Thesis Proposal

ASSOCIATION BETWEEN FALLS, FALL-RELATED INJURIES, AND PARTICIPATION
IN DIABETES-RELATED HEALTH BEHAVIORS AMONG INDIVIDUALS WITH KIDNEY
DISEASE AND DIABETES
A PROPOSAL
SUBMITTED TO THE GRADUATE SCHOOL
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE
MASTERS OF SCIENCE
BY
BRADLEY HORTON
DR. BRANDON KISTLER - ADVISOR
BALL STATE UNIVERSITY
MUNCIE, IN
DECEMBER 2019
ABSTRACT
THESIS: Association Between Falls, Fall-Related Injuries, and Participation in Diabetes-

Related Health Behaviors Among Individuals Diagnosed with Kidney Disease
and Diabetes: A Retrospective Analysis of 2016 Behavioral Risk Factor
Surveillance System Data
STUDENT: Bradley Horton
DEGREE: Master of Science
COLLEGE: College of Health
DATE: January 2019
PAGES: 61
Falls are a growing problem in the United States. In the last two decades the fall rate has
risen, causing physical and financial distress, as well as mortality. The population receiving
substantial attention for this problem is the elderly, due to their high fall risk. Unfortunately, this
focus overshadows other high risk populations including those with chronic diseases. A specific
population that warrants attention for their high fall risk are individuals with chronic kidney
disease and diabetes. This population has accumulative risk factors that are independently
associated with each disease state. Risk factors associated with glycemic control is a potential
focus to help decrease the risk of falling in this population. These glycemic risk factors are
associated with, and attenuated by, participating in diabetes health behaviors; however, it is not
known if participating in diabetes health behaviors are associated with the risk for falling. The
purpose of this study is to identify an association between participation in diabetes-related health
behaviors and the occurrence of falls among those diagnosed with CKD and diabetes. The
Behavioral Risk Factor Surveillance System 2016 questionnaire data will be utilized to identify
the association. The study results may help the development of future fall prevention programs
for this population.
ii
ACKNOWLEDGEMENTS
You do not need to write this for your proposal…..if you are going to use this for your
thesis/project, I’d urge you to keep it here so it “holds the place” for your real paper.
iii
TABLE OF CONTENTS
PAGE
ABSTRACT ................................................................................................................................. ii
ACKNOWLEDGEMENTS ........................................................................................................... iii
TABLE OF CONTENTS ............................................................................................................... iv
CHAPTER 1: INTRODUCTION ...................................................................................................1
Problem Statement ...............................................................................................................4
Purpose Statement ................................................................................................................5
Research Questions ..............................................................................................................5
Research Hypotheses ...........................................................................................................5
Rationale ..............................................................................................................................6
Assumptions.........................................................................................................................7
Definitions............................................................................................................................7
Summary ..............................................................................................................................9
CHAPTER 2: REVIEW OF LITERATURE ................................................................................10
Introduction: Falls in the United States .............................................................................10
Fall Rate and Outcomes .........................................................................................10
Fall Risk Factors ....................................................................................................11
At Risk Populations ...............................................................................................12
Summary ................................................................................................................13
Chronic Kidney Disease (CKD) and Falls .........................................................................14
CKD Prevalence.....................................................................................................14
CKD Fall Risk........................................................................................................14
iv
PAGE
CKD Fall Risk Factors ...........................................................................................15
Summary ................................................................................................................17
Association of Diabetes with Falls and Chronic Kidney Disease......................................17
Diabetes Prevalence and Fall Risk .........................................................................17
Diabetes and CKD and Comorbidities ...................................................................18
Diabetes Fall Risk Factors .....................................................................................19
Summary ................................................................................................................21
Falls, Diabetes Health Behaviors and the BRFSS .............................................................22
Diabetes Health Behaviors and Glycemic Control ................................................22
The Behavioral Risk Factor Surveillance System (BRFSS) ..................................22
Studies: Health Behaviors Assessed in BRFSS .....................................................23
Summary ................................................................................................................26
Studies Utilizing Behavioral Risk Factor Surveillance Data .............................................26
Summary ................................................................................................................28
Summary ............................................................................................................................29
CHAPTER 3: METHODOLOGY ................................................................................................30
Institutional Review Board ................................................................................................30
Sample................................................................................................................................30
Instruments .........................................................................................................................31
Letter of Permission and Consent ......................................................................................31
Methods..............................................................................................................................32
Data Analysis ....................................................................................................................33
v
PAGE
Summary ............................................................................................................................34
CHAPTER 4: RESULTS ..................................................................................................................
CHAPTER 5: DISCUSSION ............................................................................................................
CHAPTER 6: CONCLUSION AND RECOMMENDATIONS ......................................................
REFERENCES ..............................................................................................................................36
LIST OF APPENDICES ................................................................................................................43
Appendix A: Institutional Review Board Documents ......................................................43
A-1: IRB Approval Letter ......................................................................................44
A-2: CITI Completion Certificate ..........................................................................46
Appendix B: Survey Instruments .......................................................................................48
B-1: BRFSS Questions ..........................................................................................49
B-2: BRFSS Variable Codes ..................................................................................53
vi
LIST OF TABLES
PAGE
Table 1 ....................................................................................................................................
Table 2 ....................................................................................................................................
Table 3 ....................................................................................................................................
Table 5 ....................................................................................................................................
Table 6 ....................................................................................................................................
Table 7 ....................................................................................................................................
Table 8 ....................................................................................................................................
Table 9 ....................................................................................................................................
vii
LIST OF FIGURES
PAGE
Figure 1 ....................................................................................................................................
Figure 2 ....................................................................................................................................
Figure 3 ....................................................................................................................................
Figure 5 ....................................................................................................................................
Figure 6 ....................................................................................................................................
viii
CHAPTER 1
INTRODUCTION
Fall occurrences are a growing concern in the United States, with the fall rate of the
general population rising 1.2% each year between 2004 and 2013 (Verma et al., 2016). Although
trauma-related mortality declined 6% between 2002 and 2010 (p<0.01), fall-related mortality
increased 46% (p<0.01), resulting in a rate increase from 5.95 per 100,000 people to 8.70 per
100,000 people (Sise, Calvo, Spain, Weiser & Staudenmayer, 2014). Fall events, the primary
cause of injury among all ages, often lead to injuries requiring medical attention (Timsina et al.,
2017; Adams, Kirzinger & Martinez, 2013). Not only can falls cause physical harm, but they
also can add a financial burden to both the fall sufferer and the health care system, with
emergency department costs at an estimated $111 billion per year on fall-related accidents
(Verma et al., 2016). While it is known that the elderly are at a higher risk for falling than others
(Tumsina et al., 2017), other populations are also at high risk for falling, including individuals
diagnosed with chronic kidney disease (CKD) or diabetes (Lopez-Soto et al., 2015; Pijpers et al.,
2012).
The incidence and prevalence of CKD in the Unites States is rising; the number of cases
has increased 7.5% annually between 2009 and 2015 (USRDS, 2018). In addition to the time and
attention it takes to manage their disease, CKD also puts individuals at an increased risk for
falling, with some researchers observing a rate as high as 1.76 falls per person a year (Roberts,
Jeffrey, Carlisle & Brierley, 2007). The increased risk for falling among CKD patients is
associated with risk factors unique to this disease state, including hemodynamic shifts, muscle
weakness, neuropathy, disease progression, nutrition status, polypharmacy, and comorbidities
(Lopez-Soto et al., 2015).
Diabetes is a common comorbidity of CKD, with nearly 40% of individuals with CKD
also having diabetes (USRDS, 2018). Various studies indicate that diabetes itself can be a cause
of CKD (Lamarca et al., 2013; Shin et al., 2014). While CKD independently increases the risk
for falling, diabetes presents its own unique factors increasing fall risk (Pijpers et al., 2012).
Yang, Hu, Zhang and Zou (2016) observed that 25% of people with diabetes fell relative to only
18% of those without diabetes. This difference is attributed to diabetes fall-related risk factors
include poor glycemic control (hypoglycemia and hyperglycemia), diabetic peripheral
neuropathy (DPN), altered gait, retinopathy, and polypharmacy (Gu & Dennis, 2017; Vinik et
al., 2017). The combined risk factors in individuals with both CKD and diabetes puts them at an
even greater risk for falling (Li, Tomlinson, Naglie, Cook & Jassal, 2008).
Among those diagnosed with both CKD and diabetes, many fall risk factors, including
DPN and retinopathy, are related to glycemic control (Gu & Dennis, 2017; Gupta et al., 2017),
suggesting that glycemic control can prevent or attenuate the development of these fall risk
factors. There are many health-related behaviors individuals diagnosed with CKD and type 2
diabetes mellitus (T2DM) can take to achieve and maintain blood glucose control and to reduce
their risk for falls, including daily self-checks of blood glucose, monitoring of hemoglobin A1C,
consistent use of insulin, frequent visits to the doctor or other health care professionals, annual
vision exams, and checking for foot sores (Mahan & Raymond, 2017; Jeffcoate, Vileikyte,
Boyko, Armstrong & Boulton, 2018). Participating in these health-related behaviors can help
2
individuals diagnosed with CKD and diabetes achieve glycemic control and help monitor if their
glucose control is being maintained (Miller et al., 2013; Loh, Tan, Saw & Sethi, 2011). It is
hypothesized that if glycemic control can be achieved through participation in these behaviors,
fall risk factors, such as DPN and retinopathy, can be avoided or improved in the CKD with
diabetes population, thereby decreasing fall risk.
The Behavioral Risk Factor Surveillance System (BRFSS) is an annual telephone survey
used to collect data concerning chronic health conditions and heath behaviors within the United
States (Boyle, 2017). Although a robust source of data, BRFSS data is self-reported, which
comes with many inherent biases, including a tendency to exaggerate, to under-report due to
embarrassment, and social desirability bias (Rosenman, Tennekoon & Hill, 2011). The BRFSS
questionnaire includes questions pertaining to CKD and fall occurrences as well as health
behaviors associated with glycemic control, including questions about frequency of doctor visits,
blood glucose monitoring, A1C checks, insulin use, foot sore checks, eye exams, and diagnosis
of retinopathy (CDC, 2015).
Glycemic control can be monitored and improved by participating in diabetes-related
health behaviors, many of which are included in the Behavioral Risk Factor Surveillance System
Questionnaire (CDC, 2015). If improved glycemic control is achieved, fall risk factors, and the
subsequent number of fall incidence, should concomitantly decrease. However, little is known
about whether participating in these health behaviors, or the accumulating number of health
behaviors in which an individual participates, has an association and influence on fall risk in
patients with CKD. Thus, determining if there is an association between participation in
diabetes-related health behaviors as outlined in BRFSS and the occurrence of falls among a
population diagnosed with CKD and T2DM is warranted.
3
Problem Statement
In the United States, falls are among the primary events associated with fatal and nonfatal
injuries (Verma et al., 2016; Timsina et al. 2017). Between 2002 and 2010, the mortality rate
related to fall-events increased by 46% (Sise et al., 2014). Falls not only cause physical injury
and death but place an economic burden on the individual and healthcare system (Verma et al.,
2016). A population of special interest that requires further research are individuals with chronic
kidney disease associated with diabetes (Shin et al., 2014). Patients with CKD and diabetes are at
a higher risk for falls due to various risk factors like DPN (Yang et al., 2016). According to
Vinik et al. (2017), diabetes-related neuropathy can contribute to impaired balance and altered
gait, which can lead to falling. Fall risk factors such as neuropathy are directly linked to poor
glycemic control (Gu & Dennis, 2017). Research shows that patients who participate in diabetes-
related health behaviors (i.e., check blood glucose, check hemoglobin A1c, visit their doctor)
have an increased well-being (Rosiek et al., 2016) as well as improved glycemic control (Miller
et al., 2013; Loh et al., 2011). Improved glycemic control can attenuate fall risk factors. It is not
known, however, if participating in diabetes-related health behaviors, or if the number of health-
related behaviors in which an individual participates, is associated with the risk of suffering a fall
and fall-related injury among individuals diagnosed with CKD and type 2 diabetes. The data and
information need to examine this association can be collected from the BRFSS. Thus, utilizing
BRFSS data to examine the relationship between participation in diabetes-related health
behaviors and fall-related events among individuals diagnosed with CKD and diabetes is
warranted.
4
Purpose
The purpose of this retrospective quantitative study is to determine the association
between participation in diabetes-related health behaviors as outlined in the 2016 BRFSS and the
occurrence of falls among a population diagnosed with CKD and T2DM.
Research Questions
The following research question will be addressed in this study:
RQ#1: Does the subsample of patients who were asked about diabetes behaviors reflect the
sample of patients with CKD and T2DM in BRFSS?
RQ#2: Is there a relationship between diabetes-related health behaviors and the occurrence of
falls among those diagnosed with CKD and T2DM?
RQ#3: Is there a relationship between diabetes-related health behaviors and the occurrence of
fall-related injuries (FRI) among those diagnosed with CKD and T2DM?
Research Hypotheses
The following null and directional hypotheses will be tested in this study:
Hypothesis 1a: There will be no difference in any demographic, chronic disease, lifestyle, or
behavior (including falls and FRI) among participants who answered diabetes behavior questions
and those who did not answer these questions.
Hypothesis 2a: There will be a positive association between insulin use and incidences of
falls/FRI.
Hypothesis 2b: There will be a negative relationship between the frequency of checking
blood glucose and incidences of falls/FRI.
5
Hypothesis 2c: There will be a negative association between the frequency of self-
checking feet for sores and incidences of falls/FRI.
Hypothesis 2d: There will be a negative association between the frequency of health
professionals checking a patient’s feet for sores in the last 12 months and
incidences of fall/FRI.
Hypothesis 2e: There will be a negative association between the frequency of seeing a
doctor, nurse, or other health professional for diabetes in the last 12 months and
the incidences of falls/FRI.
Hypothesis 2f: There will be a negative association between the frequency of checking
A1C and the incidences of falls/FRI.
Hypothesis 2g: There will be a positive association between the period of time it has been
since an eye exam and the incidences of falls/FRI.
Hypothesis 2h: There will be a positive association between a diagnosis of retinopathy
and falls/FRI.
Rationale
Fall occurrences cause physical and financial harm to individuals. Individuals diagnosed
with CKD and diabetes are at an increased risk for falling due to risk factors associated with
these disease states. Numerous risk factors are related to glycemic control. Participation in
diabetes health behaviors has a positive effect on glycemic control, which can influence these
risk factors. If an association between diabetes health behaviors and falls can be established, fall
prevention programs can be developed specific to this population with a focus on diabetes health
behavior participation. Using BRFSS data in an attempt to make an association of these variables
6
is feasible given the survey contains questions pertaining to the occurrences of falls, CKD
diagnosis, diabetes diagnosis, and participation in diabetes health behaviors.
Assumptions
The researcher makes the following assumptions in the implementation of the study and
in the interpretation of the data:
1. All survey participants answered the questions truthfully and to the best of their
knowledge.
2. Questions were worded as such, giving survey participants a clear understanding
of what was being asked.
3. The CDC presented the BRFSS data unaltered and exactly as reported by survey
participants.
4. Due to the use of self-reported data, there will be some degree of response bias.
Definitions
For the purpose of this study, the following definitions will be used:
1. Behavioral Risk Factor Surveillance System (BRFSS): a telephone survey
obtaining information regarding chronic disease and health related behaviors by
interviewing adults in all 50 states (Boyle, 2017)
2. Chronic kidney disease (CKD): a disease state in which kidney damage decreases
the function and filtering ability of the kidney leading to a buildup of waste and
excess nutrients in the blood (CDC, 2018)
7
3. Type 2 Diabetes Mellitus (T2DM): a progressive disease caused by long periods
of hyperglycemia, leading to insulin resistance, macrovascular, and microvascular
complications (Mahan & Raymond, 2017)
4. Diabetic Peripheral Neuropathy (DPN): nerve damage, typically in the hands and
feet, caused by prolonged periods of hyperglycemia that can effect motor function
(Mahan & Raymond, 2017)
5. End-stage renal disease (ESRD)(Stage 5 CKD): the final stage of CKD with a
GFR of <15ml/min; at this stage the kidneys lack the ability to filter toxins,
maintain fluid balance or electrolyte balance, and produce certain hormones
leading to individuals requiring a kidney transplant or hemodialysis treatment
6. Glycemic control: the ability to maintain blood glucose in the desired range,
called euglycemic blood glucose levels, of between 80 to 130mg/dL without
drastic drops or rises (Mahan & Raymond, 2017)
7. Hemodialysis: a treatment used in ESRD that filters the blood of toxins, minerals,
etc.; semipermeable membranes of machines or the peritoneal cavity of the body
is used in place of the kidney for filtration of blood (Mahan & Raymond, 2017)
8. Hemodynamic shifts: changes in blood pressure caused by shifts in blood volume
during hemodialysis treatment (Mahan & Raymond, 2017)
9. Hemoglobin A1C: a diagnostic test of long term blood glucose concentrations
with diabetes being diagnosed at 6.5%; can be used to assess long term glycemic
control (Mahan & Raymond, 2017)
8
10. Hyperglycemia: high levels of blood glucose; diagnosed as fasting blood glucose
126mg/dL (Mahan & Raymond, 2017)
11. Hypoglycemia: a drop in blood glucose 50mg/dL (Mahan & Raymond, 2017)
12. Intradialytic: occurring or carried out during hemodialysis (Suri, 2015)
13. Orthostatic hypotension: a 20mm Hg decrease in systolic blood pressure or a
10mm Hg decrease in diastolic blood pressure within three minutes of standing,
relative to the blood pressure when sitting (Lanier, Mote & Clay, 2011)
14. Polypharmacy: the use of four or more medications during a single time period
15. Postural sway: the horizontal movement around an individual’s center of gravity
in relation to a sense of balance associated with input from vestibular and visual
systems (Zhou, Habtemariam, Iloputaife, Lipsitz & Manor, 2016)
16. Retinopathy: diminished vision and eye function caused by damage to blood
vessels and the retina from toxic blood glucose levels (Mayo Clinic, 2018)
Summary
Falls are a common problem among adults in the United States that can lead to injuries,
fatalities, and financial strain. The population with both CKD and diabetes are at an increased
risk for falling relative to the general population. Numerous factors, including poor glycemic
control, may increase fall risk in this population. However, it is not known if participating in
behaviors that may improve glycemic control reduce falls in this population. If an association
between diabetes health behaviors and falls can be established, this information could help the
development of fall prevention programs in this high risk population.
9
CHAPTER 2
REVIEW OF LITERATURE
occurrence of falls among a population diagnosed with CKD and T2DM. This chapter will
present a review of the literature that describes and relates the incidence of falls with chronic
kidney disease, diabetes, and participation in diabetes health behaviors.
Falls in the United States
Fall Rate and Outcomes
The fall rate in The United States is rising. According to Verma et al. (2016), there was
an observed increase in the total population fall rate of 1.2% a year between 2004 and 2013. The
trend appears largely in part to the rate of falls in adults age 65; although the fall rate for older
men and women increased by 5% and 4% , respectively, from 2004 to 2013, the increase was
only significant for women (p<0.05).
Injuries from falls are also increasing. Data from the National Health Survey indicates
that adults 18 and older have an increasing rate of fall-related injury of 1% per year (Verma et
al., 2016). Falls are now the primary cause of injury among virtually all age groups and are the
leading cause of medically attended nonfatal injuries (Timsina et al., 2017). Using data from the
2012 National Health Survey, it was determined that falls, overexertion, being struck by an
object, and transportation were the leading causes for seeking medical attention, but falls were
overwhelmingly the primary cause at 13.4 million cases (Adams, Kirzinger & Martinez, 2013).
When seeking medical attention for a fall, sprains and straining of joints are the most common
injury at 38%; more serious injuries such as fractures are also common at 28% (Verma et al.
2016).
In the most severe cases, falls can result in mortality. According to Sise et al. (2014),
between 2002 and 2010 the total trauma related mortality rate decreased by 6% (p<0.01).
However, the fall related mortality rate increased by 46% from 5.95 per 100,000 people to 8.70
per 100,000 people (p<0.01). This indicates that although mortality from other trauma events
such as vehicle accidents and fire arm incidents have decreased or stabilized, fall morality has
had a significant increase.
Falls can place a financial strain on families and the healthcare system. Center for
Disease Control (CDC) data shows that the total lifetime annual cost of fall related injuries in the
US resulting in fatality, hospitalization, or emergency room treatment is 111 billion dollars. The
lifetime annual cost per person a year is $471.32 (Verma et al. 2016). According to Florence et
al. (2018), in 2015 the total medical costs for falls exceeded 50 billion dollars. These financial
observations place fall injuries among the top 20 most expensive medical conditions in the
United States with a positive relationship between age and the cost of treating fall related injuries
(Burns, Stevens, & Lee, 2016).
Fall Risk Factors
There are different types of fall risk factors (CDC, 2015). Biological risk factors
including muscle weakness, impaired balance, medication side effects, chronic health conditions
11
(e.g. arthritis and stroke), disease states, nutritional status (e.g. vitamin D), hypotension, vision
impairment, loss of sensation in feet, etc. Behavioral risk factors include sedentary lifestyle,
alcohol use, and simply using improper equipment to stand at increased heights. Lastly,
environmental risk factors include clutter and tripping hazards, wet walking surfaces, lack of
stair railings, absence of bars inside tubs or showers, and poorly designed public spaces. Timsina
et al. (2017) observed that large objects (15%), stairs/steps (14%), and surface contamination
(13%) were the most common environmental causes of fall related injuries. The most common
risk factors for falls are environmental factors, which play a role in half of all falls; however, it is
typical for two or more factors from any category to interact and cause a fall (CDC, 2015).
At-Risk Populations
Older adults are at increased risk for falls. The prevalence for falls assessed using the
Health and Retirement Study data from 2010 showed an increase with each successive age group
with 32% among those 65-69 falling to 56.7% among those 90 and older falling (Schenker &
London, 2015). The overall fall rate increased from 28.2% in 1998 to 36.3% in 2010 for adults
age 65. Interestingly, the rate increase of falls was highest in the lower age range of 65-69. This
is contradictory to the notion that the greater increase in falls should be observed in the oldest
population groups due to their increasing overall number (Timsina et al., 2017); regardless, the
increasing United State fall rate is related to an increasing rate in adults age 65.
Many of the highest risk populations suffer from diseases of the brain and nervous
system. According to Renfro, Maring, Bainbridge and Blair (2016), individuals with
intellectual/developmental disabilities (IDD), multiple sclerosis (MS), Parkinson’s disease,
Alzheimer’s disease, or have suffered a cerebrovascular accident such as stroke, are at a greater
risk for falling. It has been reported that the rate of falls for individuals with IDD is high, with a
12
rate of 0.85 falls a year among younger individuals and a rate of 1.06 among older individuals
(Salb et al., 2015). A meta-analysis of individuals with MS by Gunn, Newell, Haas, Marsden,
and Freeman (2012) observed a rate of roughly 50% with increased risk being associated with
impairments in balance, lower cognition, progress of disease, and the use of a walking device.
Cerebrovascular accidents are a common risk factor for suffering a fall or fall related injury
among adults; a study by Jorgensen, Engstad, and Jacobsen (2002) observed that the risk for
suffering a fall was twice as high for stroke sufferers relative to age-matched individuals that had
not suffered a stroke.
In more recent years, diseases such as chronic kidney disease (CKD) and diabetes have
been identified as high-risk populations for falls. CKD is a complex disease involving blood
volume shifts, polypharmacy, comorbidities, etc., which increases the risk for falling (Lopez-
Soto et al., 2015). Current diabetes and falls research indicates that increased fall risk is
associated with poor glycemic control resulting in hypoglycemia or hyperglycemia, decreased
motor and sensory function caused by diabetic neuropathy, and retinopathy effecting balance
(Yang et al., 2016).
Summary
The rate of falls is increasing in the United States leading to injury, hospitalization and
financial burden. There are numerous fall risk factors involving interactions of biological,
behavioral, and environmental influences. Populations at higher risk for falls include the elderly,
those who suffer from neurological diseases and cerebrovascular accidents, and those with
chronic diseases such as CKD and diabetes.
13
Chronic Kidney Disease and Falls
CKD Prevalence
According to the 2018 United States Renal Data System (USRDS), the prevalence of
CKD stages 1-4 is roughly 14.8%, meaning that about 30 million adults have CKD in the United
States. These numbers are likely low due to limited awareness by individuals in stages 1-3 CKD.
In 2015, nearly 500,000 patients were classified as having end stage renal disease (ESRD, stage
5 CKD) and receive dialysis treatment.
There has been a steady increase in CKD. Coresh et al. (2007) found that CKD
prevalence increased from 10% in 1988 to 1994 to 13.1% in 1999 to 2004 (95% CI = 9.2-10.9%;
12-14.1% respectively) with a prevalence ratio of 1.3 (95% CI, 1.2-1.4). More recently, ESRD
has increased 7.5% from 2009 to 2015; this is thought to be attributed to the increasing age and
size of the older adult population (USRDS, 2018).
CKD Fall Risk
CKD prevalence is important due to this population being at an increased risk for falling.
A study by Kistler, Khubchandani, Jakubowicz, Wilund, and Sosnoff (2018) using 2014 BRFSS
data indicated that individuals with CKD had an odds ratio of 1.81 (95% CI = 1.63-2.01) for
falling and 1.50 (95% CI = 1.27-1.78) for suffering a fall related injury after adjusting for
demographics, health conditions and lifestyle factors (p<0.05).
The exact fall rate in CKD is under dispute. A study of CKD patients not receiving
hemodialysis by Roberts, Jeffrey, Carlisle and Brierley (2007) found a rate of 1.76 falls/patient a
year for people >65 and a rate of 1.30 falls/patient for individuals <65. Cook et al. (2006)
observed a lower rate of 0.22 falls/patient a year in hemodialysis patients. However, a meta-
analysis by Lopez-Soto et al. (2015) observed a fall rate of 1.18 to 1.6 falls/patient a year for
14
those on hemodialysis. Desmet, Beguin, Swine and Jadoul (2005) observed fall related injuries,
finding a rate 0.37 per patient a year which required medical attention among those on
hemodialysis. Although the specific rates vary, these studies indicate there is a higher rate of
falling in the CKD population for patients receiving and not receiving hemodialysis. The
different rates observed may be associated with heterogeneity among the studies, e.g. study
samples consisting of all hemodialysis patients versus using sample of patients at different stages
of disease progression.
CKD Fall Risk Factors
Falls are a complex interaction of risk factors involving behavior, the environment, and
an individual’s biology; a diagnosis of CKD adds to the complexity. Factors such as
hemodynamic shifts, comorbidities, functionality, polypharmacy, malnutrition, age, and the stage
of CKD can influence the risk for falling (Lopez-Soto et al., 2015).
Age is a risk factor for falls in the general population but even more so in CKD. In a
study comparing falls in older (65) and younger (<65) CKD patients, 38% of older patients fell
while only 4% of younger patients fell. The older group had a significantly greater fall rate of
1.76 falls/patient a year compared to 0.13 falls/patient a year in the younger group (p<0.001;
Roberts et al., 2007). Paliwal, Slattum and Ratliff (2017) garnered similar results in that the CKD
age group of 65 were more likely to fall than the age group of <65.
The older a CKD patient is, the more likely they will reach or have reached ESRD,
requiring dialysis treatment or a kidney transplant (USRDS, 2018). Dialysis treatment adds a
unique risk factor for falling (Lopez-Soto et al., 2015). According to Abdel-Rahman, Turgut,
Turkmen and Balogun (2011), intradialytic hypotension is a problem in roughly 30% of
hemodialysis patients and is a risk for falling. In a study by Roberts, Kenny and Brierley (2003),
15
22 of 23 patients had a decrease in systolic blood pressure upon standing post-dialysis. Sixteen of
the patients were diagnosed with orthostatic hypotension, 10 of which complained of dizziness or
unsteadiness, which can put these patients at greater risk for falling.
A compounding factor associated with age and ESRD is frailty. McAdams et al. (2013)
observed frailty independently predicted a 3.09-fold higher number of falls in CKD patients after
adjusting for age, sex, race, comorbidities, disabilities, and the number of medications (95% CI =
1.38-6.90; p=0.006). Kutner, Zhang, Huang and Wasse (2014), observed participants classified
as frail were twice as likely to report a fall among 762 hemodialysis patients (OR = 2.39; 95% CI
= 1.22-4.71, p=0.01). Functionality can be associated with frailty, but it is also an independent
fall risk factor in CKD.
A functionality study by Desmut et al. (2005) utilized a simple walk test of 10 meters
without assistance; failing the walking test was an independent risk factor for falling in CKD
(OR = 2.057: 95% CI = 1.32-3.20, p<0.01). Shin et al. (2014) assessed the postural sway of
hemodialysis patients against a healthy control group. A significantly larger 95% confidence area
sway was observed in the CKD group (465.8420 versus 7103.978.5, p<0.01) indicating that
they were less functionally stable when standing or walking, thereby increasing fall risk.
Nutrition can be an integral part of optimal body function. According to Rossier, Pruijm,
Hannnane, Burnier, and Teta (2012), patients with CKD diagnosed as malnourished (based from
European Best Practice Guidelines) were more likely to suffer a fall (OR = 8.4; 95% CI = 1.7-
42.4, p=0.01). Although debated, albumin can be associated with malnutrition (Mahan &
Raymond, 2017). Li, Tomlinson, Naglie, Cook and Jassal (2008) observed that CKD patients
with higher albumin were at a decreased risk of falling (HR = 0.91; 95% CI = 0.84-0.98,
p=0.01). Vitamin D levels can also be associated with malnutrition. Rothenbacher et al. (2014)
16
conducted a study of the vitamin D status of 1,385 participants 65 and older; 2.8% of the
participants had CKD. Stages 4 and 5 CKD patients had 75% deficiency, while stage 1 had 42%
deficiency (p=0.0012). CKD patients identified as deficient (serum vitamin D <50nmol/L) were
found to have an increased risk of falling (HRR = 1.93; 95% CI = 1.10-3.37).
Ingestion of medications are also associated with fall risk in CKD. According to Desmut
et al. (2005), the total number of prescription drugs ingested is a risk factor for suffering a fall
(OR = 1.2; 95% CI = 1.1-1.4; p<0.01); the more drugs prescribed the greater risk for suffering a
fall. Drugs like antidepressants were found to be a significant risk factor for suffering a fall (OR
= 5.3; 95% CI = 2.3-12.2, p<0.0001). Polypharmacy, common due to comorbidity conditions,
can influence the risk for falling in CKD (Lopez-Soto et al., 2015).
According to Cook et al. (2006), CKD patients that fall are more likely to have a
comorbid condition at baseline assessed by Charlson Comorbidity Index scores (11.00 versus
9.8, p=0.03). Multiple diseases and conditions can accompany CKD; however, diabetes is one of
the most common and can exacerbate the risk for falling in CKD (Lopez-Soto et al., 2015).
Summary
CKD is prevalent in the Unites States and adds risk for suffering a fall. Studies show that
CKD patients have a high fall rate. There are multiple risk factors associated with the higher rate
of falling, including but not limited to, age, frailty, functionality, orthostatic hypotension from
hemodialysis treatment, malnutrition, medications, and comorbidities like diabetes.
17
Association of Diabetes with Falls and Chronic Kidney Disease
Diabetes Prevalence and Fall Risk
The American Diabetes Association (2018) indicates that 30.3 million Americans (9.4%
of the population) had diabetes in 2015, with 1.5 million individuals being diagnosed every year.
This is suspected to increase due to roughly 84.1 million Americans being classified as
prediabetic. Having diabetes presents numerous potential complications to health including
hyperglycemia, hypoglycemia, ketoacidosis, dyslipidemia, hypertension, retinopathy and
diabetic peripheral neuropathy (DPN) (Mahan & Raymond, 2017), with a less talked about
aspect being the increased risk for falls.
Pijpers et al. (2012) found that older people with diabetes were more likely to fall than
those without. The researchers observed that 30.6% of individuals with diabetes fell, while only
19.4% without fell (p=0.017). Individuals with diabetes were more likely to suffer recurrent falls
with a rate of 129.7 versus 77.4 per 1,000 people a year. Similarly, Yang et al. (2016) observed
that individuals with diabetes had a significant increased risk of suffering a fall (RR = 1.64: 95%
CI = 1.27-2.11, p=0.02), with 25% of people with diabetes and 18.2% without suffering a fall.
Diabetes and CKD as Comorbidities
The likelihood of having both disease conditions is high. According to USRDS (2018)
40% of individuals with CKD also have diabetes. It is common to suffer from both diseases due
to diabetes injuring blood vessels of the kidneys, thereby decreasing the ability of the kidneys to
filter blood (NKF, 2017). According to Lamarca et al. (2013), diabetes was the second leading
cause (34%) of CKD in a study of 102 patients. Shin et al. (2014) had similar findings, with type
2 diabetes being the second leading cause of CKD patients receiving hemodialysis in their study
sample.
18
Having both CKD and diabetes can have a significant effect on the risk for falling. Li et
al. (2008) observed that 34% of CKD hemodialysis patients with diabetes suffered a fall while
only 20% of CKD patients without suffered a fall. Desmut et al. (2005) focused on fall events in
CKD, with a subpopulation of 27% (n=84) that also had diabetes. CKD patients with diabetes
had a fall odds ratio of 2.75 (95% CI = 1.17-6.41, p=0.01). Kistler et al. (2018) found similar
results when they reported that diabetes in CKD patients was associated with an increased risk of
falling after adjusting for demographics, lifestyle and other chronic health conditions (AOR =
1.25: 95% CI = 1.02-1.53, p<0.05). In addition, these researchers noted an association between
the length of time since diabetes diagnosis and suffering a fall (AOR = 1.45: 95% CI = 1.04-
2.02, p<0.01).
Diabetes Fall Risk Factors
Diabetes adds unique fall risk factors in the CKD population. Some common fall risk
factors of diabetes include poor glycemic control, diabetic peripheral neuropathy (DPN), altered
gait, retinopathy, and polypharmacy (Gu & Dennis, 2017; Vinik et al, 2017).
Glycemic control is associated with hypoglycemia or hyperglycemia. Hypoglycemia
associated with a lowering of A1C in early diabetes treatment can have an effect on falls due to
disrupting homeostasis. The body adjusts to higher glucose levels before treatment, so when
glucose and A1C are lowered in these early stages, homeostasis is disrupted and increases the
risk of syncope. (Grubb & Olshansky, 2005). Nelson, Dufraux, and Cook (2007) found that an
A1C of 7% significantly correlated with falls in diabetes (r=0.24, p=0.011). Puar et al. (2012)
observed an increased risk of suffering a fall resulting in a hip fracture; participants with a
HbA1c <6% were twice as likely to suffer a fall resulting in a hip fracture as those with a A1C
<8% (OR = 3.13; 95% CI = 2.10-4.64, p<0.001). Schwartz et al. (2008) found that an A1C of
19
6% for people using insulin to control their diabetes was associated with an increased risk of
falling (OR = 4.36; 95% CI 1.32-14.46, p<0.05). Lower A1C from baseline in patients with
diabetes, indicating potential hypoglycemic episodes, can be associated with increased risk for
falls (Nelms, 2011); however, lowering of A1C quickly also decreases developing fall risk
factors of DPN and DR that are associated with hyperglycemia.
Hyperglycemia can lead to the development of neuropathy. Nearly 50% of individuals
with type 2 diabetes will develop DPN caused by glucose toxicity, leading to nerve damage and
apoptosis of cells (Gu & Dennis, 2017). The position statement of the American Diabetes
Association (ADA) recognizes DPN as a major risk factor for falls (ADA, 2017). According to
the findings of Nelson et al. (2007), there is a significant correlation between peripheral
neuropathy and falls (r =0.24, p=0.006). A study by Schwartz et al. (2008), observed an
increased risk of falling when DPN was diagnosed using a nerve response amplitude test (OR =
1.50: 95% CI = 1.07-2.12, p<0.05).
DPN leads to associated fall risk factors including altered gait and walking stability.
According to Menz, Lord, St. George and Fitzpatrick (2004), DPN causes changes in nerve
function and sensorimotor function that contributes to fall risk. In their study they compared
factors of gait in DPN versus a control group. These researchers observed that individuals with
DPN walked more slowly (f=21.9, p<0.001), took shorter steps (f=15.7, p<0.001), had
inconsistent timing of steps (f=4.79, p=0.003), had significantly smaller pelvic acceleration
(f=9.49, p=0.003), and unfavorable harmonic ratios of the head (f=4.55, p=0.037) and pelvis
(f=4.94, p=0.03). These observations indicate that DPN causes an altered gait due to decreased
coordination and stability, which increases the risk for falling.
20
Hyperglycemia can cause retinopathy. According to Gupta et al. (2017), mild to moderate
diabetic retinopathy (DR) is associated with an increased likelihood of falling due to altered
depth perception and balance. Their study observed that those with DR were more likely to fall
than those without diabetes and DR (OR = 1.31; 95% CI = 1.07-1060, p=0.008). Those with DR
compared to those with diabetes but not DR were more likely to fall; mild DR had an odds ratio
of 1.81 (95% CI = 1.23-2.67, p=0.003) and moderate DR had an odds ratio of 1.89 (95% CI =
1.16-3.07, p=0.01). To help control glycemia, hyperlipidemia, hypertension, and other symptoms
of diabetes that can lead to conditions like retinopathy, medications are often prescribed.
Medication use can increase fall risk in diabetes. A common medication prescribed in this
population are statins. According to Lopez, Jacobson, Leslie, Saxe and Jenson (2017), statins
alone predicted admissions for fall related injuries to the hospital (95% CI 0.07-0.05, p=0.010).
Huang et al. (2012) found that antihypertensive medications like digoxin and diuretics are
associated with an increased risk of falling (OR = 1.22; 95% CI = 1.05-1.42, p<0.05: OR = 1.08;
95% CI = 1.02-1.16, p<0.05, respectively). The number of drugs ingested also influences fall
risk in diabetes.
Similarly, Huang, Karter, Danielson, Warton & Ahmed (2010) found an increased risk
for falling when taking 4 to 5 drugs (HR = 1.22; 95% CI = 1.04-1.43, p<0.05), 6 to 7 drugs (HR
= 1.33; 95% CI = 1.12-1.58, p<0.05), or 7+ drugs (HR = 1.59; 95% CI = 1.34-1.89, p<0.05).
These finding are similar to those of Desmut et al. (2005) who observed that CKD patients are
more likely to fall as the number of prescribed medications increases.
Summary
Diabetes is a common comorbidity of CKD and can cause CKD. Diabetes alone is a risk
factor for falling. In addition, diabetes is also a risk factor for falls in CKD. Fall risk factors
21
specifically associated with diabetes include glycemic control (hypoglycemia or hyperglycemia),
DPN, altered gait, retinopathy, and polypharmacy. These risk factors compound the fall risk in
CKD, leading CKD patients with diabetes to potentially having a higher risk for falling than non-
diabetic CKD patients.
Falls, Diabetes Health Behaviors, and the Behavior Risk Factor Surveillance System
Diabetes Health Behaviors and Glycemic Control
A plausible approach to decreasing fall risk in the CKD with diabetes population is to
address the modifiable risk factor of glycemic control, which can decrease fall risk factors such
as DPN and DR (Gu & Dennis, 2017; Gupta, et al, 2017). Diabetes health behaviors that can
help assess and/or achieve glycemic control include daily self-checks of blood glucose,
hemoglobin A1C monitoring, insulin use, frequent doctors or other health care professional
visits, vision exams, and checking for foot sores (Mahan & Raymond, 2017; Jeffcoate, Vileikyte,
Boyko, Armstrong and Boulton, 2018). Many of these health behaviors are addressed in the
Behavioral Risk Factor Surveillance System (BRFSS) national telephone survey (CDC, 2015).
The Behavioral Risk Factor Surveillance System
BRFSS collects data regarding health, chronic disease, and risk behaviors. BRFSS asks
questions regarding falls, CKD diagnosis, diabetes diagnosis, and assess participation in many
diabetes health behaviors (CDC, 2015). Currently no studies have directly evaluated the
outcomes of participating in diabetes health behaviors in BRFSS and the number of accumulated
behaviors with the risk for falls or fall outcomes in the CKD with diabetes population. However,
studies indicate that various diabetes health behaviors inquired in the BRFSS questionnaire can
influence falls.
22
There are weaknesses and limitation to the data collected by BRFSS (CDC 2017). The
survey administered separately by state, with each state adding and/or omitting specific modules
and questions. This makes the data not truly representative of the entire US population for certain
data sets. The interviews are done by telephone, so bias is introduced due to specific people and
populations less likely to take calls from unknown numbers; it is possible there is a difference
between people who choose to participate and those that so not. Interviews are given in only
English or Spanish, so large pockets of individuals throughout the US that do not speak either
language are excluded. Interviews are only conducted by telephone, which excludes lower
income households without a land line or cellphone. All of the data is self-reported and is subject
to response error and the potential for false response or miss representing information.
Studies: Health Behaviors Assessed in BRFSS
An important BRFSS question concerns the frequency of self-checking blood glucose
(CDC, 2015). Miller et al. (2013) observed that the more frequent self-monitoring blood glucose
(SMBG) measurements per day, the stronger the association with improved glycemic control
determined by A1C (p<0.001). According to Karter et al. (2001), individuals with diabetes who
checked their blood glucose at least once a day had a significantly lower A1C of 0.6 points
relative to those that checked blood glucose less (p<0.0001); this indicates that SMBG
measurements are linked with improved glycemic control.
Frequency of checking A1C is an important diabetes health behavior addressed in the
BRFSS (CDC, 2015). Loh, Tan, Saw and Sethi (2011), observed that patients checking their
A1C every 4 weeks had a significant decrease in A1C, relative to patients checking their A1C
less then every 4 weeks (p<0.05); however, this was only observed in patients with an A1C>8%
and was not significant in those <7%. Parcero, Yaeger and Bienkowski (2011) obtained similar
23
results. Patients with an A1C >7% that followed the ADA guidelines of checking every 3 to 4
months had a significantly reduced A1C level relative to patients that did not check as frequently
during a 12-month period (6.5 vs 7.3, p<0.001). These findings show the more frequently A1C is
checked the better the glycemic control.
The frequency of monitoring blood glucose and A1C can positively influence glycemic
control and fall risk factors due to improving self-efficacy of the patient (Burgard & Gallagher,
2006). When patients are actively participating in their health care management, they have
increased interest and investment in their health. When self-efficacy occurs with more frequent
checking of blood glucose and A1C, the patient is more aware of their disease management and
can better achieve glycemic control and decrease the risk for developing fall risk factors.
The BRFSS asks about insulin use to control diabetes (CDC, 2015), and it is reported that
roughly 30% of individuals with type 2 diabetes use insulin (ADA, 2018). Schwartz et al. (2008)
found that individuals using insulin to control their diabetes are more likely to suffer a fall. Yang
et al. (2016) observed that insulin can increase the risk for falling (RR=1.94: 95% CI = 1.42-
2.63, p<0.05). Insulin use can increase the risk for falling due to its ability to significantly
decrease blood glucose causing hypoglycemic episodes; these episodes can lead to syncope
(Grubb & Olshansky, 2005). The need to use insulin for controlling type 2 diabetes is influenced
by key factors. According to the American Diabetes Association (2018), the most important
factor is if the body’s cells respond to insulin for glucose uptake. If the body’s cells are insulin
resistant, administration of insulin is futile and medication therapy is the best treatment option to
lower blood glucose. If the body’s cells do respond to insulin but do not produce enough or none
at al due to -cell damage, insulin is a treatment option along with medication. Insulin use in this
circumstance is ideal in early diagnosis of diabetes when blood glucose may be especially
24
elevated and/or A1C is 10% or above. Another factor is if an individual responds to medications;
in some cases a person will not respond to medications, making insulin a necessary treatment.
Age is also a factor. As we age the pancreas can gradually decrease insulin production. Older
patients with diabetes often require insulin treatment for this reason.
Doctor visit frequency for diabetes is assessed in BRFSS (CDC, 2015). Morrison,
Shubina and Turchin (2011) compared diabetes patients who visit the doctor every two weeks
with those who visit every three to six months. The two-week group had a significantly smaller
median time to reach a goal of A1C<7% of 4.4 weeks, with the three to six month group having
a median time of 24.9 months (p<0.0001). This indicates more frequent doctor visits can help
lower blood glucose and achieve glycemic control faster, reducing the chance of developing the
fall risk factors. However, lowering A1C too fast (indicating hypoglycemic episodes) can
increase fall risk short term (Nelms et al, 2011). More frequent doctor’s visits could decrease fall
risk by allowing the doctor to better treat and manage a patients diabetes to achieve glycemic
control. The more often a patient visits the doctor the better a doctor can respond to changes in
health status and blood sugar levels by altering treatments and medications in response.
BRFSS inquires if diabetes patients have been diagnosed with retinopathy and the
frequency of eye exams (CDC, 2015). Gupta et al. (2017) observed that those diagnosed with DR
are at an increased risk for falling relative to those with diabetes absent of DR. No studies were
found regarding frequency of eye exams associated with glycemic control or falls. However, a
study by Gibson (2012) observed that 73% of individuals with DR are undiagnosed, especially in
less severe cases. If people are unaware they have DR, they cannot receive proper eye care,
glasses, or surgeries to correct vision, which could improve balance and decrease the risk for
falling (NIH, 2018).
25
BRFSS asks how frequently an individual performs a foot sore self-check or if (and how
often) they have a healthcare professional check for foot sores. Checking for foot sores is an
important part of diabetes care, being that they are an indicator of poor glycemic control
(Jeffcoate, Vileikyte, Boyko, Armstrong and Boulton, 2018). Further, foot sores can be a direct
result of peripheral neuropathy, which is perhaps the best indicator of long-term glycemic control
(Noor, Zubair & Ahmad, 2015). Allen, Powell-Cope, Mbah, Bulat and Njoh (2017) found that
diabetes patients with a foot sore/ulcer were significantly more likely to suffer a fall (OR = 2.26;
95% CI = 1.96-2.60, p<0.01) and/or experience a fracture (OR = 3.65; 95% CI = 2.59-5.15,
p<0.01) relative to diabetes patients without a sore/ulcer. No studies have aimed to observe the
frequency of checking for foot sores in association with falls. The frequency of checking for foot
sores, whether it is a self-check or by a health professional, can influence fall occurrences. If a
foot sore is detected early, treatment can be administered and prevent severe infection. If foot
sores are not frequently checked for or assessed, a severe infection can occur. A severe infection
can cause pain and discomfort when walking (Noor, Zubair & Ahmad, 2015); this could cause a
patient to modify their gait, effecting their balance and leading to a fall. Sever foot sores can also
lead to amputation of parts of the foot are the entire foot, leading to impaired mobility and an
increased risk for falling (Noor, Zubair & Ahmad, 2015).
Summary
Questions about multiple diabetes health behaviors that are associated with glycemic
control are included in the BRFSS. Studies indicate that participating in a number of these
behaviors and the frequency of these behaviors can have a positive effect on glycemic control,
thereby potentially decreasing fall risk. This indicates that BRFSS data can be beneficial to
assess how well a population is controlling their diabetes and associated fall risk factors.
26
Studies Utilizing Behavioral Risk Factor Surveillance System Data
Kistler et al. (2018) conducted a study using BRFSS data to assess the risk of falls in
CKD patients 65 while considering demographics, lifestyle factors, and other chronic
conditions. These researchers identified their population based on the responses to specific
questions in the BRFSS such as, “Has a doctor, nurse, or other health professional ever told you
that you have kidney disease (excluding kidney stone, bladder infection, or incontinence)?” An
answer of “yes” was considered CKD. Other BRFSS questions were used pertaining to variables
associated with lifestyle, chronic conditions, and falls. The differences in these variables between
those with CKD and those without CKD were compared using 2 tests. Multivariate logistical
regression was used for analysis of CKD history, which was then used as an independent
variable to compile odds ratios for falls and fall-related injuries as outcomes. Adjusted odds
ratios were obtained by controlling for demographic, lifestyle, and health behaviors. All data was
analyzed using complex sample survey data analysis. Results indicated an increased risk for
falling in CKD patients 65, with a diagnosis of diabetes further increasing that risk. The
lifestyle/health behavior of recently participating in exercise was also associated with fall risk
(AOR = 0.68; 95% CI = 0.56-0.81). This demonstrates BRFSS data can be utilized to identify
participation in health behaviors of a disease state population while assessing fall risk.
Santorelli, Ekanayake and Wilkerson-Leconte (2017) assessed the number of patients
with diabetes who were participating in diabetes education classes in New Jersey. BRFSS data
was used to identify individuals with diabetes from the question, “Have you ever been told by a
doctor, nurse, or other health professional you have diabetes?” This population was further
grouped by asking, “Have you ever taken a course or class in how to manage your diabetes
yourself?” A chi square test was used to confirm annual estimates for diabetes prevalence and
27
the percentage of adults who did not participate in a diabetes self-management class. Annual
samples were combined for 2013-2015 and annual weights were adjusted. Non-participation was
assessed using demographics, socioeconomic, and clinical factors with a Rao-Scott chi square
test for bivariate association between each factor and nonparticipation. The study found that of
643,817 diabetes patients identified in New Jersey, 58% (95% CI = 55.8-60.3%) never
participated in diabetes self-management classes. These findings indicate that a population with a
specific disease state can be identified and assessed for participation in health behaviors using
BRFSS data. However, this study did not evaluate falls as an outcome variable.
A study by Johnson, Richards, and Churilla (2015), examined the association between
diabetes self-management education (participating in a diabetes classes) and participating in
many of the diabetes care behaviors that would be examined in this proposed study. The diabetes
diagnosis question was used to obtain the study sample in BRFSS 2008 and the diabetes module
questions were used to identify participation in diabetes health behaviors. The researchers found
that those who had 10 or more hours in a diabetes education class were more likely to check
A1C (OR = 2.69; 95% CI: 1.30-5.58), but found no association with checking blood glucose,
having eye exams, or checking feet for ulcers.
A study by Johnson, Ghildayal, Rockwood, and Serson-Rose (2014), utilized BRFSS
2011 data to examine the difference in diabetes self-care activities by race, ethnicity, and insulin
use. This study utilized many of the questions and variables of interest for this proposed study
including blood glucose monitoring, foot checks, and insulin use. The researchers observed
racial differences for every diabetes self-care activity among non-insulin users but only glucose
monitoring and foot checks among insulin users. The most important finding was that diabetes
elf care was low among all adults regardless of race.
28
Summary
No current studies have assessed falls for CKD patients with diabetes in association with
participation in diabetes health behaviors. However, studies have demonstrated the ability to
identified specific disease states and relate them to participation in health behaviors and/or falls
using BRFSS data.
Summary
The fall rate is rising in the United States, causing physical harm and financial strain.
There are numerous risk factors for falling in the general population, but specific disease states
increase that risk with disease related risk factors. CKD and diabetes are among those disease
states. Diabetes increases the risk for falling and is often a comorbidity and cause of CKD.
Independently these disease states have a higher risk for falling, but when combined the risk
factors are compounded.
There is a complex interplay of CKD and diabetes variables that can influence falling.
Due to this complexity, focusing on one set of variables and their effect on falls is appropriate.
Studies indicate that a number of fall risk factors associated with diabetes are related to glycemic
control, and there by influences fall risk in the CKD with diabetes population. Glycemic control
is influenced by participating in certain diabetes health behaviors
There are no current studies accessing the participation in multiple diabetes health
behaviors and the risk of falls in the CKD with diabetes population. Statistical analysis of
BRFSS data can be used to assess if the risk for falling in this unique population is effected by
participation in diabetes health behaviors; answers to health behavior questions among this
population can be compared among groups using 2 statistical analysis, while using logistic
29
regression to assess main outcome variables like falls. The results may help point to key aspects
of diabetes care that can be added to fall prevention practices for the CKD with diabetes
population.
30
CHAPTER 3
METHODOLOGY
occurrence of falls among a population diagnosed with CKD and T2DM. This chapter will
describe the methods used to conduct this secondary analysis of previously collected BRFSS
data.
Institutional Review Board
Permission will be requested from Ball State University Institutional Review Board prior
to implementing this study (Appendix A-1). The researcher that will conduct this study has
completed the Collaborative Institutional Training Initiative (CITI) training (Appendix A-2). All
persons participating in this research will have completed CITI training prior to their
participation (Appendix A-2).
Sample
The population for this study will be all individuals who completed the 2016 BRFSS
questionnaire and answered “yes” to question 6.11 that asked if the respondent had ever been
diagnosed with CKD and “yes” to question 6.12 that asked if the respondent had ever been
diagnosed with diabetes. Power analysis will not be conducted due to the inability to control for
the number of participants in secondary analysis data; however, a rule of at least 10 participants
per variable will be implemented for statistical analysis (Coladarci & Cobb, 2014). Final
inclusion criteria consists of: i) answering “yes” to a diagnosis of CKD, and ii) answering “yes”
to a diagnosis of diabetes.
The BRFSS 2016 weighted data sample will be utilized for this study. Unweighted data
makes the assumptions: 1) Each record has equal probability of being selected and 2)
Noncoverage and nonresponse are equal among all segments of the population. These
assumptions are never met and can affect the results of the data set by introducing bias. The
BRFSS 2016 data is weighted in two steps. First, design weight is calculated [stratum weight X
(1 / # of p hones in household) X (# of adults in household)] by taking into account the number
of phones and adults in each household, the number of available records, and the number of
records selected from each geographic strata. Second, the design weight is adjusted by raking
variables [design weight X raking adjustment variables]; BRFSS 2016 raked the design weight to
8 margins including age by gender, race or ethnicity, education, marital status, tenure, gender by
race or ethnicity, age group by race or ethnicity, and phone ownership. The 5-year American
Community Survey PUMS dataset (2011-2015) was used to estimate the multiplier values for the
raking margins education, marital status, and tenure.
Instruments
The BRFSS questionnaire includes a standardized core of questions asked every year in
all 50 states to persons 18 years of age and older. In addition, a rotating core of questions on
various topics is included every other year, with a module on the incidence of falls being one
such module. States must ask the standardized questions each year, but they can choose which
optional module(s) they will employ based on the specific health interests of the state. The
32
questionnaire used for this study will be the 2016 BRFSS which includes the rotating questions
regarding falls. The questions used for this study include: 6.11, 6.12, 13.1, 13.2, and Module 2
questions 1-8 (Appendix B-1). Module 2 (diabetes health behaviors) is an optional module only
used by states choosing to do so based upon increased diabetes health concerns. A link to the full
questionnaire is provided. The BRFSS questionnaire has been tested and found to be both
reliable and valid as measured against other surveys and survey methods (Pierannunzi, Hu, &
Balluz, 2013). Reliability of the instrument will not be conducted by the researcher.
Letter of Permission and Letter of Consent
Letters of permission and consent are not required for this study. This study will analyze
secondary data, which does not require permission to access a physical location or require
permission from BRFSS questionnaire participants. Permission from the CDC to use BRFSS
data and materials is not required as the information is in the public domain. All published
material derived from the data, however, must acknowledge the CDC’s BRFSS as the original
source (CDC, 2018).
Methods
According to the CDC (2018), the BRFSS questionnaire centers around a core group of
questions pertinent to health information and concerns within the United States. Four questions
may be added to the core group responding to current research, emerging health concerns, and
Heathy People 2020 goals. The CDC gives technical and methodological assistance to state
health departments to conduct the surveys. In-house state health department interviewers,
contracted telephone call centers, or universities are given basic training on how to conduct a
survey. Surveying starts as early as late January and continues throughout the year. Surveys are
33
conducted by telephone only. Phone numbers are selected using Random Digital Dialing (RDD)
techniques for both landlines and cell phones; cell phone interview data inclusion began in 2011,
making pre and post 2011 data not comparable (CDC, 2018). Interviews are conducted seven
days a week during the day and evening. It takes an interviewer roughly eighteen minutes to
conduct each interview, with five to ten additional minutes depending on the states added set of
questions (module)(CDC, 2017).
States collect and submit data monthly to the CDC. Survey response data is collected
using Ci3 WinCATI system program software. The software incorporates consistency edits and
response code range checks in the CATI system to decrease interviewer data entry error. Once
the CDC begins receiving data, editing programs and cumulative data quality checks are
conducted to detect problems. Every variable from the BRFSS interview is given a code category
labeled refused and assigned values of 9, 99, or 999. Once data is gathered, it is weighted to
make the sample representative of the population. BRFSS data weighing consists of design
factors or design weight and demographic adjustment of the population by iterative proportional
fitting or raking. Data is than compiled and made available to the public by the CDC.
For this study, the BRFSS 2016 data will be downloaded from the CDC website. The
data will be stored on a password-protected computer. The data will be handled and observed
only by researchers affiliated with the study.
Data Analysis
The BRFSS 2016 data is downloaded from the CDC website onto a password protected
computer hard drive. All names and identifiable information was removed by the CDC prior to
making the data available in the public domain. The codes, previously assigned to variables by
the CDC, are found in the BRFSS 2016 codebook (Appendix B-2).
34
Using the SAS statistical analysis software, a data set from BRFSS 2016 will be extracted
and compiled by excluding all data of participants that answered “no” to question 6.11 (i.e.,
CKD diagnosis). The data will be further grouped by answering “yes” to question 6.12 (i.e.,
diabetes diagnosis).
Question One:
Descriptive statistics will be used to compare CKD with diabetes patients that answered
the diabetes health behavior questions to those whom did not. Covariates that will be compared
include sex, race marital status, employment, education, general health, access to health care,
current smoking, heavy drinking, difficulty waking/climbing stairs, exercise, obesity, chronic
conditions (cancer, arthritis, stroke, and depression), falls, and fall related injuries. Chi-square
will be used to compare categorical variables and a T-test will be used to compare continuous
variables that are normally distributed; Mann-Whitney U will be used to compare continuous
variables not normally distributed.
Question Two:
Descriptive statistics will be computed for all variables previously listed comparing those
who have fallen and those who have not fallen. Chi-square will be used to compare falling to not
falling for the sample of CKD with diabetes patients that answered at least one diabetes question.
Logistical regression will be used to analyze the association between falls and participation in
diabetes health behaviors.
Question Three:
Descriptive statistics will be computed for all variables previously listed comparing those
who have suffered a fall related injury and those who have not suffered a fall-related injury. Chi-
35
square will be used to compare suffering a fall-related injury to not suffering a fall-related injury
for the sample of CKD with diabetes patients that answered at least one diabetes question.
Logistical regression will be used to analyze the association between fall-related injuries and
participation in diabetes health behaviors.
Crude and adjusted logistic regression will be used to measure the association of falls and
fall related injuries with diabetes health behaviors. Odds ratios for diabetes health behavior
participation and the likelihood of falling will be obtained. Multiple models will be applied to
measure the association. Model 1 will be unadjusted and compare falls to CKD with diabetes
patients that participated in at least one diabetes health behavior to those that did not. Model 2
will adjust for demographics (e.g. sex, race, marital status, employment, and education). Model 3
will adjust for physical function, health, and lifestyle factors (e.g. smoking, exercise, obesity,
ect.). Model 4 will adjusts for chronic health conditions in addition to CKD and diabetes (e.g.
cancer, arthritis, heart disease, and depression). Model 5 will adjust for demographics, physical
function, health, lifestyle, and chronic conditions.
Statistical significance will be set at   0.05. For multiple comparisons of adjusted
models, a Bonferroni correction will be used with an   0.005. Data will analyzed using SPSS
v.25 for Windows (SPSS, 2018).
Summary
The purpose of this retrospective quantitative study is to identify an association between
participation in diabetes-related health behaviors outlined in BRFSS 2016 and the occurrence of
falls among a population diagnosed with CKD and type 2 diabetes. The BRFSS 2016
questionnaire includes a set of core questions asked every year regarding chronic disease
diagnosis and a set of questions asked every other year that includes fall occurrence; detailed
36
diabetes health behavior questions are contained in Module 2. According to Creative Research
System’s Sample Size Calculator (2012), a minimum of 600 survey participants that answered
these questions is required to determine this studies speculative association and hypotheses.
Statistical analyses of these variables will be conducted using descriptive statistics, chi-square,
and numerous adjusted logistical regression models. The data collected from these analyses will
provide a better understand of falls in association with diabetes health behavior participation in
the CKD with diabetes population. The findings could potentially help form fall prevention
programs and protocol for this unique population.
37
REFERENCES
Abdel-Rahman, E. M., Turgut, F., Turkmen, K., & Balogun, R. A. (2011). Falls in elderly
hemodialysis patients. Quarterly Journal of Medicine, 104, 829-838. doi:
10.1093/qjmed/hcr108
Adams, P. F., Kirzinger, W. K., & Martinez, M. (2013). Summary health statistics for the U.S.
population: National Health Interview Survey, 2012. National Center for Health
Statistics Series 10, 259. Retrieved from
https://www.cdc.gov/nchs/data/series/sr_10/sr10_259.pdf
Allen, L., Powell-Cope, G., Mbah, A., Bulat, T., & Njoh, E. (2017). A retrospective review of
adverse events related to diabetic foot ulcers. Ostomy Wound Management, 63(3), 30-33.
American Diabetes Association (ADA)(2017). Diabetic neuropathy: A position statement by the

American Diabetes Association. Diabetes Care, 40, 136-154. doi: 10.2337/dc16-2042
American Diabetes Association (ADA)(2018). Insulin & other injectables. Retrieved from
http://www.diabetes.org/living-with-diabetes/treatment-and-
care/medication/insulin/?loc=lwd-slabnav
American Diabetes Association (ADA)(2018, March 22). Statistics about diabetes: Overall
numbers, diabetes and prediabetes. Retrieved from http://www.diabetes.org/diabetes-
basics/statistics/
Boyle, M. A. (2017). Community nutrition in action: An entrepreneurial approach 7th edition.

Boston, MA: Cengage Learning.
Burgard, M. & Gallagher, K. I. (2006). Self-monitoring: Influencing effective behavior change in

your clients. ACSM’s Health & Fitness Journal, 10(1), 14-19.
Burns, E. R., Stevens, J. A., & Lee, R. (2016). The direct costs of fatal and non-fatal falls among
older adults – United States. Journal of Safety Research, 58, 99-103. doi:
10.1016/j.jsr.2016.05.001
Centers for Disease Control and Prevention (CDC). (2015). Preventing Falls: A Guide to
Implementing Effective Community-Based Fall Prevention Programs. Atlanta, GA.
Retrieved from
https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/fallpreventionguide-2015-a.pdf
Centers for Disease Control and Prevention (CDC). (2015). Behavioral Risk Factor Surveillance
System 2016. Retrieved from https://www.cdc.gov/brfss/questionnaires/pdf-
ques/2016_BRFSS_Questionnaire_FINAL.pdf
Centers for Disease Control and Prevention (CDC). (2017). Behavioral Risk Factor Surveillance
System Overview BRFSS 2016. Retrieved from
https://www.cdc.gov/brfss/annual_data/2016/pdf/overview_2016.pdf
Centers for Disease Control and Prevention (CDC). (2018). Chronic kidney disease. Retrieved
from http://www.cdc.gov/dotw/ckd/index.html
Centers for Disease Control and Prevention (CDC). (2018, January 2). BRFSS frequently asked
questions (FAQs) [Webpage]. Retrieved from
https://www.cdc.gov/brfss/about/brfss_faq.htm
Coladarci, T. & Cobb, C. D. (2014). Fundamentals of statistical reasoning in education.

Danvers, MA: Wiley.
Cook, W. L., Tomlinson, G., Donaldson, M., Markowitz, S. N., Nagile, G., Sobolev, B., &
Jassal, S. V. (2006). Falls and fall-related injuries in older dialysis patients. Clinical
Journal of the American Society of Nephrology, 1, 1197-1204. doi:
10.2215/CJN.01650506
Coresh, J., Selvin, E., Stevens, L. A., Manzi, J., Kusek, J. W., Eggers, P., Lente, F. V., & Levey,
A. S. (2007). Prevalence of chronic kidney disease in the United States. The Journal of
the American Medical Association, 298(17), 2038-2047.
Creative Research Systems Sample Size Calculator (2012). [Web Software] Retrieved from
https://www.surveysystem.com/sscalc.htm
Desmet, C., Beguin, C., Swine, C., & Jadoul, M. (2005). Falls in hemodialysis patients:
Prospective study of incidence, risk factors, and complications. American Journal of
Kidney Disease, 45(1), 148-153.
Florence, C. S., Bergen, G., Atherly, A., Burns, E. R., Stevens, J. A., & Drake, C. (2018).
Medical costs of fatal and nonfatal falls in older adults. Journal of the American
Geriatrics Society, 66, 693-698. doi: 10.1111/jgs.15304
Gibson, D. M. (2012). Diabetic retinopathy and age-related macular degeneration in the U.S.
American Journal of Preventative Medicine, 43(1), 48-54. doi:
10.1016/j.amepre.2012.02.028
Grubb, B. P. & Olshansky, B. (2005). Syncope: Mechanisms and management 2nd edition.
Malden, MA: Blackwell Publishing.
Gu, Y. & Dennis, S. M. (2017). Are falls prevention programs effective at reducing the risk
factors for falls in people with type-2 diabetes mellitus and peripheral neuropathy: A
systematic review and synthesis. Journal of Diabetes and Its Complications 31, 504-516.
doi: 10.1016/j.jdiacomp.2016.10,004
39
Gunn, H. J., Newell, P., Haas, B., Marsden, J. F., & Freeman, J. A. (2012). Identification of risk
factors for fals in multiple sclerosis: A systematic review and meta-analysis. Physical
Therapy, doi: 10.2522/ptj.20120231
Gupta, P., Aravindhan, A., Gan, A. T. L., Man, R. E. K., Fenwick, E. K., Mitchell, P., Tan, N.,
Sabanayagam, C., Wong, T. Y., Cheng, C. Y., & Lamoureux, E. L. (2017). Association
between the severity of diabetic retinopathy and falls in an Asian population with
diabetes: The Singapore Epidemiology of Eye Disease Study. JAMA Ophthalmology,
135(12), 1410-1416.
Huang, A. R., Mallet, L., Rochefort, C. M., Eguale, T., Buckeridge, D. L., & Tamblyn, R.
(2012). Medication-related falls in the elderly: Causative factors and preventive
strategies. Drugs & Aging, 29(5), 359-376.
Huang, E. S., Karter, A. J., Danielson, K. K., Warton, E. M., & Ahmed, A. T. (2010). The
association between the number of prescription medications and incident falls in multi-
ethnic population of adult type-2 diabetes patients: The diabetes and aging study. Journal
of General Internal Medicine, 25, 141-146.
Jeffcoate, W. J., Vileikyte, L., Boyko, E. J., Armstrong, D. G., & Boulton, A. J. M. (2018).
Current challenges and opportunities in the prevention and management of diabetic foot
ulcers. Diabetes Care, 41, 645-652. doi: 10.2337/dc17=1836
Johnson, P. J., Ghildayal, N., Rockwood, T., & Serson-Rose, S. A. (2014). Differences in
diabetes self-care activities by race/ethnicity and insulin use. Diabetes Education, 40(6),
767-777. doi: 10.1177/0145721714552501
Johnson, T. M., Richards, J., & Churilla, J. R. (2015). Care utilization patterns and diabetes self-
management education duration. Diabetes Spectrum, 28(3), 193-200. doi:
10.2337/diaspect.28.3.193
Jorgensen, L., Engstad, T., & Jacobsen, B. K. (2002). Higher incidence of falls in long-term
stroke survivors than in population controls. American Heart Association Journal, 33,
542-547.
Karter, A J., Ackerson, L. M., Darbinian, J. A., D’Agostion, R. B., Ferrara, A., Liu, J., & Selby,
J. V. (2001). The American Journal of Medicine, 111, 1-9.
Kistler, B. M., Khubchandani, J., Jakubowicz, G., Wilund, K., & Sosnoff, J. (2018). Falls and
fall-related injuries among US adults aged 65 or older with chronic kidney disease.
Preventing Chronic Disease, 15. doi: 10.588/pcd15.170518
Kutner, N. G., Zhang, R., Huang, Y., & Wasse, H. (2014). Falls among hemodialysis patients:
Potential opportunities for prevention. Clinical Kidney Journal, 0, 1-7. doi:
10.1093/ckj/sfu034
40
Lanier, J. B., Mote, M. B., & Clay, E. C. (2011). Evaluation and managemnet of orthostatic
hypotension. American Family Physican, 84(5), 527-536.
Lamarca, F., Carrero, J. J., Rodrigues, J. D. C., Bigogno, F. G., Fetter, R. L., & Avesani, C. M.
(2013). Prevalence of sarcopenia in elderly maintenance hemodialysis patients: The
impact of different diagnostic criteria. The Journal of Nutrition, Health, & Aging. doi:
10.1007/s12603-014-0455-y
Li, M., Tomlinson, G., Naglie, G., Cook, W. L., & Jassal, S. V. (2008). Geriatric comorbidities,
such as falls, confer an independent mortality risk to elderly dialysis patients. Nephrology
Dialysis Transplantation, 23, 1396-1400. doi: 10.1093/ndt/gfm778
Loh, T. P., Tan, K. M., Saw, S., & Sethi, S. K. (2011). Glycated haemoglobin: What is the
diagnostic yield at shortened test intervals? Diabetes Research and Clinical Practice,
94(2), 40-42.
Lopez, J. M., Jacobson, L. E., Leslie, K. L., Saxe, J. M., & Jenson, C. D. (2017). Statin use
predicts fall risk among older adults. [University of the Pacific, Stockton CA]
Lopez-Soto, P. J., Giorgi, A. D., Senno, E., Tiseo, R., Ferraresi, A., Canella, C., Rodrigez-
Borrego, M. A., Manfrendi, R., & Fabbian, F. (2015). Renal disease and accidental falls:
A review of published evidence. BMC Nephrology, 176(16). doi: 10.1186/s12882-015-
0173-7
Mahan, L. K. & Raymond, J. L. (2017). Krause’s food & the nutrition care process. St. Louis,
MO: Elsevier.
Mayo Clinic. (2018, May 30). Diabetic retinopathy [Web page]. Retrieved from
https://www.mayoclinic.org/diseases-conditions/diabetic-retinopathy/symptoms-
causes/syc-20371611
McAdams, M. A., Suresh, S., Law, A., Salter, M. L., Gimenez, L. F., Jaar, B. G., Walston, J. D.,
& Segey, D. L. (2013). Frailty and falls among adult patients undergoing chronic
hemodialysis: A prospective cohort study. BMC Nephrology, 14(244). Retrieved from
http://www.biomedcentral.com/1471-2369/14/224
Menz, H. B., Lord, S. R., St. George, R., & Fitzpatrick, R. C. (2004). Walking stability and
sensorimotor function in older people with diabetic peripheral neuropathy. Archives of
Physical Medicine and Rehabilitation, 85, 245-252. doi: 10.1016/j.apmr.2003.06.015
Miller, K. M., Beck, R. W., Bergesnstal, R. M., Goland, R. S., Haller, M. J., McGill, J. B.,
Rodriguez, H., Simmons, J. H., & Hirsch, I. B. (2013). Evidence of strong association
between frequency of self-monitoring of blood glucose and hemoglobin A1C levels in
T1D exchange clinic registry participants. Diabetes Care. doi: 10.2337/dc12-1770
41
Morrison, F., Shubina, M., & Turchin, A. (2011). Encounter frequency and blood glucose, blood
pressure and cholesterol in patients with diabetes. Archives of Internal Medicine, 171(17),
1542-1550. doi: 10.1001/archinternmed.2011.400
National Institute of Health (NIH): National Institute of Diabetes and Digestive and Kidney
Diseases (2017). Diabetic Eye Disease. Retrieved from
https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-
problems/diabetic-eye-disease
National Kidney Foundation (NKF)(2017). Diabetes: A major risk factor for kidney disease.
Retrieved from https://www.kidney.org/atoz/content/diabetes
Nelson, J. M., Dufraux, K., & Cook, P. F. (2007). The relationship between glycemic control and
falls in older adults. Journal of American Geriatrics Society, 55, 2041-2044. doi:
10.111/j.1532-5415.2007.01430.x
Noor, S., Zubair, M., & Ahmad, J. (2015). Diabetic foot ulcer: A review on pathophysiology,
classification and microbial etiology. Diabetes & Metabolic Syndrome: Clinical Research
& Reviews, 9, 192-199. doi: 10.1016/j.dsx.2015.04.007
Paliwal, Y., Slattum, P. W., & Ratliff, S. M. (2017). Chronic health conditions as a risk factor for
falls among the community-dwelling US older adults: A zero-inflated regression
modelling approach. BioMed Research International. doi: 10.1155/2017/5146378
Parcero, A. F., Yaeger, T., & Bienkowski, R. S. (2011). Frequency of monitoring hemoglobin
A1C and achieving diabetes control. Journal of Primary Care & Community Health,
2(3), 205-208. doi: 10.1177/2150131911403932
Pierannunzi, C., Hu, S. S., & Balluz, L. (2013). BMC Medical Research Methodology, 13(49).
Retrieved from http://www.biomedcentral.com/1471-2288/13/49
Pijpers, E., Ferreira, I., De Jongh, R. T., Deeg, D. J., Lips, P., Stehouwer, C. D. A., &
Nieuwenhuijzen-Kruseman, A. C. (2012). Older individuals with diabetes have an
increased risk of recurrent falls: Analysis of potential mediating factors: The longitudinal
Ageing Study Amsterdam. Age and Ageing, 41, 358-365. doi: 10.1093/ageing/afr145
Puar, T. H., Khoo, J. J., Cho, L. W., Xu, Y., Chen, Y. T., Chuo, A. M., Poh, C, B., & Ng, J. M.
(2012). Association between glycemic control and hip fracture. Journal of American
Geriatric Society, 60, 1493-1497. doi: 10.1111/j.1532-5415.2012.04052.x
Renfro, M., Maring, J., Bainbridge, D., & Blair, M. (2016). Fall risk among older adult high-risk
populations: A review of current screening and assessment tools. Current Geriatric
Reports, Physical Therapy and Rehabilitation. doi: 10.1007/s13670-016-0181-x
Roberts, R. G., Kenny, R. A., & Brierley, E J. (2003). Are elderly haemodialysis patients at risk
of falls and postural hypotension? International Urology and Nephrology, 35, 415-421.
42
Roberts, R. G., Jeffrey, C., Carlisle, G., & Brierley, E. (2007). Prospective investigation of the
incidence of falls, dizziness and syncope in haemodialysis patients., International
Urology and Nephrology, 39, 275-279. doi: 10.1007/s11255-006-9088-3
Rosenman, R., Tennekoon, V., & Hill, L. G. (2011). Measuring bias in self-reported data.
International Journal of Behavioral Health Research, 2(4), 320-332. doi:
10.1504/IJBHR.2011.043414
Rosiek, A., Kornatowski, T., Frackowiak-Maciejewska, N., Rosiek-Kryszewska, A.,

Wyzgowski, P., Leksowski, K. (2016). Health behaviors of patients diagnosed with type
2 diabetes mellitus and their influence on the patients’ satisfaction with life. Therapeutics
and Clinical Risk Management, 12, 1783-1792. doi: 10.2147.TCRM.S118014
Rossier, A., Pruijm, M., Hannnane, D., Burnier, M., & Teta, D. (2012). Incidence, complications
and risk factors for severe falls in patients on maintenance haemodialysis. Nephrology
Dialysis Transplantation, 27, 352-357. doi: 10.1093/ndt/gfr326
Rothenbacher, D., Klenk, J., Denkinger, M. D., Herbolsheimer, F., Nikolaus, T., Peter, R.,
Boehm, B. O., Rapp, K., Dallmeier, D., & Koenig, W. (2014). Prospective evaluation of
renal function, serum vitamin D level, and risk of fall and fracture in community-
dwelling elderly subjects. Osteoporosis International, 25, 923-932. doi: 10.1007/s00198-
013-2565-5
Salb, J., Woodard, C., Offenhauber, J., Becker, C., Sieber, C., & Freiberger (2015). Prevalence
and characteristics of falls in adults with intellectual disability living in a residential
facility: A longitudinal study [PreFallID]. Intellectual and Developmental Disabilities,
53(3), 228-239. doi: 10.1352/1934-9556-53.3.228
Santorelli, M. L., Ekanayake, R. M., & Wilkerson-Leconte, L. (2017). Participation in a diabetes

self-management class among adults with diabetes, New Jersey 2013-2015. Preventing
Chronic Disease, 14. doi: 10.5888/pcd14.170023
Schenker, Y. & London, A. J. (2015). The epidemiologic data on falls, 1998-2010: More older
Americans report falling. JAMA Internal Medicine, 175(3), 443-445. doi:
10.1001/jamainternmed.2014.7533
Schwartz, A. V., Vittinghoff, E., Sellmeyer, D. E., Feingold, K. R., Rekeneire, N. D.,
Strotmeyer, E. S., Shorr, R. I., Vinik, A. I., Odden, M. C., Park, S. W., Faulkner, K, A., &
Harris, T. B. (2008). Diabetes-related complications, glycemic control, and falls in older
adults. Diabetes Care, 31(3), 391-396.
Shin, S., Chung, H. R., Fitchen, P. J., Kistler, B. M., Park, H. W., Wilund, K. R., & Sosonff, J. J.
(2014). Postural control in hemodialysis patients. Gait Posture, 39(2), 723-727. doi:
10.1016/j.gaitpost.2013.10.006
43
Sise, R. G., Calvo, R. Y., Spain, D. A., Weiser, T. G., & Staudenmayer, K. L. (2014). The
epidemiology of trauma-related mortality in the United State from 2002 to 2010. Journal
of Trauma and Acute Care Surgery, 76(4). doi: 10.1097/TA.0000000000000169
Suri, R. S. (2015). KDOQI hemodialysis adequacy clinical practice guideline update 2015: What
you need to know [PowerPoint Presentation]. Retrieved from
https://www.kidney.org/sites/default/files/KDOQI-HD-update-NRAA-2016_FINAL.pdf
Talbot, L. A., Musiol, R. J., Witham, E. K., & Metter, E. J. (2005). Falls in young, middle-aged
and older community dwelling adults: Perceived cause, environmental factors and injury.
BMC Public Health, 5(86). doi: 10.1186/1471-2458-5-86
Timsina, L. R., Willetts, J. L., Brennan, M. J., Marucci-Wellman, H., Lombardi, D. A.,
Courtney, T. K., & Verma, S. K. (2017). Circumstances of fall-related injuries by age and
gender among community-dwelling adults in the United States. PLoS one, 12(5). doi:
10.1371/journal.pone.0176561
United States Renal Data Sytstem (USRDS)(2018). 2017 USRDS Annual Data Report:
Executive Summary. Retrieved from
https://www.usrds.org/2017/download/2017_Volume_1_CKD_in_the_US.pdf
Verma, S. K., Willets, J. L., Corns, H. L., Marucci-Wellman, H. R., Lombardi, D. A., &
Courtney, T. K. (2016). Falls and fall-related injuries among community-dwelling adults
in the United States. PLoS One. doi: 10.1371/journal.pone.0150939
Vinik, A. I., Camacho, P., Reddy, S., Valencia, W. M., Trence, D., Matsumotom, A. M., &
Morley, J. E. (2017). Aging, Diabetes,, and Falls. Endocrine Practice, 23(9), 1117-1139.
doi: 10.4158/EP171794.RA
Yang, Y., Hu, X., Zhang, Q., & Zou, R. (2016). Diabetes mellitus and risk of falls in older
adults: A systematic review and meta-analysis. Age and Aging, 45, 761-767.
doi:10.1093/ageing/afw140
Zhou, J., Habtemariam, D., Iloputaife, I., Lipsitz, L. A., & Manor, B.. (2016). The complexity of
standing postural sway associates with future falls in community-dwelling older adults:
The MOBILIZE Boston Study. Scientific Reports, 7(2924). doi: 10.1038/s45198-017-
03422-4
44
APPENDIX A
INSTITUTIONAL REVIEW BOARD DOCUMENTS
Appendix A-1 Institutional Review Board Letter

Appendix A-2 CITI Certificate of Completion
45
APPENDIX A-1 – IRB Approval Letter
46
47
Appendix A-2 – CITI Certificate of Completion
COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM)

COMPLETION REPORT - PART 1 OF 2
COURSEWORK REQUIREMENTS*
* NOTE: Scores on this Requirements Report reflect quiz completions at the time all requirements for the course were met. See list below for details.
See separate Transcript Report for more recent quiz scores, including those on optional (supplemental) course elements.
• Name: Bradley Horton (ID: 7145153)
• Institution Affiliation: Ball State University (ID: 1568)
• Institution Email: brhorton@bsu.edu
• Institution Unit: Nutrition and Health Sciences
• Phone: 317-370-6650
• Curriculum Group: Social & Behavioral Research - Basic/Refresher
• Course Learner Group: Same as Curriculum Group
• Stage: Stage 1 - Basic Course
• Description: Choose this group to satisfy CITI training requirements for Investigators and staff involved primarily in
Social/Behavioral Research with human subjects.
• Record ID: 26982871
• Completion Date: 10-May-2018
• Expiration Date: 09-May-2021
• Minimum Passing: 80
• Reported Score*: 100
REQUIRED AND ELECTIVE MODULES ONLY DATE COMPLETED SCORE

Belmont Report and Its Principles (ID: 1127) 04-May-2018 3/3 (100%)
Students in Research (ID: 1321) 07-May-2018 5/5 (100%)
History and Ethical Principles - SBE (ID: 490) 07-May-2018 5/5 (100%)
Defining Research with Human Subjects - SBE (ID: 491) 08-May-2018 5/5 (100%)
The Federal Regulations - SBE (ID: 502) 08-May-2018 5/5 (100%)
Assessing Risk - SBE (ID: 503) 08-May-2018 5/5 (100%)
Informed Consent - SBE (ID: 504) 09-May-2018 5/5 (100%)
Privacy and Confidentiality - SBE (ID: 505) 09-May-2018 5/5 (100%)
Research with Prisoners - SBE (ID: 506) 09-May-2018 5/5 (100%)
Research with Children - SBE (ID: 507) 09-May-2018 5/5 (100%)
Research in Public Elementary and Secondary Schools - SBE (ID: 508) 09-May-2018 5/5 (100%)
International Research - SBE (ID: 509) 09-May-2018 5/5 (100%)
Internet-Based Research - SBE (ID: 510) 10-May-2018 5/5 (100%)
Research and HIPAA Privacy Protections (ID: 14) 10-May-2018 5/5 (100%)
Vulnerable Subjects - Research Involving Workers/Employees (ID: 483) 10-May-2018 4/4 (100%)
Conflicts of Interest in Human Subjects Research (ID: 17464) 10-May-2018 5/5 (100%)
Unanticipated Problems and Reporting Requirements in Social and Behavioral Research (ID: 14928) 10-May-2018 5/5 (100%)
Ball State University (ID: 13475) 10-May-2018 No Quiz
For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution
identified above or have been a paid Independent Learner.
Verify at: www.citiprogram.org/verify/?ke0c4af12-ea1c-40d9-a9b8-3a161783db05-26982871
Collaborative Institutional Training Initiative (CITI Program)
Email: support@citiprogram.org
Phone: 888-529-5929
Web: https://www.citiprogram.org
48
COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI PROGRAM)
COMPLETION REPORT - PART 2 OF 2
COURSEWORK TRANSCRIPT**
** NOTE: Scores on this Transcript Report reflect the most current quiz completions, including quizzes on optional (supplemental) elements of the
course. See list below for details. See separate Requirements Report for the reported scores at the time all requirements for the course were met.
• Name: Bradley Horton (ID: 7145153)
• Institution Affiliation: Ball State University (ID: 1568)
• Institution Email: brhorton@bsu.edu
• Institution Unit: Nutrition and Health Sciences
• Phone: 317-370-6650
• Curriculum Group: Social & Behavioral Research - Basic/Refresher
• Course Learner Group: Same as Curriculum Group
• Stage: Stage 1 - Basic Course
• Description: Choose this group to satisfy CITI training requirements for Investigators and staff involved primarily in
Social/Behavioral Research with human subjects.
• Record ID: 26982871
• Report Date: 10-May-2018
• Current Score**: 100
REQUIRED, ELECTIVE, AND SUPPLEMENTAL MODULES MOST RECENT SCORE

Students in Research (ID: 1321) 07-May-2018 5/5 (100%)
Ball State University (ID: 13475) 10-May-2018 No Quiz
History and Ethical Principles - SBE (ID: 490) 07-May-2018 5/5 (100%)
Defining Research with Human Subjects - SBE (ID: 491) 08-May-2018 5/5 (100%)
Belmont Report and Its Principles (ID: 1127) 04-May-2018 3/3 (100%)
The Federal Regulations - SBE (ID: 502) 08-May-2018 5/5 (100%)
Assessing Risk - SBE (ID: 503) 08-May-2018 5/5 (100%)
Informed Consent - SBE (ID: 504) 09-May-2018 5/5 (100%)
Privacy and Confidentiality - SBE (ID: 505) 09-May-2018 5/5 (100%)
Research with Prisoners - SBE (ID: 506) 09-May-2018 5/5 (100%)
Research with Children - SBE (ID: 507) 09-May-2018 5/5 (100%)
Research in Public Elementary and Secondary Schools - SBE (ID: 508) 09-May-2018 5/5 (100%)
International Research - SBE (ID: 509) 09-May-2018 5/5 (100%)
Internet-Based Research - SBE (ID: 510) 10-May-2018 5/5 (100%)
Research and HIPAA Privacy Protections (ID: 14) 10-May-2018 5/5 (100%)
Vulnerable Subjects - Research Involving Workers/Employees (ID: 483) 10-May-2018 4/4 (100%)
Unanticipated Problems and Reporting Requirements in Social and Behavioral Research (ID: 14928) 10-May-2018 5/5 (100%)
Conflicts of Interest in Human Subjects Research (ID: 17464) 10-May-2018 5/5 (100%)
For this Report to be valid, the learner identified above must have had a valid affiliation with the CITI Program subscribing institution
identified above or have been a paid Independent Learner.
Verify at: www.citiprogram.org/verify/?ke0c4af12-ea1c-40d9-a9b8-3a161783db05-26982871
Collaborative Institutional Training Initiative (CITI Program)
Email: support@citiprogram.org
Phone: 888-529-5929
Web: https://www.citiprogram.org
49
APPENDIX B
SURVEY INSTRUMENTS
Appendix B-1 BRFSS Questions

Appendix B-2 BRFSS Variable Codes
50
APPENDIX B-1 – BRFSS Questions
51
52
53
54
APPENDIX B-2 – BRFSS Variable Codes
Question Label Variable SAS Code

(Ever told) you have kidney disease? CHCKIDNY
(Ever told) you have diabetes? DIABETE3
Now taking insulin INSULIN
How Often Check Blood for Glucose BLDSUGAR
How Often Check Feet for Sores or FEETCHK2
Irritations
Times Seen Health Professional for Diabetes DOCTDIAB
Times Checked for Glycosylated CHKHEMO3
Hemoglobin
Times Feet Check for Sores/Irritations FEETCHK
Last Eye Exam Where Pupils Were Dilated EYEEXAM
Ever Told Diabetes Has Affected Eyes DIABEYE
Ever Taken Class in Managing Diabetes DIABEDU
Had Fall Past Twelve Months FALL12MN
*Variable values assigned to answering the questions can be found next to the response in the questionnaire; please see Appendix B-1
55

Thesis Proposal

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Thesis Proposal

Hochgeladen von

Copyright:

Verfügbare Formate

ASSOCIATION BETWEEN FALLS, FALL-RELATED INJURIES, AND PARTICIPATION

IN DIABETES-RELATED HEALTH BEHAVIORS AMONG INDIVIDUALS WITH KIDNEY

DISEASE AND DIABETES

SUBMITTED TO THE GRADUATE SCHOOL

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE DEGREE

DR. BRANDON KISTLER - ADVISOR

BALL STATE UNIVERSITY

THESIS: Association Between Falls, Fall-Related Injuries, and Participation in Diabetes-

STUDENT: Bradley Horton

DEGREE: Master of Science

COLLEGE: College of Health

DATE: January 2019

purpose of this study is to identify an association between participation in diabetes-related health

for this population.

ACKNOWLEDGEMENTS ........................................................................................................... iii

TABLE OF CONTENTS ............................................................................................................... iv

CHAPTER 1: INTRODUCTION ...................................................................................................1

Problem Statement ...............................................................................................................4

Purpose Statement ................................................................................................................5

Research Questions ..............................................................................................................5

Research Hypotheses ...........................................................................................................5

CHAPTER 2: REVIEW OF LITERATURE ................................................................................10

Introduction: Falls in the United States .............................................................................10

Fall Rate and Outcomes .........................................................................................10

Fall Risk Factors ....................................................................................................11

At Risk Populations ...............................................................................................12

Chronic Kidney Disease (CKD) and Falls .........................................................................14

CKD Fall Risk........................................................................................................14

CKD Fall Risk Factors ...........................................................................................15

Association of Diabetes with Falls and Chronic Kidney Disease......................................17

Diabetes Prevalence and Fall Risk .........................................................................17

Diabetes and CKD and Comorbidities ...................................................................18

Diabetes Fall Risk Factors .....................................................................................19

Falls, Diabetes Health Behaviors and the BRFSS .............................................................22

Diabetes Health Behaviors and Glycemic Control ................................................22

The Behavioral Risk Factor Surveillance System (BRFSS) ..................................22

Studies: Health Behaviors Assessed in BRFSS .....................................................23

Studies Utilizing Behavioral Risk Factor Surveillance Data .............................................26

CHAPTER 3: METHODOLOGY ................................................................................................30

Institutional Review Board ................................................................................................30

Letter of Permission and Consent ......................................................................................31

Data Analysis ....................................................................................................................33

CHAPTER 4: RESULTS ..................................................................................................................

CHAPTER 5: DISCUSSION ............................................................................................................

CHAPTER 6: CONCLUSION AND RECOMMENDATIONS ......................................................

LIST OF APPENDICES ................................................................................................................43

Appendix A: Institutional Review Board Documents ......................................................43

A-1: IRB Approval Letter ......................................................................................44

A-2: CITI Completion Certificate ..........................................................................46

Appendix B: Survey Instruments .......................................................................................48

B-1: BRFSS Questions ..........................................................................................49

B-2: BRFSS Variable Codes ..................................................................................53

weakness, neuropathy, disease progression, nutrition status, polypharmacy, and comorbidities

(Lopez-Soto et al., 2015).

include poor glycemic control (hypoglycemia and hyperglycemia), diabetic peripheral

diabetes population, thereby decreasing fall risk.

of retinopathy (CDC, 2015).

Glycemic control can be monitored and improved by participating in diabetes-related

patients with CKD. Thus, determining if there is an association between participation in

population diagnosed with CKD and T2DM is warranted.

known, however, if participating in diabetes-related health behaviors, or if the number of health-

BRFSS data to examine the relationship between participation in diabetes-related health