Pounds off with empowerment (POWER): a clinical trial of weight management strategies for black and white adults with diabetes who live in medically underserved rural communities

Applying RE-AIM to the Evaluation of FUEL Your Life

Weight management programs are becoming increasingly common in workplace settings; however, few target middle-aged men. The purpose of this article is to describe the process evaluation of a worksite translation of the Diabetes Prevention Program in a predominantly middle-aged male population. The translated program, FUEL Your Life, was largely self-directed, with support from peer health coaches and occupational health nurses. The RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework was used to examine the factors that influenced program implementation using data from an environmental assessment, participant surveys, peer health coach surveys, and occupational health nurse interviews. An overwhelming majority of the employees who enrolled in the study were overweight or obese (92%). Overall, the program was effective for weight maintenance; those with higher levels of participation and engagement had better weight loss outcomes. The peer health coach and family elements of the intervention were underused. The program was successful in reaching the intended population; however, the program had limited success in engaging this population. Not surprisingly, weight loss was a function of participant engagement and participation. Increasing participant engagement and participation is important to the success of weight management interventions translated to the worksite setting. Garnering buy-in and support from management can serve to increase the perceived importance of weight management in worksites. With management support, weight management protocols could be integrated as a component of the mandatory safety and health assessments already in place, fostering promotion of healthy weight in the workforce.

Outcomes of a church-based diabetes prevention program delivered by peers: a feasibility study

PURPOSE

This purpose of this study was to investigate the feasibility and potential health impact of a church-based diabetes prevention program delivered by peers.

METHODS

Thirteen at-risk African American adults were recruited to a peer-led diabetes prevention program adapted from the National Diabetes Education Program's Power to Prevent curriculum. The program consisted of 6 core education sessions followed by 6 biweekly telephone support calls. Components of feasibility examined included recruitment, attendance, and retention. Baseline, 8-week, and 20-week assessments measured clinical outcomes (percentage body weight change, waist circumference, lipid panel, blood pressure) and lifestyle behaviors (eg, physical activity and diet).

RESULTS

Of the 13 participants enrolled at baseline, 11 completed the intervention. Mean attendance across 6 core sessions was 5.2 classes (87%). At 8 weeks, significant improvements were found for physical activity (P = .031), waist circumference (P = .049), serum cholesterol (P = .036), systolic blood pressure (P = .013), and fat intake (P = .006). At 20 weeks, not only did participants sustain the improvements made following the core intervention, but they also demonstrated additional improvements for HDL (P = .002) and diastolic blood pressure (P = .004).

CONCLUSION

Findings suggest that it is feasible to conduct a peer-led diabetes prevention program in a church-based setting that has a potentially positive impact on health-related outcomes.

Diabetes and obesity: new data on mechanisms and intervention trials

The increase in obesity and Type 2 diabetes on a global scale has heightened interest in how to counteract this epidemic. Improved lifestyle is a fundamental approach but other remedies, such as drugs and surgery, have also been tested. One question requiring further research is what happens after weight loss. Ongoing studies will try to address this question, including the Swedish Obese Subjects (SOS) study, and the Look Action for HEAlth in Diabetes (Look AHEAD) trial in the USA, the latter looking at obese Type 2 diabetes patients.

Improving diabetes care in rural areas: a systematic review and meta-analysis of quality improvement interventions in OECD countries

BACKGROUND AND AIMS

Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.

METHODS

We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.

RESULTS

Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).

CONCLUSIONS

This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.

Translation of a behavioral weight loss intervention for mid-life, low-income women in local health departments

OBJECTIVE

To translate a behavioral weight loss intervention for mid-life, low-income women in real world settings.

DESIGN AND METHODS

In this pragmatic clinical trial, we randomly selected six North Carolina county health departments and trained their current staff to deliver a 16-session evidence-based behavioral weight loss intervention (special intervention, SI). SI weight loss outcomes were compared to a delayed intervention (DI) control group.

RESULTS

Of 432 women expressing interest, 189 completed baseline measures and were randomized within health departments to SI (N = 126) or DI (N = 63). At baseline, average age was 51 years, 53% were African American, mean weight was 100 kg, and BMI averaged 37 kg/m2 . A total of 96 (76%) SI and 55 (87%) DI participants returned for 5-month follow-up measures. The crude weight change was -3.1 kg in the SI and -0.4 kg in the DI group, for a difference of 2.8 kg (95% CI 1.4 to 4.1, p = 0.0001). Diet quality and physical activity improved significantly more in the SI group, and estimated intervention costs were $327 per participant.

CONCLUSION

This pragmatic short-term weight loss intervention targeted to low-income mid-life women yielded meaningful weight loss when translated to the county health department setting.

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

OBJECTIVE

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

METHODS

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

RESULTS

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

CONCLUSION

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

PRACTICAL IMPLICATIONS

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

Interventions for improving nutrition and physical activity behaviors in adult African American populations: a systematic review, January 2000 through December 2011

Introduction

The incidence of preventable chronic diseases is disproportionally high among African Americans and could be reduced through diet and physical activity interventions. Our objective was to systematically review the literature on clinical outcomes of diet and physical activity interventions conducted among adult African American populations in the United States.

Methods

We used the Preferred Reporting Items for Systematic Review and Meta Analysis construct in our review. We searched Medline (PubMed and Ovid), Cochrane, and DARE databases and restricted our search to articles published in English from January 2000 through December 2011. We included studies of educational interventions with clinically relevant outcomes and excluded studies that dealt with nonadult populations or populations with pre-existing catabolic or other complicated disorders, that did not focus on African Americans, that provided no quantitative baseline or follow-up data, or that included no diet or physical activity education or intervention. We report retention and attendance rates, study setting, program sustainability, behavior theory, and education components.

Results

Nineteen studies were eligible for closer analysis. These studies described interventions for improving diet or physical activity as indicators of health promotion and disease prevention and that reported significant improvement in clinical outcomes.

Conclusion

Our review suggests that nutrition and physical activity educational interventions can be successful in improving clinically relevant outcomes among African Americans in the United States. Further research is needed to study the cost and sustainability of lifestyle interventions. Further studies should also include serum biochemical parameters to substantiate more specifically the effect of interventions on preventing chronic disease and reducing its incidence and prevalence.

Intensive weight loss intervention in older individuals: results from the Action for Health in Diabetes Type 2 diabetes mellitus trial

OBJECTIVES

To compare the effects of 4 years of intensive lifestyle intervention on weight, fitness, and cardiovascular disease risk factors in older and younger individuals.

DESIGN

Randomized controlled clinical trial.

SETTING

Sixteen U.S. clinical sites.

PARTICIPANTS

Individuals with type 2 diabetes mellitus: 1,053 aged 65 to 76 and 4,092 aged 45 to 64.

INTERVENTIONS

An intensive behavioral intervention designed to promote and maintain weight loss through caloric restriction and increased physical activity was compared with diabetes mellitus support and education.

MEASUREMENTS

Standardized assessments of weight, fitness (based on graded exercise testing), and cardiovascular disease risk factors.

RESULTS

Over 4 years, older individuals had greater intervention-related mean weight losses (6.2%) than younger participants (5.1%; interaction P = .006) and comparable relative mean increases in fitness (0.56 vs 0.53 metabolic equivalents; interaction P = .72). These benefits were seen consistently across subgroups of older adults formed according to many demographic and health factors. Of a panel of age-related health conditions, only self-reported worsening vision was associated with poorer intervention-related weight loss in older individuals. The intensive lifestyle intervention produced mean increases in high-density lipoprotein cholesterol (2.03 mg/dL; P < .001) and decreases in glycated hemoglobin (0.21%; P < .001) and waist circumference (3.52 cm; P < .001) over 4 years that were at least as large in older as in younger individuals.

CONCLUSION

Intensive lifestyle intervention targeting weight loss and increased physical activity is effective in overweight and obese older individuals to produce sustained weight loss and improvements in fitness and cardiovascular risk factors.

Hope and the use of behavioural strategies related to diet and physical activity

BACKGROUND

The use of specific behavioural strategies such as portion control or meal planning is important for weight management, although studies of determinants of strategy use are limited. The present study explored the concept of hope and its association with the use of behavioural strategies.

METHODS

Data were obtained from a larger cross-sectional survey conducted in 2009 among 178 patients of a city-county sponsored primary care clinic in the Midwest region of the USA. Hope was measured with subscales representing 'agency' (determination in meeting goals) and 'pathways' (perception of ways to meet goals) and a total score. Diet and physical activity-related strategies were captured with five and two scales, respectively.

RESULTS

Analyses showed a significant (P < 0.05) association between both the total hope score and the agency subscale and all behavioural strategy measures. The pathways subscale was significantly associated with physical activity-related strategies, and a subset of diet-related strategies.

CONCLUSIONS

The hope measures should be explored further in the context of a weight loss intervention to determine their predictive association with the use of specific behavioural strategies.

Development of a rural health framework: implications for program service planning and delivery

PURPOSE

To describe the development and application of an evidence-based rural health framework to guide rural health program, policy and service planning.

METHODS

A literature review of rural health programs, focusing on health promotion, chronic disease prevention and population health, was conducted using several bibliographic databases.

FINDINGS

Thirty papers met the criteria for review, describing chronic disease interventions and public health policies in rural settings. Twenty-one papers demonstrated effective intervention programs and highlighted potential good practices for rural health programs, which were used to define key elements of a rural health framework.

CONCLUSIONS

The rural health framework was applied to an influenza immunization program to demonstrate its utility in assisting public health providers to increase uptake of the vaccine. This rural health framework provides an opportunity for program planners to reflect on the key issues facing rural communities to ensure the development of policies and strategies that will prudently and effectively meet population health needs.

Weight loss maintenance in African American women: a systematic review of the behavioral lifestyle intervention literature

We performed a systematic review of the behavioral lifestyle intervention trials conducted in the United States published between 1990 and 2011 that included a maintenance phase of at least six months, to identify intervention features that promote weight loss maintenance in African American women. Seventeen studies met the inclusion criteria. Generally, African American women lost less weight during the intensive weight loss phase and maintained a lower % of their weight loss compared to Caucasian women. The majority of studies failed to describe the specific strategies used in the delivery of the maintenance intervention, adherence to those strategies, and did not incorporate a maintenance phase process evaluation making it difficult to identify intervention characteristics associated with better weight loss maintenance. However, the inclusion of cultural adaptations, particularly in studies with a mixed ethnicity/race sample, resulted in less % weight regain for African American women. Studies with a formal maintenance intervention and weight management as the primary intervention focus reported more positive weight maintenance outcomes for African American women. Nonetheless, our results present both the difficulty in weight loss and maintenance experienced by African American women in behavioral lifestyle interventions.

Behavioral interventions to improve glycemic control in African Americans with type 2 diabetes: a systematic review

OBJECTIVE

The use of behavioral interventions has been shown to improve glycemic control, however, the effectiveness of different behavioral interventions in one of the most high risk populations, African Americans, remains unclear. Our systematic review identified and examined findings of published behavioral interventions targeted at African Americans to improve glycemic control. The goal of our study was to distinguish which interventions were effective and identify areas for future research.

DESIGN

Medline, PsychInfo, and CINAHL were searched for articles published from January 2000 through January 2012 using a reproducible strategy. Study eligibility criteria included interventions aimed at changing behavior in adult African Americans with type 2 diabetes and measured glycemic control.

RESULTS

Ten studies met the inclusion criteria, of which five showed a statistically significant change in HbA1c in the intervention group when compared to the control group. Summary information and characteristics of the reviewed studies are provided.

CONCLUSIONS

Characteristics of successful interventions included using problem solving with the patient, culturally tailoring the intervention, and using a nurse educator. Limitations include the limited number of intervention studies available using glycemic control as the outcome measure. Clinical trials are needed to determine how best to tailor interventions to this largely underserved population and studies should describe details of cultural tailoring to provide information for future programs.

Effectiveness of weight loss interventions for obese older adults

OBJECTIVE

The consequences of obesity among older adults are significant, yet few obesity interventions target this group. Unfamiliarity with weight loss intervention effectiveness and concerns that weight loss negatively affects older adults may be inhibiting targeting this group. This paper reviews the evidence on intentional weight loss and effective weight loss interventions for obese older adults to help dispel concerns and guide health promotion practice.

DATA SOURCE

PubMed articles.

STUDY INCLUSION AND EXCLUSION CRITERIA

Randomized controlled trials examining behavioral and pharmaceutical weight loss strategies with 1-year follow-up targeting obese (body mass index ≥ 30) older adults (mean age ≥ 60 years), and studies with quasi-experimental designs examining surgical weight loss strategies targeting older adults were examined.

DATA EXTRACTION

Abstracts were reviewed for study objective relevancy, with relevant articles extracted and reviewed.

DATA SYNTHESIS

Data were inserted into an analysis matrix.

RESULTS

Evidence indicates behavioral strategies are effective in producing significant (all p < .05) weight loss without significant risk to obese older adults, but effectiveness evidence for surgical and pharmaceutical strategies for obese older adults is lacking, primarily because this group has not been targeted in trials or analyses did not isolate this group.

CONCLUSION

These findings support the promotion of intentional weight loss among obese older adults and provide guidance to health promotion practitioners on effective weight loss interventions to use with this group.

Worksite translation of the Diabetes Prevention Program: formative research and pilot study results from FUEL Your Life

This article summarizes formative research and pilot study findings from a workplace translation of the Diabetes Prevention Program (DPP). The overarching goal was to devise a relatively straightforward weight management intervention suitable for use in a wide array of work settings. This project was conducted in conjunction with Union Pacific Railroad at one of their locomotive maintenance facilities. Participating employees were predominately male and middle-aged. Formative data were collected through stakeholder interviews, focus groups, and direct observation of the work environment. These results were used to adapt the DPP into a largely self-directed intervention augmented by peer health coaches and the on-site nurse. A small pilot test of the adapted program (n = 67) produced modest but statistically significant weight reductions at both 6 (core intervention period) and 12 months (maintenance period). These results are discussed in terms of the original DPP and other DPP translation studies.

Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis

BACKGROUND

Diabetes self-management education (DSME) can be delivered in many forms. Group based DSME is widespread due to being a cheaper method and the added advantages of having patient meet and discuss with each other. assess effects of group-based DSME compared to routine treatment on clinical, lifestyle and psychosocial outcomes in type-2 diabetes patients.

METHODS

A systematic review with meta-analysis. Computerised bibliographic database were searched up to January 2008 for randomised controlled trials evaluating group-based DSME for adult type-2 diabetics versus routine treatment where the intervention had at least one session and =/>6 months follow-up. At least two reviewers independently extracted data and assessed study quality.

RESULTS

In total 21 studies (26 publications, 2833 participants) were included. Of all the participants 4 out of 10 were male, baseline age was 60 years, BMI 31.6, HbA1c 8.23%, diabetes duration 8 years and 82% used medication. For the main clinical outcomes, HbA1c was significantly reduced at 6 months (0.44% points; P=0.0006, 13 studies, 1883 participants), 12 months (0.46% points; P=0.001, 11 studies, 1503 participants) and 2 years (0.87% points; P<0.00001, 3 studies, 397 participants) and fasting blood glucose levels were also significantly reduced at 12 months (1.26 mmol/l; P<0.00001, 5 studies, 690 participants) but not at 6 months. For the main lifestyle outcomes, diabetes knowledge was improved significantly at 6 months (SMD 0.83; P=0.00001, 6 studies, 768 participants), 12 months (SMD 0.85; P<0.00001, 5 studies, 955 participants) and 2 years (SMD 1.59; P=0.03, 2 studies, 355 participants) and self-management skills also improved significantly at 6 months (SMD 0.55; P=0.01, 4 studies, 534 participants). For the main psychosocial outcomes, there were significant improvement for empowerment/self-efficacy (SMD 0.28, P=0.01, 2 studies, 326 participants) after 6 months. For quality of life no conclusion could be drawn due to high heterogeneity. For the secondary outcomes there were significant improvements in patient satisfaction and body weight at 12 months for the intervention group. There were no differences between the groups in mortality rate, body mass index, blood pressure and lipid profile.

CONCLUSIONS

Group-based DSME in people with type 2 diabetes results in improvements in clinical, lifestyle and psychosocial outcomes.

Effects of food-related interventions for African American women with type 2 diabetes

PURPOSE

The purpose of this systematic review is to synthesize research that tested culturally competent food-related interventions designed for African American women with type 2 diabetes, to review the current state of the literature and suggest recommendations for future research. Many African American women with type 2 diabetes are challenged to change their culturally rooted food habits to achieve diabetes control. Diabetes educators and clinicians who work with African American women need knowledge of effective interventions to assist their clients.

METHODS

Online databases and research articles' reference lists were searched for relevant studies published from 1989 to 2010 that tested culturally competent type 2 diabetes management interventions for African American women, that included at least 1 educational session on diet or nutrition, and that addressed a physiologic outcome, such as glycosylated hemoglobin or fasting blood glucose.

RESULTS

Fifteen studies met the inclusion criteria for this review. Among them, 64% to 100% of the participants were African Americans, and 65% to 100% were women. Six studies showed significant improvements in food practices, and 8 showed significant improvements in glycemic control as a result of the interventions.

CONCLUSIONS

Few studies focused solely on helping African American women make culturally relevant dietary changes to control type 2 diabetes. Most interventions addressed food habits as one of many components for diabetes control, perhaps overwhelming research participants with large amounts of varied information. Targeted interventions are recommended that focus on dietary changes as the foundation for diabetes self-management education for African American women.

Weight management by phone conference call: a comparison with a traditional face-to-face clinic. Rationale and design for a randomized equivalence trial

State-of-the-art treatment for weight management consists of a behavioral intervention to facilitate decreased energy intake and increased physical activity. These interventions are typically delivered face-to-face (FTF) by a health educator to a small group of participants. There are numerous barriers to participation in FTF clinics including availability, scheduling, the expense and time required to travel to the clinic site, and possible need for dependent care. Weight management clinics delivered by conference call have the potential to diminish or eliminate these barriers. The conference call approach may also reduce burden on providers, who could conduct clinic groups from almost any location without the expenses associated with maintaining FTF clinic space. A randomized trial will be conducted in 395 overweight/obese adults (BMI 25-39.9 kg/m(2)) to determine if weight loss (6 months) and weight maintenance (12 months) are equivalent between weight management interventions utilizing behavioral strategies and pre-packaged meals delivered by either a conference call or the traditional FTF approach. The primary outcome, body weight, will be assessed at baseline, 6, 12 and 18 months. Secondary outcomes including waist circumference, energy and macronutrient intake, and physical activity and will be assessed on the same schedule. In addition, a cost analysis and extensive process evaluation will be completed.

One-year results of the Think Health! study of weight management in primary care practices

The Think Health! study evaluated a behavioral weight loss program adapted from the Diabetes Prevention Program (DPP) lifestyle intervention to assist primary care providers (PCPs) and auxiliary staff acting as lifestyle coaches (LCs) in offering weight loss counseling to their patients. In a randomized trial conducted at five clinical sites, study participants were randomly assigned in a 1:1 ratio within each site to either "Basic Plus" (n = 137), which offered PCP counseling every 4 months plus monthly LC visits during the first year of treatment, or "Basic" (n = 124), which offered only PCP counseling every 4 months. Participants were primarily (84%) female, 65% African American, 16% Hispanic American, and 19% white. In the 72% of participants in each treatment group with a 12-month weight measurement, mean (95% CI) 1-year weight changes (kg) were -1.61 (-2.68, -0.53) in Basic Plus and -0.62 (-1.45, 0.20) in Basic (difference: 0.98 (-0.36, 2.33); P = 0.15). Results were similar in model-based estimates using all available weight data for randomized participants, adjusting for potential confounders. More Basic Plus (22.5%) than Basic (10.2%) participants lost ≥ 5% of their baseline weight (P = 0.022). In a descriptive, nonrandomized analysis that also considered incomplete visit attendance, mean weight change was -3.3 kg in Basic Plus participants who attended ≥ 5 LC visits vs. + 0.53 kg in those attending <5 LC visits. We conclude that the Basic Plus approach of moderate-intensity counseling by PCPs and their staff can facilitate modest weight loss, with clinically significant weight loss in high program attenders.

Training peers to deliver a church-based diabetes prevention program

PURPOSE

The purpose of this study was to examine the feasibility and acceptability of training peers to function as lifestyle coaches and to deliver a church-based lifestyle modification program.

METHODS

We recruited 6 African-American adults to participate in an 8-hour peer lifestyle coach (PLC) training program followed by a subsequent 2-hour booster session. The PLC training program addressed several key areas, including: (1) developing empowerment-based facilitation, active listening, and behavior change skills; (2) learning self-management strategies (eg, reading food labels, counting calories); (3) practicing session delivery; and (4) interpreting clinical lab results. Training evaluation was conducted retrospectively (immediately following the delivery of the diabetes prevention intervention rather than after the 8-hour training session) and measured program satisfaction and efficacy from the perspective of participants.

RESULTS

Peer lifestyle coaches' confidence levels for performing core skills (eg, asking open-ended questions, 5-step behavioral goal-setting process) and advanced skills (eg, addressing resistance, discussing sensitive topics) were uniformly high. Similarly, PLCs were very satisfied with the length of training, balance between content and skills development, and preparation for leading group- and individual-based support activities.

CONCLUSIONS

Findings suggest that it is feasible to customize a PLC training program that is acceptable to participants and that equips participants with the knowledge and skills to facilitate a church-based diabetes prevention intervention.

Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes

BACKGROUND

Few studies have explored the association between neighborhood characteristics and adherence to diabetes self-management behaviors, and none have examined the influence of neighborhood safety on adherence to treatment regimens among patients with diabetes.

OBJECTIVE

To assess whether neighborhood safety is associated with self-reports of technical quality of care and with nonadherence to diabetes treatment regimens.

DESIGN

A cross-sectional analysis of a population-based sample of California adults responding to the 2007 California Health Interview Survey. Multivariable logistic regression models were used to examine the association of self-reported neighborhood safety with technical quality of care and treatment nonadherence, adjusted for sociodemographic characteristics, barriers to access to care, and health status.

PARTICIPANTS

Adults with type 2 diabetes currently receiving medical treatment.

MAIN MEASURES

Patient-reported neighborhood safety, performance of recommended processes of care by provider, treatment nonadherence (patient delays in filling prescriptions and obtaining needed medical care).

KEY RESULTS

Self-reported neighborhood safety was not associated with process measures of technical quality of care, but was associated with treatment nonadherence. Specifically, compared to those who report living in a safe neighborhood, a higher proportion of patients living in unsafe neighborhoods reported delays in filling a prescription for any reason (21.9% vs. 12.8%, aOR = 1.69, 95%CI 1.19, 2.40) and delays in filling a prescription due to cost (12.2% vs. 6.8%, aOR = 1.63, 95%CI 1.02, 2.62).

CONCLUSIONS

Contextual factors, such as neighborhood safety, may contribute to treatment nonadherence in daily life, even when the technical quality of care delivered in the clinic is not diminished.

Medication intensification in diabetes in rural primary care: a cluster-randomised effectiveness trial

OBJECTIVE

To determine the effectiveness of a provider-based intervention to improve medication intensification among patients with diabetes.

DESIGN

Effectiveness cluster-randomised trial. Baseline and follow-up cross-sections of diabetes physicians' patients.

SETTING

Eleven U.S. Southeastern states, 2006-2008.

PARTICIPANTS

205 Rural primary care physicians, 95 completed the study.

INTERVENTION

Multicomponent interactive intervention including web-based continuing medical education (CME), performance feedback and quality improvement tools.

PRIMARY OUTCOME MEASURES

Medication intensification, a dose increase of an existing medication or the addition of a new class of medication for glucose, blood pressure and lipids control on any of the three most recent office visits.

RESULTS

Of 364 physicians attempting to register, 102 were randomised to the intervention and 103 to the control arms; 95 physicians (intervention, n=48; control, n=47) provided data on their 1182 of their patients at baseline (intervention, n=715; control, n=467) and 945 patients at follow-up (intervention, n=479; control, n=466). For A1c control, medication intensification increased in both groups (intervention, pre 26.4% vs post 32.6%, p=0.022; control, pre 24.8% vs post 31.1%, p=0.033) (intervention, adjusted OR (AOR) 1.37; 95% CI 1.06 to 1.76; control, AOR 1.41 (95% CI 1.06 to 1.89)); however, we observed no incremental benefit solely due to the intervention (group-by-time interaction, p=0.948). Among patients with the worst glucose control (A1c >9%), intensification increased in both groups (intervention, pre 34.8% vs post 62.5%, p=0.002; control, pre 35.7% vs post 61.4%, p=0.008).

CONCLUSIONS

A wide-reach, low-intensity, web-based interactive multicomponent intervention had no significant incremental effect on medication intensification for control of glucose, blood pressure or lipids for patients with diabetes of physicians practising in the rural Southeastern USA.

TRIAL REGISTRATION

NCT00403091.

Successful long-term weight loss maintenance in a rural population

BACKGROUND

Few investigations of successful long-term weight loss beyond two years have been conducted, and none has examined weight changes in medically underserved rural populations of older adults. The purpose of this study was to assess long-term weight loss maintenance 3.5 years after the completion of an initial six-month lifestyle intervention for obesity among women aged 50-75 years residing in rural communities.

METHODS

One hundred and ten obese women with a mean (± standard deviation) age of 60.08 ± 6.17 years and mean body mass index of 36.76 ± 5.10 kg/m(2) completed an in-person assessment during which their weight and adherence to behavioral weight management strategies were evaluated.

RESULTS

Participants showed a mean weight reduction of 10.17% ± 5.0% during the initial six- month intervention and regained 6.95% ± 9.44% from the completion of treatment to follow-up assessment 3.5 years later. A substantial proportion of participants (41.80%) were able to maintain weight reductions of 5% or greater from baseline to follow-up. "Successful" participants (those who maintained losses of 5% or greater at follow-up) reported weighing themselves, self-monitoring their intake and calories, planning meals in advance, and choosing lower calorie foods with greater frequency than "unsuccessful" participants (those who lost less than 5%).

CONCLUSION

Collectively, these findings indicate that a large proportion of participants were able to maintain clinically significant weight losses for multiple years after treatment, and that self-monitoring was a key component of successful long-term weight management.

The Lifestyle Interventions and Independence for Elders Study: design and methods

BACKGROUND

As the number of older adults in the United States rises, maintaining functional independence among older Americans has emerged as a major clinical and public health priority. Older people who lose mobility are less likely to remain in the community; demonstrate higher rates of morbidity, mortality, and hospitalizations; and experience a poorer quality of life. Several studies have shown that regular physical activity improves functional limitations and intermediate functional outcomes, but definitive evidence showing that major mobility disability can be prevented is lacking. A Phase 3 randomized controlled trial is needed to fill this evidence gap.

METHODS

The Lifestyle Interventions and Independence for Elders (LIFE) Study is a Phase 3 multicenter randomized controlled trial designed to compare a supervised moderate-intensity physical activity program with a successful aging health education program in 1,600 sedentary older persons followed for an average of 2.7 years.

RESULTS

LIFE's primary outcome is major mobility disability, defined as the inability to walk 400 m. Secondary outcomes include cognitive function, serious fall injuries, persistent mobility disability, the combined outcome of major mobility disability or death, disability in activities of daily living, and cost-effectiveness.

CONCLUSIONS

Results of this study are expected to have important public health implications for the large and growing population of older sedentary men and women.

Intentional weight loss in overweight and obese individuals and cognitive function: a systematic review and meta-analysis

High adiposity in middle age is associated with higher dementia risk. The association between weight loss and cognitive function in older adults is still controversial. A meta-analysis was undertaken to estimate the effectiveness of intentional weight loss on cognitive function in overweight and obese adults. A structured strategy was used to search randomized and non-randomized studies reporting the effect of intentional and significant weight loss on cognitive function in overweight and obese subjects. Information on study design, age, nutritional status, weight-loss strategy, weight lost and cognitive testing was extracted. A random-effect meta-analysis was conducted to obtain summary effect estimates for memory and attention-executive domains. Twelve studies met inclusion criteria. Seven were randomized trials and the remaining five included a control group. A low-order significant effect was found for an improvement in cognitive performance with weight loss in memory (effect size 0.13, 95% CI 0.00-0.26, P=0.04) and attention/executive functioning (effect size 0.14, 95% CI 0.01-0.27, P<0.001). Studies were heterogeneous in study design, sample selection, weight-loss intervention and assessment of cognitive function. Weight loss appears to be associated with low-order improvements in executive/attention functioning and memory in obese but not in overweight individuals.

Rationale, design, and sample characteristics of a practical randomized trial to assess a weight loss intervention for low-income women: the Weight-Wise II Program

Obesity is common among low-income mid-life women, yet most published weight loss studies have not focused on this population and have been highly resourced efficacy trials. Thus, practical type 2 translational studies are needed to evaluate weight loss interventions for low-income women. In this paper, we present the rationale, study design, and baseline characteristics of a type 2 translational study that evaluates both the processes and outcomes of a weight loss intervention for low-income women given at 6 county health departments in North Carolina. Key features of this study include random selection of study sites, intervention delivery by current staff at study sites, efforts to integrate the intervention with local community resources, a focus on evaluating the processes of translation using the RE-AIM framework, use of an evidence-based weight loss intervention, a detailed description of participant recruitment and representativeness, and a practical randomized trial designed to assess the effectiveness of the intervention. Of 81 health departments invited to participate, 30 (37%) were eligible and willing, and 6 were selected at random to deliver the intervention. Of 432 potential participants screened by phone, 213 (49%) were eligible and of these, 189 (89%) completed baseline measures and were randomized to receive a 5-month weight loss intervention or a delayed intervention. The mean age was 51, mean BMI 37 kg/m(2), 53% were African American, and 43% had no health insurance. The results of this study should be informative to key stakeholders interested in real world weight loss interventions for low-income mid-life women.

Moving from evidence-based medicine to evidence-based health

While evidence-based medicine (EBM) has advanced medical practice, the health care system has been inconsistent in translating EBM into improvements in health. Disparities in health and health care play out through patients' limited ability to incorporate the advances of EBM into their daily lives. Assisting patients to self-manage their chronic conditions and paying attention to unhealthy community factors could be added to EBM to create a broader paradigm of evidence-based health. A perspective of evidence-based health may encourage physicians to consider their role in upstream efforts to combat socially patterned chronic disease.

Dietary interventions for weight loss and cardiovascular risk reduction in people of African ancestry (blacks): a systematic review

Objective

To systematically review weight and cardiovascular risk reduction in blacks by diet and lifestyle changes.

Design

Randomised and non-randomised controlled trials of diet with/without lifestyle changes with duration of intervention ≥3 months, and published between January 1990 and December 2009, were searched in electronic databases including MEDLINE, EMBASE, CINAHL and CCTR (Cochrane Controlled Trials Register). Studies were included if they reported weight/BMI changes with changes in at least one of the following: systolic and diastolic blood pressure, fasting plasma lipids and glucose, and glycated haemoglobin.

Setting

Clinical, community and church-based interventions.

Subjects

Study participants were of African ancestry (blacks).

Results

Eighteen studies met the inclusion criteria. Average mean difference in weight loss was −2·66 kg, with improvements in all outcomes except total cholesterol. No significant difference was observed in outcome measures between all studies and studies that recruited only healthy participants or patients with type 2 diabetes.

Conclusions

Diet and lifestyle changes result in weight loss with improvements in cardiovascular risk factors in blacks. However, more culturally tailored programmes have been suggested to motivate and encourage blacks to participate in intervention trials.

Informed citizen and empowered citizen in health: results from an European survey

Background

The knowledge about the relationship between health-related activities on the Internet (i.e. informed citizens) and individuals' control over their own experiences of health or illness (i.e. empowered citizens) is valuable but scarce. In this paper, we investigate the correlation between four ways of using the Internet for information on health or illness and citizens attitudes and behaviours toward health professionals and health systems and establish the profile of empowered eHealth citizens in Europe.

Methods

Data was collected during April and May 2007 (N = 7022), through computer-assisted telephone interviews (CATI). Respondents from Denmark, Germany, Greece, Latvia, Norway, Poland and Portugal participated in the survey. The profiles were generated using logistic regressions and are based on: a) socio-demographic and health information, b) the level of use of health-related online services, c) the level of use of the Internet to get health information to decide whether to consult a health professional, prepare for a medical appointment and assess its outcome, and d) the impact of online health information on citizens' attitudes and behavior towards health professionals and health systems.

Results

Citizens using the Internet to decide whether to consult a health professional or to get a second opinion are likely to be frequent visitors of health sites, active participants of online health forums and recurrent buyers of medicines and other health related products online, while only infrequent epatients, visiting doctors they have never met face-to-face. Participation in online health communities seems to be related with more inquisitive and autonomous patients.

Conclusions

The profiles of empowered eHealth citizens in Europe are situational and country dependent. The number of Europeans using the Internet to get health information to help them deal with a consultation is raising and having access to online health information seems to be associated with growing number of inquisitive and self-reliant patients. Doctors are increasingly likely to experience consultations with knowledgeable and empowered patients, who will challenge them in various ways.

Cognitive-behavioral treatment of nonalcoholic Fatty liver disease: a propensity score-adjusted observational study

The effectiveness of cognitive-behavior treatment (CBT) in nonalcoholic fatty liver disease (NAFLD), largely related to overweight/obesity and considered the hepatic expression of the metabolic syndrome (MS), has so far been tested in very limited samples. In a tertiary referral center, consecutively observed NAFLD subjects were offered a CBT program aimed at weight loss and increased physical activity, based on 13 group sessions; 68 cases entered the treatment protocol, those who refused (n = 82) were given recommendations for diet and physical activity. Treatment goals (weight loss ≥7% initial body weight, normalization of liver enzymes, and improved parameters of MS) were tested by logistic regression at 6 months (all cases) and at 2 years, both on intention-to-treat and in completers (Diet, 78; CBT, 65). The results were adjusted for the propensity score of attending the CBT program, based on civil, anthropometric and clinical variables. At baseline the CBT group had a larger prevalence of obesity and more severe insulin resistance (homeostasis model assessment (HOMA)). At follow-up, CBT was associated with a higher probability of weight loss and normal liver enzymes (6-month: odds ratio (OR), 2.56; 95% confidence interval (CI), 1.15-5.69; 2-year intention-to-treat: OR, 3.57, 95% CI, 1.59-8.00), after adjustment for propensity and changes in body weight. A similar trend was observed in the outcome goals of insulin resistance and the score of MS, which were both reduced. In conclusion, subjects with NAFLD participating in a CBT program significantly improve their general and liver parameters. The beneficial effects are largely maintained at 2-year follow-up, in keeping with the lifestyle-related pathogenesis of disease.

The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults

This article reviews the evidence and nutrition practice recommendations from the American Dietetic Association's nutrition practice guidelines for type 1 and type 2 diabetes in adults. The research literature was reviewed to answer nutrition practice questions and resulted in 29 recommendations. Here, we present the recommendations and provide a comprehensive and systematic review of the evidence associated with their development. Major nutrition therapy factors reviewed are carbohydrate (intake, sucrose, non-nutritive sweeteners, glycemic index, and fiber), protein intake, cardiovascular disease, and weight management. Contributing factors to nutrition therapy reviewed are physical activity and glucose monitoring. Based on individualized nutrition therapy client/patient goals and lifestyle changes the client/patient is willing and able to make, registered dietitians can select appropriate interventions based on key recommendations that include consistency in day-to-day carbohydrate intake, adjusting insulin doses to match carbohydrate intake, substitution of sucrose-containing foods, usual protein intake, cardioprotective nutrition interventions, weight management strategies, regular physical activity, and use of self-monitored blood glucose data. The evidence is strong that medical nutrition therapy provided by registered dietitians is an effective and essential therapy in the management of diabetes.

Design, recruitment and start up of a primary care weight loss trial targeting African American and Hispanic adults

Primary care offices are critical access points for obesity treatment, but evidence for approaches that can be implemented within these settings is limited. The Think Health! (¡Vive Saludable!) Study was designed to assess the feasibility and effectiveness of a behavioral weight loss program, adapted from the Diabetes Prevention Program, for implementation in routine primary care. Recruitment of clinical sites targeted primary care practices serving African American and Hispanic adults. The randomized design compares (a) a moderate-intensity treatment consisting of primary care provider counseling plus additional counseling by an auxiliary staff member (i.e., lifestyle coach), with (b) a low-intensity, control treatment involving primary care provider counseling only. Treatment and follow up duration are 1 to 2 years. The primary outcome is weight change from baseline at 1 and 2 years post-randomization. Between November 2006 and January 2008, 14 primary care providers (13 physicians; 1 physician assistant) were recruited at five clinical sites. Patients were recruited between October 2007 and November 2008. A total of 412 patients were pre-screened, of whom 284 (68.9%) had baseline assessments and 261 were randomized, with the following characteristics: 65% African American; 16% Hispanic American; 84% female; mean (SD) age of 47.2 (11.7) years; mean (SD) BMI of 37.2(6.4) kg/m(2); 43.7% with high blood pressure; and 18.4% with diabetes. This study will provide insights into the potential utility of moderate-intensity lifestyle counseling delivered by motivated primary care clinicians and their staff. The study will have particular relevance to African Americans and women.

A study of a culturally enhanced EatRight dietary intervention in a predominately African American workplace

CONTEXT

The workplace may be an ideal venue for engaging African American women in behavioral interventions for weight reduction.

OBJECTIVE

To examine the effectiveness of a culturally enhanced EatRight dietary intervention among a group of predominately African American women in a workplace setting.

DESIGN

Crossover design study.

SETTING

Workplace.

PARTICIPANTS

A total of 39 women volunteered for this study, of whom 27 completed it.

INTERVENTION

The control period involved observation of participants for 22 weeks after receiving standard counseling on lifestyle methods to achieve a healthy weight; following the control period, participants crossed over to the 22-week intervention period. The intervention was culturally enhanced using feedback derived from formative assessment and delivered as 15 group sessions.

MAIN OUTCOME MEASURES

The primary outcome measure was the difference in weight change between the control and intervention periods; changes in waist circumference and quality of life were secondary outcomes.

RESULTS

Most participants were obese, with a mean baseline body mass index of 36 kg/m², weight of 97.9 kg, and waist circumference of 111 cm. Weight increased during the control period by 0.7 kg but decreased by 2.6 kg during the intervention (net difference = -3.4 kg, P <.001), with 30% of participants losing 5% or more of body weight. Compared to the control period, there was a significant decrease in waist circumference (-3.6 cm, P =.006) and improvement in weight-related quality of life (5.7, P =.03).

CONCLUSIONS

This pilot study demonstrated the feasibility of a culturally enhanced behavioral weight loss intervention in a predominately African American workplace setting. The workplace may be conducive for targeting African American women who are disproportionately affected by obesity.

Living Well with Diabetes: a randomized controlled trial of a telephone-delivered intervention for maintenance of weight loss, physical activity and glycaemic control in adults with type 2 diabetes

BACKGROUND

By 2025, it is estimated that approximately 1.8 million Australian adults (approximately 8.4% of the adult population) will have diabetes, with the majority having type 2 diabetes. Weight management via improved physical activity and diet is the cornerstone of type 2 diabetes management. However, the majority of weight loss trials in diabetes have evaluated short-term, intensive clinic-based interventions that, while producing short-term outcomes, have failed to address issues of maintenance and broad population reach. Telephone-delivered interventions have the potential to address these gaps.

METHODS/DESIGN

Using a two-arm randomised controlled design, this study will evaluate an 18-month, telephone-delivered, behavioural weight loss intervention focussing on physical activity, diet and behavioural therapy, versus usual care, with follow-up at 24 months. Three-hundred adult participants, aged 20-75 years, with type 2 diabetes, will be recruited from 10 general practices via electronic medical records search. The Social-Cognitive Theory driven intervention involves a six-month intensive phase (4 weekly calls and 11 fortnightly calls) and a 12-month maintenance phase (one call per month). Primary outcomes, assessed at 6, 18 and 24 months, are: weight loss, physical activity, and glycaemic control (HbA1c), with weight loss and physical activity also measured at 12 months. Incremental cost-effectiveness will also be examined. Study recruitment began in February 2009, with final data collection expected by February 2013.

DISCUSSION

This is the first study to evaluate the telephone as the primary method of delivering a behavioural weight loss intervention in type 2 diabetes. The evaluation of maintenance outcomes (6 months following the end of intervention), the use of accelerometers to objectively measure physical activity, and the inclusion of a cost-effectiveness analysis will advance the science of broad reach approaches to weight control and health behaviour change, and will build the evidence base needed to advocate for the translation of this work into population health practice.

TRIAL REGISTRATION

ACTRN12608000203358.

TeleHealth improves diabetes self-management in an underserved community: diabetes TeleCare

OBJECTIVE

To conduct a 1-year randomized clinical trial to evaluate a remote comprehensive diabetes self-management education (DSME) intervention, Diabetes TeleCare, administered by a dietitian and nurse/certified diabetes educator (CDE) in the setting of a federally qualified health center (FQHC) in rural South Carolina.

RESEARCH DESIGN AND METHODS

Participants were recruited from three member health centers of an FQHC and were randomized to either Diabetes TeleCare, a 12-month, 13-session curriculum delivered using telehealth strategies, or usual care.

RESULTS

Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin (GHb) in the Diabetes TeleCare group from baseline to 6 and 12 months (9.4 +/- 0.3, 8.3 +/- 0.3, and 8.2 +/- 0.4, respectively) compared with usual care (8.8 +/- 0.3, 8.6 +/- 0.3, and 8.6 +/- 0.3, respectively). LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care. Although not part of the original study design, GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group (9.2 +/- 0.4, 7.4 +/- 0.5, and 7.6 +/- 0.5, respectively) compared with usual care (8.7 +/- 0.4, 8.1 +/- 0.4, and 8.1 +/- 0.5, respectively) in a post hoc analysis of a subset of the randomized sample who completed a 24-month follow-up visit.

CONCLUSIONS

Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population.

Lifestyle Interventions and the Prevention and Treatment of Type 2 Diabetes

The diabetes epidemic is fueled by a societal increase in insulin resistance, caused by lifestyle factors, particularly excessive caloric intake and physical inactivity. Aging also plays a role in the increase in insulin resistance; however, even in older populations, the increase in insulin resistance appears to be attributable mainly to age-related obesity and inactivity. Insulin resistance reflects deposition of visceral, hepatic, and intramyocellular fat, while toxic messages from the adipose organ (free fatty acids, cytokines, and oxidative stress) impair insulin action to restrain glucose production in the liver and promote glucose disposal in muscle. Unexercised muscle is also insulin resistant because of intracellular sequestration of glucose transporters. These processes lead to hyperglycemia if compensatory secretion of insulin is inadequate due to decreases in pancreatic β -cell function and mass, ultimately resulting in the development of prediabetes and, later, type 2 diabetes mellitus (T2DM). Lifestyle interventions, programs that promote diabetes risk reduction and weight loss through behavior change, increased physical activity, and dietary modification, can decrease insulin resistance and prevent or delay the development of prediabetes and progression to T2DM. Lifestyle interventions are also important to improve diabetes management, particularly early in the natural history before loss of β -cell function and mass is so extensive that multidrug pharmacologic therapy is required. Effective interventions often include both an increase in physical activity (ideally, at least 150 minutes per week of moderate-to-vigorous aerobic exercise and strength training) and dietary modification to promote weight loss. major contributor to morbidity and mortality. T2DM can lead to renal dysfunction, peripheral and autonomic neuropathy, vision problems, and cardiovascular disease.2 In the United States alone, from 2005 to 2050, the prevalence of diagnosed diabetes is expected to more than double from 5.6% to 12.0%.3 In 2005 to 2006, the prevalence of prediabetes and diabetes combined was estimated to be 42.3% for Americans aged 20 years or older. The total prevalence of

Mediating the effect of self-care management intervention in type 2 diabetes: a meta-analysis of 47 randomised controlled trials

OBJECTIVE

To perform a meta-analysis assessing the effects of self-care management interventions in improving glycaemic control in type 2 diabetes by analysing the impact of different study characteristics on the effect size.

METHODS

A literature search in eight scientific databases up to November 2007 included original studies of randomised controlled trials involving adult patients diagnosed with type 2 diabetes and evaluating a self-care management intervention.

RESULTS

The 47 included studies yielded 7677 participants. The analysis showed a 0.36% (95% CI 0.21-0.51) improvement in glycaemic control in people who received self-care management treatment. In the univariate meta-regression sample size (effect size 0.42%, p=0.007) and follow-up period (effect size 0.49%, p=0.017) were identified to have significant effect on the effect size in favour of small studies and short follow-up. For type of intervention and duration of intervention there was a non-significant effect on effect size in favour of educational techniques and short interventions.

CONCLUSION

In type 2 diabetes, there are improvements in glycaemic control in people who receive self-care management treatment with a small advantage to intervention with an educational approach.

PRACTICE IMPLICATIONS

Further research on frequency and duration of intervention may provide useful information to identify the most effective regime.

State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

Nutritional intervention programme among a Japanese-Brazilian community: procedures and results according to gender

Objective

To describe the results of a nutritional intervention programme among Japanese-Brazilians according to gender.

Design

A non-controlled experimental study.

Setting

The research included three points of clinical, nutritional and physical activity evaluation: at baseline (in 2005), after the first year and at the end of the second year (in 2007). The paired Student t test and multiple linear regression analysis were used to evaluate changes in the subjects’ profile (clinical, nutritional and physical activity variables).

Subjects

Japanese-Brazilians (n 575) of both genders, aged over 30 years.

Results

We verified statistically significant reductions in body weight (0·9 kg), waist circumference (2·9 cm), blood pressure, fasting blood glucose (>3 mg/dl) and total cholesterol (>20 mg/dl) and its fractions, in both genders. We also found reductions in intake of energy (among men), protein (among women) and fat (both genders) and increases in intake of total fibre (among women) and carbohydrate (among men).

Conclusions

The intervention programme indicated meaningful benefits for the intervention subjects, with changes in their habits that led to a ‘healthier’ lifestyle positively impacting their nutritional and metabolic profile.

Self-management support in "real-world" settings: an empowerment-based intervention

OBJECTIVE

This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period.

METHODS

This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants' self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting.

RESULTS

The control period found significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), following a healthy diet (p<0.01), and monitoring blood glucose (p<0.01). The intervention period found significant additional improvements for A1C (p<0.001), weight (p<0.05), BMI (p<0.05), and LDL (p<0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C (p<0.01).

CONCLUSION

Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.

PRACTICAL IMPLICATIONS

Incorporating empowerment principles in DSMS interventions may be useful for supporting patients' self-management efforts in "real-world" settings.

Screening, referral, and participation in a weight management program implemented in five CHCs

Community health centers have the potential to lessen obesity. We conducted a retrospective evaluation of a quality improvement program that included electronic body mass index (BMI) screening with provider referral to an in-clinic lifestyle behavior change counselor with weekly nutrition and exercise classes. There were 26,661 adult patients seen across five community health centers operating the weight management program. There were 23,593 (88%) adult patients screened, and 12,487 (53%) of these patients were overweight or obese (BMI >or=25). Forty percent received a provider referral, 15.6% had program contact, and 2.1% had more than 10 program contacts. A mean weight loss of seven pounds was observed among those patients with more than 10 program contacts. No significant weight change was observed in patients with less contact. Achieving public health impact from guideline recommended approaches to CHC-based weight management will require considerable improvement in patient and provider participation.

Ke 'Ano Ola: Moloka'i's community-based healthy lifestyle modification program

We evaluated a community-based 12-week healthy lifestyle program in Moloka'i, HI, called Ke 'Ano Ola, which was developed to decrease chronic disease risk through health education emphasizing weight loss, exercise, and risk factor reduction. Program leaders' strong commitment and positive role modeling, along with social and group support and community involvement, were key elements. A pre-post evaluation of weight, blood pressure, total cholesterol, and blood sugar showed significant improvements for weight (mean change [Delta] = -7.4 lbs; P < .001), systolic blood pressure (Delta = -3.8 mm Hg; P = .027), diastolic blood pressure (Delta = -4.6 mm Hg; P < .001), and total cholesterol (Delta = -9.7 mg/dL; P < .001). Attrition was low, with 89% of participants attending all 12 sessions. Our findings show that lifestyle improvements in a predominantly Native Hawaiian community are achievable in a support group setting.

Obesity management interventions: a review of the evidence

The burden of disease associated with the obesity epidemic shortens lives, and prevalence is accelerating. As with other chronic diseases, improved outcomes are associated with effective self-management of obesity across the life span. The disease of obesity, then, fits squarely within the disease management and chronic care models. This article reviews selected interventions, described in peer-reviewed literature, designed to achieve significant weight loss for individuals identified as overweight or obese. The study objective is to provide an overview of the full range of methods and models for weight loss, including some available without medical supervision. The intended audience includes individuals and organizations with an expressed interest in disease management and the chronic care models. Our review identified promising lines of investigation for future research that span diverse medical disciplines applied to obesity. The quality of the studies included in our review was uneven, and compromises the current evidence for effectiveness and efficacy. Generally, our results showed that combination approaches-surgical or pharmacologic, combined with a behavioral intervention-were most likely to be effective.