obesity and type II diabetes in Mexico has recently propelled the nation into the public health spotlight. In the state of Yucata n, the experience of diabetes is greatly impacted by two cultural constructions of disease. In this setting, elements of Yucatec Mayan health practices as well as the biomedical model affect the approach to type II diabetes. Both frameworks offer unique un- derstandings of the etiology of diabetes and recommend different ways to manage the condition. Based on in-depth and semi-structured interviews with both community members and clinicians, the present study seeks to understand how …
The American Pediatric Type 2 Diabetes Epidemic: Considerations For Targeted Diabetes Prevention Programs, Dolores Dodson
The American Pediatric Type 2 Diabetes Epidemic: Considerations For Targeted Diabetes Prevention Programs, Dolores Dodson
Master of Public Health Program Student Publications
Childhood obesity is an identified risk factor for several long-term health issues such as type 2 diabetes mellitus (T2DM). According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death within the United States. The CDC has implemented an evidence-based program, The National Diabetes Prevention Program (DPP), to prevent the development of T2DM among individuals with prediabetes. Prediabetes is defined as having elevated glucose levels glycated hemoglobin [A1C] levels between 5.7%-6.5%) that are not elevated enough to meet diabetes diagnosis criteria (A1C levels > 6.5%). The DPP is a lifestyle change program that has …
Non-Communicable Disease And Diabetes Screening In Community Settings In Low- And Middle-Income Countries: A Case Study In Senegal, West Africa, Rhonda Belue
Saint Louis University Journal of Health Law & Policy
Sub-Saharan Africa is faced with a significant and increasing burden of non-communicable diseases such as type 2 diabetes mellitus (diabetes). In Senegal, the prevalence of diabetes has been documented to be as high as 8.1% in urban-dwelling Senegalese and is fast approaching the United States prevalence of approximately nine percent; however, insufficient resources are available for prevention efforts and disease management. As a result, many cases remain undiagnosed, leading to an increased likelihood of diabetes complications and mortality. Many of these cases remain undiagnosed or are diagnosed only after complications have developed, such as the need for amputation, kidney failure, …
Reorienting Health Services To People With Chronic Health Conditions: Diabetes And Stroke Services In Malaysia, Sri Lanka And Thailand, Vasoontara Yiengprugsawan, Judith Healy, Hal Kendig, Malinee Neelamegam, Palitha Karunapema, Vijj Kasemsup
Reorienting Health Services To People With Chronic Health Conditions: Diabetes And Stroke Services In Malaysia, Sri Lanka And Thailand, Vasoontara Yiengprugsawan, Judith Healy, Hal Kendig, Malinee Neelamegam, Palitha Karunapema, Vijj Kasemsup
Epidemiology and Biostatistics Faculty Publications
This paper explores whether middle-income Asian countries are reorienting their health services in response to non-communicable diseases (NCDs). Malaysia, Sri Lanka, and Thailand were selected as case studies of Asian societies experiencing rapid increases both in NCDs and an aging population. While NCD programs, especially those related to diabetes and stroke, are well-established in Thailand, health services struggle to respond to increasing numbers of people with chronic health problems. Health services at all levels must plan ahead for more patients with chronic and often multiple conditions who require better integrated health care.