CLC’s Diabetes Prevention and Food Security Initiative Focuses on Addressing the Disease and Its Social Determinants in Ventura County

For the 84 million Americans — that’s 1 in 3 adults—who have prediabetes, most do not even know that they have it. With prediabetes, blood sugar levels are higher than normal, greatly elevating the risk for type 2 diabetes, heart disease and stroke.

Prediabetes, however, can be reversed and presents a tremendous opportunity for prevention efforts. If caught early, simple lifestyle changes such as losing weight if you’re overweight, eating healthier, and exercise can have lasting results.

Because food insecurity at any level is associated with prediabetes in the US adult population, food insecure young adults are – and should be – targets for early clinical intervention.

Communities Lifting Communities (CLC), in partnership with the Ventura County Community Health Needs Assessment (CHNA) Collaborative, and HealthBegins, worked together to design an Upstream Quality Improvement Campaign to address diabetes and the social determinants of diabetes in Ventura County.

The Ventura County CHNA Collaborative consists of Adventist Health Simi Valley, Camarillo Healthcare District, Clinicas del Camino Real, Community Memorial Hospital, Gold Coast Health Plan, and the Ventura County Health Care Agency Departments of Public Health and Ambulatory Care.

Over a six-month period (August 2018 – January 2019), the pilot partnership helped stakeholders in Ventura County design targeted campaigns to better understand the diabetes population and chart a path toward meaningful data collection and measurable results.

To develop these targeted campaigns, known as Upstream Quality Improvement (QI) Campaigns, stakeholders receive facilitation, tools, training and technical assistance from HealthBegins, a consulting and technology firm dedicated to improving care and the social determinants of health. HealthBegins’ “Get Ready, Get Set, Go Upstream” framework provides hospital and community partners with an easy-to- follow structure for teams to utilize as they plan and implement their work.

“Healthcare is moving from a flat-earth to round-earth paradigm,” said Kathryn Stiles, director of community integration at Adventist Health Simi Valley. “Our high- energy collaborative is filled with great potential for the grassroots advocacy necessary to move this upstream effort forward.”

Quick start campaigns in Ventura County quickly realized that prediabetic adults should indeed be the priority population and identified food insecurity as the region’s social determinant of health.

A few early-win interventions highlighted the need to identify prediabetic patients in residency clinics, free clinics, case management populations, senior nutrition programs and patients referred to health education programs. Additionally, incorporating consistent data tracking such as Hunger Vital Signs Screening into workflows, electronic health records and intake forms was critical.

Erin Slack, an epidemiologist with the Ventura County Health Care Agency and chair of the Ventura County CHNA Collaborative, said, “Going upstream and tackling prediabetes is our greatest impact opportunity. Our ability to engage clinics, share data across health systems and expand resources is vital to this effort.”

She added, “Innovative new resources to address social needs are what our communities require most. Imagine being able to offer a prescription for food at a local Farmer’s Market.”

Moving forward, partners and stakeholder participants will continue to identify and improve processes and outcome measures in collaboration with community agencies. New education and training programs for clinical and front-line staff are being developed to improve workflow, and exciting new community-based food resource partnership opportunities are being explored to assist patients with tools that enhance healthy living.

The Communities Lifting Communities diabetes prevention and food security initiative focuses on developing and implementing a comprehensive community prevention strategy to address diabetes and the social determinants of diabetes.


  • More than 100 million Americans live with diabetes (30.3 million) or prediabetes (84.1 million)
  • Only 11.6 percent of adults with prediabetes knew they had it
  • 1.5 million Americans are diagnosed with diabetes each year
  • Diabetes is the seventh leading cause of death in the United States
  • 25% of Americans 65 years or older have Type 1 or Type 2 diabetes
  • $327 billion was the estimated total cost of diagnosed diabetes in the US in 2017

Sources: The Centers for Disease Control and Prevention; American Diabetes Association

For additional information about Communities Lifting Communities, contact Karen Ochoa, CLC Project Manager, at (213) 538-0765 or