Everyone is able to prevent diabetes or better self-manage their diabetes.

The Experience

When we achieve this result:

  • Everyone in Buncombe County is able to either prevent developing Type 2 diabetes or to successfully manage an existing condition.
  • Buncombe will be a safe environment where people are inspired (not just able) to lead an active lifestyle and eat readily available, nutritious, healthful food.
  • Nutrition and exercise are regular parts of school curriculum.
  • Clinics are accessible within communities so individuals do not have to travel to receive healthcare.
  • People who are at risk of diabetes or who have diabetes receive culturally and linguistically appropriate education about behaviors they can engage in to prevent or manage their disease.
Why Is This Important?

Type 2 diabetes is associated with obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, older age, and race/ethnicity. In Buncombe County, the disparity in diabetes mortality between the White non-Hispanic population and the Black non-Hispanic population is startling. In 2015, the age-adjusted mortality rate for White non-Hispanics was 18.6/100,000 while the Black non-Hispanic rate was 3.6 times that, at 53.6/100,000.

Reducing the prevalence of diabetes is an objective of Healthy NC 2020. Chronic diseases such as heart disease, cancer, and diabetes are major causes of death and disability in North Carolina. Although genetics and other factors contribute to the development of these chronic health conditions, individual behaviors play a major role. As much as 50% of individual health can be attributed to behavior alone. Physical inactivity, unhealthy eating, smoking, and excessive alcohol consumption are four behavioral risk factors underlying much of the burden caused by chronic disease. According to the CDC, diabetes is a leading cause of death, lower-limb amputation not related to trauma, new cases of blindness, and kidney failure in the United States. It also is a major contributor to cardiovascular disease, the number one cause of death in this country. In addition, diabetes cost the nation an estimated $245 billion in direct and indirect costs. To read more about diabetes go here.


Asheville Buncombe Institute of Parity Achievement (ABIPA): providing education, health services and advocacy from a unique understanding of the African-American experience and a demonstrated ability to increase collaboration, connection, awareness and trust across diverse segments of the community

Buncombe County Health and Human Services:

HHS Community Service Navigators: connecting residents with Buncombe County Health and Human Services, strengthening communities' capacity to help meet citizen needs, empowering citizens and communities as change agents to promote positive outcomes, building and enhancing collaborative partnerships, and reducing over-utilization of costly services

Minority Health Equity Project: bringing together five different community partners and Buncombe County Health and Human Services to pool resources to promote health equity.

Cooperative Extension: providing food, nutrition, and agricultural education and resources

Council on Aging: Providing education, innovative programming, and coordination of resources for aging

Eschelmen School of Pharmacy (UNC): training doctor of pharmacy students, with the option of a Rural Pharmacy Health Certificate

Family Resource Center at Emma: providing emergency assistance through a food pantry, a clothing closet, emergency financial assistance for rent and utilities, parenting classes and holiday assistance

Land of Sky Regional Council: coordinating Living Healthy classes and training leaders for the Living Health classes. For more information, visit Living Healthy WNC.

Mountain Area Health Education Center (MAHEC): providing high quality, compassionate healthcare as a foundation for training top physicians and health professionals

School Nursing Program: School Health is available to reach over 30,000 students in Buncombe County and Asheville City schools. They do health assessments, train school staff on health -related issues, advise staff and families about contagious diseases, participate on school wellness teams, and much more.

Mountain Area Nutritional Needs Alliance (MANNA) Foodbank: a member of Feeding America, the nation’s largest domestic hunger relief organization, MANNA distributes food through 229 community-based food assistance agencies in 16 Western North Carolina counties

Mission Health Disease Management Programs: providing the educational foundation and tools people need to take charge of chronic diseases.

Mission Health Partners (Accountable Care Organization): a network of hospitals, physicians, and other healthcare providers working together to improve healthcare quality, performance, efficiency and value for the patients of western North Carolina.

NC Center for Health & Wellness (UNCA): working to impact policy, build capacity and ignite community initiatives by working through a web of cross sector relationships organized around building healthier places throughout the state; providing data collection and evaluation for the Minority Health Equity Project and other CHIP efforts

Western North Carolina Community Health Services (WNCCHS): Federally Qualified Health Center providing primary healthcare, dental, behavioral health, and support services

YMCA: providing programs youth development, healthy living, and social responsibility; offering affordable opportunities for exercise and wellness education

YWCA: working to eliminate racism, empower women, stand up for social justice, help families and strengthen our community; providing affordable opportunities for exercise and wellness education.

Partners the group hopes to engage in the future:

  • Schools - Migrant Health, Norma Brown, Nancy Moore, Rosario Villarreal (contacted June 2016)
  • Council on Aging
  • Primary Care / OB Providers
  • FQHC - Dale Fell Center is going to have clinics in housing communities (contacted June 2016)
  • WCU Nursing students
  • AB Tech Nursing program
  • VA Hospital
  • WNC Dietetic Association
  • Asheville City Neighborhood Advisory - Marsha Stickford
  • PACE
  • Faith-based organizations
  • Planning (built environments)
Data Holes

The Community Health Improvement Process team at the Mountain Area Health Education Center is working to identify strategies to reduce diabetes prevalence and mortality in Buncombe County. Poverty and access to healthy food sources are of particular interest.

Community Partners have identified the following holes in data:

  • Access to fresh fruits and vegetables or exercise opportunities
  • Data from Harvard (about results of Community Health Worker model???)
  • Measuring the proportion that have diabetes appropiately managed with normal or improved HbA1c
  • Self-reported or provider identified positive health behavior changes
  • Percent of population 18 and older have been screened in past year for diabetes

For more additional indicators that are being monitored, click here.

Scorecard Result Program/Strategy Community-level Indicator Performance/Shared Measure Action Actual Value Target Value Tag S R CI S PM A @System.Threading.Thread.CurrentThread.CurrentUICulture.DateTimeFormat.ShortDatePattern.ToLower().Replace("yyyy", "yy") m/d/yyyy