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Social Determinants of Health

The Case of Winter Doldrums

Bui, Simonetti, Benson, Malek and Anderson
Published 05/17/2015

A 45-year-old man with previously well-controlled type 2 diabetes mellitus and hypertension is evaluated for recent elevation in blood sugars. Over the past 6 months, his hemoglobin A1C has increased and you also note several elevated blood pressure recordings in his daily log. He readily admits that his medication adherence has worsened, and he has been more reliant on fast food. He attributes these changes to recent financial strain and an inability to afford his monthly medications and fresh food. He has less income from landscaping work in the winter months, and his utility bills have dramatically increased, largely due to costs of heating his poorly insulated home. On physical examination, his blood pressure is 149/92mmHg and his BMI is 27. His A1C is 8.2%.

In addition to ensuring that he is prescribed generic medications that are available on the local pharmacy’s $4 prescription list, which of the following options might help your patient improve medication adherence and access to healthier food?

  1. Refer him to a dietician and/or diabetes educator

  2. Refer him to the food bank and department of public welfare to apply for cash assistance and/or Medicaid

  3. Referral to a weatherization assistance program to reduce energy bills thereby freeing up money for food and prescriptions

  4. Verify that his blood pressure cuff is calibrated correctly

  5. Motivational interviewing to improve his medication and diet adherence.

Fast fact: Weatherization assistance programs include a wide variety of measures to improve energy efficiency and reduce utility costs, including window replacement, heating and cooling system inspection and repair, and repair or replacement of low efficiency electrical appliances. Weatherization and energy efficient programs could provide health benefits for low-income families who suffer disproportionally from house fire, injuries and asthma.  Patients may also be referred to a Low-Income Home Energy Assistance Program to help with utility costs during the winter months.


Where to apply for weatherization assistance. U.S. Office of Energy & Renewable Energy. Available at:

Low-Income Home Energy Assistance Program (LIHEAP). U.S. Office of Energy & Renewable Energy. Available at:

Salls AM, et al. Rapid health assessment impact: weatherization plus health in Connecticut. 2013