COME TOGETHER

ROBERT VOSBURGH

Nearly 15 million Americans of all ages suffer from diabetes; another 6 million don't even know they have it. Together, they represent 7% of the U.S. population.

And every one of them is a supermarket shopper.

"I think we have a tremendous opportunity to be able to influence peoples' lifestyle choices through diet," said Don Clark, director of pharmacy operations for K-VA-T Food Stores/Food City, Abingdon, Va. "And this just doesn't apply to diabetics. It's just the most obvious one, the one you start with."

The recent surge in coverage of diabetes reveals the extent of a problem that has smoldered for years; now, public health officials are comparing the spread of the disease to a wildfire. Last year alone, 1.5 million new cases were diagnosed in people aged 20 years and older. The numbers are staggering, and there is no indication they are likely to subside anytime soon.

"I was talking with one of our diabetic counselors just today and she had picked up eight new patients in one store," Clark said.

This increasing tide of special-needs shoppers is in the aisles right now. Medical specialists and dietary counselors repeatedly point out that often, these consumers are undergoing a significant life change and face the formidable task of altering entrenched eating habits that weren't always the healthiest. Particularly among the newly diagnosed, there's an absence of knowledge, and therefore, they feel vulnerable, confused and frightened.

And even though they might be getting counseling, diabetics can easily fall victim to old behaviors when they walk through the automatic doors and into the aisles. Experts say there is a compelling need for supermarkets to help the medical community follow through on life-saving education.

"The key ingredient is planning, and that is what can make or break success - just learning how to plan ahead," noted Suzanne Farrell, a Denver-based registered dietitian and spokeswoman for the American Dietetic Association. "Part of that involves grocery shopping, and what to do once you are in the store."

Yet, many retail diabetes programs are outdated and inconsistent. As a result, they are in danger of becoming irrelevant at a time when there is a pressing need to bring education and counseling to the store level - or even right to the shelf.

Trouble in the Aisles

For diabetics in particular, food is both treatment and trouble, savior and savage. Unlike celiac disease, which involves only certain grains, or dairy-specific lactose intolerance, diabetics face a much wider challenge, since just about every food item they consume has some impact on their health.

"If I had to give it a buzzword, it's lifestyle management. That's basically what it becomes," said Bill Ritchey, head pharmacist at Weber's IGA in Sedona, Ariz. "You have to manage more than just your calories. You have to manage every aspect of your life, like the amount of exercise you get, your sleep patterns and medications. For a lot of people, that means breaking a lot of old habits."

Prevention, testing and access to health care and information have emerged as the primary strategies employed in stemming the continued spread of diabetes. Karmeen Kulkarni, president of health care and education for the American Diabetic Association, Alexandria, Va., said that newly diagnosed patients in particular are emotional and in need of supervision.

"They either grieve or get angry or go into denial about a diagnosis, just like any other major disease," she said. "Some are more matter-of-fact about it, and are determined to learn about it and live with it. Regardless of the response, though, it's important that they feel comfortable living with it."

She added that once diagnosed, diabetics often face a crash course in the science of healthful eating. There's much they must learn about carbohydrates, blood glucose and the interaction between the two. In the process of becoming accustomed to their new condition, they not only require dietary controls, sufferers also need some attitude adjustment.

"Today, we have the technology, the information, the medication and the nutrition knowledge to customize a diabetes regimen for the person, and have that fit into their lifestyle, rather than having the person fit into diabetes," she said.

Supermarket retailers interested in being a component of that regimen must consider a number of factors: staffing, available expertise, floor space, product selection, after-hours events, sponsorships and educational opportunities, among others. The good news is that it doesn't have to be a three-ring circus. Any operator, of any size, can contribute to diabetes solutions at some fundamental level.

Determining Strategy

A casual search of the Internet or store circulars reveals an impressive number of conventional retailers who are involved with diabetes, exhibiting a broad spectrum of programs. Some discreetly advertise special sections in their pharmacies devoted to diabetic needs. Others promote large public events. The diversity of products and services offered attests to a history of supermarket involvement in diabetes management over the past decades.

The difference between then and now, however, is that the American public has suddenly become much more cognizant of the disease and is developing a keen interest in prevention and stabilization. It's this crossroad of consumer awareness and intent that offers the supermarket industry its biggest opportunity.

"Supermarkets can play a huge role by offering their own tours or highlighting where healthy foods are within the store," Kulkarni said. "They can also develop and offer recipes that can even involve some of the healthier specials of the week. It makes it easier, and meaningful, for diabetic shoppers."

Smaller operators, like Weber's IGA, use the pharmacy and its staff as primary intercepts for guidance and coaching. The personal approach doesn't require banners or publicity, and instead builds trust through intimacy.

"What we try to do, in addition to giving them the medications they need, is to coach them along on their lifestyles," said Ritchey, the pharmacist. The store's small pharmacy staff is on a first-name basis with most customers, and those who are diabetic develop a relationship with associates that goes beyond the simple prescription pick-up. Jake Weber, owner of the 30,000-square-foot food/drug combo, said that his entire staff has become more aware of a general shift in the attitudes customers have about the food they buy - not just special-needs shoppers like diabetics.

"The health consciousness of the consumer today is played out when you see everyone in the aisle reading labels," he noted. "It's not just looking at fat or calories. It's a much deeper change."

Weber's receives outside assistance through its partnership with HealthWaves, a Tempe, Ariz., firm that offers screenings and educational materials on such conditions as osteoporosis, the flu and diabetes. HealthWaves sets up shop in the pharmacy area on the last Friday of every month, rotating different services.

Many independent chains collaborate with their pharmacy wholesalers. K-VA-T and Schenectady, N.Y.-based Price Chopper Supermarkets are two regional independents who market to diabetics through their affiliation with AmerisourceBergen, a Chesterbrook, Pa., full-line pharmacy distributor. The company's "Diabetes Corner" program outfits participating stores with prescription medications, over-the-counter alternatives, dietary supplements and testing equipment. The turnkey display also can include customized signage and literature.

"They'll have shelf tags identifying diabetes-friendly products in those stores, and we also have diet sections that have more sugar-free-related or low-sugar products," said Maureen Murphy, Price Chopper's consumer services manager. The section, called Diabetes Place, includes a display of glucose monitors and diabetic products, within HBC. "These are more specific products that actually target diabetics, like low-sugar spreads."

At K-VA-T, the Diabetes Corner is used as an adjunct to the typical kind of counseling that pharmacists engage in, in the day-to-day medication management with patients, Clark said.

"Part of it is diet, part of it is testing, part of it is your insulin regimen, part of it is weight control. These are all things that, in a supermarket setting, can have a direct impact on diabetic's health," he said. "It tightens the awareness in the community that Food City operates pharmacies as health centers in our stores."

Adding Value

Outreach is an important component of a diabetes marketing strategy, though it requires a bit more work. Hosting seminars, guided store tours or cooking demonstrations means organizing dedicated staffing, though experts note the payoff can be worth it. Proactive events like these improve the shopping experience for many diabetics, who need to exercise constant vigilance and make smart decisions while shopping.

"A lot of them feel they have to buy expensive dietetic foods," said the ADA's Kulkarni. "Or, they don't quite understand how to read the labels, and can get pretty tangled up in the process. Portion sizes are a challenge."

San Antonio-based H. E. Butt Grocery Co. brings solutions out of the store and into the public domain. The retailer is a presenting sponsor for the Diabetes Expo, a free event that's held all over the country by the ADA. In the Lone Star State, H-E-B helps underwrite educational speakers, cooking demonstrations, children's activities and diabetic-friendly exhibitors. The most recent expo, held in late March at the Henry B. Gonzalez Convention Center in San Antonio, also allowed the retailer to demonstrate its own-brand InControl Plus glucose meter, and showcase H-E-B's staff nutritionist, who took to a stage to prepare healthful meals and distribute recipes.

Universities, medical schools and even local government agencies are another untapped source. At K-VA-T, some stores in the Kingsport and Bristol, Tenn., areas have teamed up with two ongoing diabetes projects. Both refer participants in their respective health plans to qualified Food City pharmacists trained to help referrals on a one-on-one basis. One is Mountain States Health Alliance, run out of the Johnson City Medical Center; the other is an initiative of the Sullivan County health department, Clark said.

"They're referring diabetic patients to some of our pharmacists who've been trained to counsel them. We're receiving reimbursement for the services provided," he said, adding that earlier initiatives in other states have shown that educational services provided by qualified, participating pharmacies could actually lower the health plan costs. While the health insurance entity reduces costs, the pharmacy gains reimbursement and new customers.

Price Chopper has tapped the resources of New York's AlbanyCollege of Pharmacy. In this instance, upperclassmen are recruited to work with diabetic customers in stores.

"We have groups of interns who come and do rotations through our stores, and we've also worked with the college to develop diabetes education programs, where our pharmacists also get some training," Murphy said.

Subjects covered in past events include traveling with diabetes and the advantages of oral or injected insulin, among others. Diabetes informational sessions are also held two or three times a year at the 71 of nearly 117 Price Chopper stores with pharmacies.

The retailer's diabetes program is part of a newly introduced health-and-wellness umbrella called Healthy U, which includes a focus on healthful eating, children and nutrition, and Healthy U Connection. Here, customers with health- or diet-related questions can get answers from a registered dietitian via a toll-free number or through a link on Price Chopper's website. Additional information is found at Healthy U kiosks located adjacent to store produce sections.

Shopper Priorities

To their credit, supermarkets provide diabetic shoppers with a safe environment, provided they take advantage of it. Both food and pharmacy serve as sources of information and products. Retailers interested in moving their health-and-wellness platforms closer to the forefront should be ready with nutritional information on products, particularly those that are private label, made in-store or come from a central kitchen. Stores also should provide guidance in the manner of shopping tips, recipes and occasions for interaction. These are the intangibles that differentiate one store from another. In the diabetic's mind, it's not about the food itself.

"The thing that's good for people to understand is that there are very few foods that you're not allowed to eat," said Clark of K-VA-T. "Mom doesn't have to cook one meal for Billy and another for the rest of the family. If everybody eats this way, everybody will be healthier."

So, even though diabetics are able to shop the entire store, they cannot purchase anything and everything that meets the eye. Those with blood glucose problems must exercise particular caution in making decisions. This self-awareness is critical if a diabetic is to maintain an optimal level of health. Experts lament that all shoppers don't use a similar mind-set.

"Grocery stores have more than 50,000 items, and people just walk around in a food rut," observed Farrell, the dietitian. "They're eating the same thing all the time, and don't always see all the options that are there. Increasing that awareness of options that have more nutrients is a valuable tool that we can develop together."

In counseling, diabetics get a crash course on label reading and ingredient lists, and learn the reasoning behind carbohydrate exchanges. For the most part, this is geared toward prepared foods. However, Kulkarni points out that even the fresh food sections reveal pitfalls that retailers - with their "bigger is better" approach to merchandising - might not be aware of.

"A large apple would be like eating three regular apples, and that affects the blood glucose," Kulkarni said. "We teach patients not to select large fruits, and to try to find smaller pieces."

Because of the multitude of choice and the temptations that go with it, diabetes counselors like Farrell and Kulkarni stress the concept of planning in their education efforts.

"If you wake up and just leave for work like a lot of people do, and don't know what to eat until lunchtime, you're already setting yourself up," Farrell said. "It's a shift in the entire thought process, inventorying your whole environment."

Retailers are wise to offer some diabetic-specific foods in a special section, but by and large, diabetics shop the entire store like any consumer. Unlike sufferers of lactose or gluten intolerance, diabetics can pretty much eat everything out there. It's how much they eat of any particular food that counts.

"When it comes to diabetic meal planning, we're not encouraging anyone to go out and buy expensive dietetic types of foods," Kulkarni said. "We're focusing on the everyday items that they could use for both themselves and their families, like whole grains, low-fat dairy, lean meats and fresh produce."

Newly diagnosed diabetics are typically counseled to shop the perimeter first for produce, lean proteins and low-fat dairy. In the grocery aisles, they are cautioned to read labels and take into account serving sizes.

"We practice in my office, where we'll look at various labels and ingredients panels to help determine if something is more processed or more natural," Farrell said, adding that preparation is key to success.

"It's tough if you don't shop with a list, when you are hungry and don't have anything in the refrigerator and really have to stock up."

Walking in with a list doesn't preclude diabetics from considering impulse buys or other items promoted on endcaps or in the aisles by the retailer. However, experts says it's wise to make available nutritional information should it be asked for. For example, if a demo person is cutting samples of a new breakfast product, the retailer may want to have spec sheets available, or at least make sure the demo person is familiar with ingredients and nutrition facts.

Tying It Together

Perhaps one of the greatest ironies dealing with diabetes is that the diet espoused for them by nutritionists and clinical dietitians is almost identical to the one currently being touted by the U.S. Department of Agriculture's 2005 Dietary Guidelines for Americans, as well as multiple diet plans and public health officials in general.

"It's remarkable that the diet that a diabetic is on is also a remarkable diet to lose weight, to control your cholesterol or conditions that can be aggravated by food, like asthma or migraines," said Clark of K-VA-T.

An emphasis on grains, unprocessed foods, lean meats and low-fat dairy is the linchpin of the diabetic diet, and diabetes experts believe the surging publicity around the tremendous increase in cases can only help every American consumer think about their own dietary habits.

"A diabetes meal plan is a healthy meal plan - not just for the diabetic, for those living with them," Kulkarni said. "It's these kinds of messages that we need to get out; that we're not exactly talking about a special diet here, but about everyday healthy foods and a focus on amount, quantity and portion."

Supermarket retailers can best serve diabetics - and therefore, all shoppers - by presenting healthful options and empowering consumers to read their own labels and draw their own conclusions through a variety of educational venues, including printed literature, kiosks, recipe cards and in-store events. That's the goal at the single-store Weber's IGA, Ritchey said.

"In the end, it's all about information," he said. "I can inform you. But you have to make the choice."

Cause and Effect

Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, action, or both. Each type is capable of causing severe complications and eventual death.

Type 1

Previously called insulin-dependent diabetes mellitus or juvenile-onset diabetes. Caused by the body's own immune system, which destroys insulin-producing pancreas cells.

At risk: Primarily children and young adults, though can occur at any age.

Treatment: Insulin via injection or pump.

Risk factors: Autoimmune, genetic or environmental.

Prevalence: 5%-10% of diagnosed diabetes cases.

Type 2

Previously called non-insulin-dependent diabetes mellitus or adult-onset diabetes. Usually begins as insulin resistance, in which insulin is improperly utilized by the body. Full onset comes in time, as the pancreas loses its ability to produce insulin.

At risk: Older people, African Americans, Latinos, American Indians, some Asians and Pacific Islanders.

Treatment: Insulin, medication, diet, exercise.

Risk factors: Obesity, genetics, impaired glucose metabolism, physical inactivity, race/ethnicity.

Prevalence: 90%-95% of diagnosed diabetes cases.

Gestational Diabetes

A form of diabetes diagnosed in some women during pregnancy. Requires treatment to normalize maternal glucose levels to avoid complications in the infant. Some women develop Type 2 diabetes after pregnancy, or later in life.

At risk: African Americans, Latinos, American Indians, obese women.

Treatment: Though temporary, requires careful medical supervision and follow-up monitoring.

Risk factors: After pregnancy, up to 10% can develop Type 2 diabetes; 20%-50% can develop diabetes within 10 years.

Prevalence: Uncommon.

Other Types

Results from specific genetic conditions, such as maturity-onset diabetes of youth, as well as medical conditions or procedures.

At risk: Those predisposed to diabetes or those with a family history of the disease.

Treatment: Depends on cause.

Risk factors: Genetic conditions, surgery, drugs, malnutrition, infections.

Prevalence: 1%-5% of diagnosed diabetes cases.

SOURCE: American Diabetic Association

The Human Toll

Diabetes was the sixth-leading cause of death listed on U.S. death certificates in 2002, though experts believe this number is significantly under-reported. Studies show only 35%-40% of known diabetics had the disease noted anywhere on the death certificate. In life, diabetics face these grim statistics:

About 65% of deaths are due to heart disease or strokes.

Nearly 73% of adults have blood pressures of greater than 130/80.

The leading cause of new cases of blindness among adults aged 20-74 years.

30% aged 40 years or older have impaired sensation in their feet.

The leading cause of kidney failure, accounting to 44% of all new cases in 2002.

More than 60% of nontraumatic, lower-limb amputations.

Twice the incidence of periodontal disease among young adults.

Pregnancy complications, including major birth defects (5%-10%) and spontaneous abortions (15%-20%).

SOURCE: American Diabetes Association

A Comprehensive Approach

Diabetic customers at Pharmaca have access not only to a pharmacist, but also nutrition counselors, homeopaths, naturopaths and herbalists. The 10-store chain is known as an integrative pharmacy, covering prescription and over-the-counter medications - as well as less-traditional options like botanical dietary supplements, homepathy and natural/organic HBC.

Stores, located in California, Colorado, Oregon and Seattle, employ expert staffers who join the pharmacist in cases where patients need lifestyle and diet counseling as well as medications.

"Diabetes is so multifaceted that it requires a high-touch solution, and let's face it, people are not getting that with the typical physician," said Chris Turf, Pharmaca's director of pharmacy. "There are a good number of people who want to make their lives better, but they just don't know where to start."

Pharmaca's consultations are free, though they also offer more intensive, one-on-one sessions for a fee. Most insurance plans are accepted, just like a regular pharmacy. What differentiates Pharmaca from the rest of the field is the level of interaction between customers and the staff.

"Pharmacy wears blinders just like Western medicine does in a lot of ways. You fill a prescription, you don't ask any questions and your contact with the patient is minimal," Turf said. "You're not addressing things on a fundamental level and taking an integrative approach to try to make someone feel better."

The invitation for a customer to ask questions and look around is reflected in the stores' decor, as well as the presence of a tea/reading room in all units. Empowering them to participate in their own treatment does more good than all the medicine in the world, Turf said.

"Pharmacy has basically priced itself into a corner and has made us pill-counting machines," he said. "I think rather than dispensing medication, pharmacists should be dispensing information."