Retention Among Participants in the National Diabetes Prevention Program Lifestyle Change Program, 2012-2017

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

BACKGROUND

The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions.

OBJECTIVE

We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development.

DESIGN

Retrospective cohort study using linked claims and electronic health record data.

PARTICIPANTS

We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use.

MAIN MEASURES

We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression.

RESULTS

Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m². In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals.

CONCLUSIONS

Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

Differences in Weight Loss by Race and Ethnicity in the PRIDE Trial: a Qualitative Analysis of Participant Perspectives

BACKGROUND

Many Diabetes Prevention Program (DPP) translation efforts have been less effective for underresourced populations. In the cluster-randomized Prediabetes Informed Decision and Education (PRIDE) trial, which evaluated a shared decision-making (SDM) intervention for diabetes prevention, Hispanic and non-Hispanic Black participants lost less weight than non-Hispanic White participants at 12-month follow-up.

OBJECTIVE

To explore perspectives about weight loss from PRIDE participants of different racial and ethnic groups.

PARTICIPANTS

Sample of participants with prediabetes who were randomized to the PRIDE intervention arm (n=24).

APPROACH

We conducted semi-structured interviews within three groups stratified by DPP participation and % weight loss at 12 months: (DPP+/WL+, enrolled in DPP and lost >5% weight; DPP+/WL-, enrolled in DPP and lost <3% weight; DPP-/WL-, did not enroll in DPP and lost <3% weight). Each group was further subdivided on race and ethnicity (non-Hispanic Black (NHB), non-Hispanic White (NHW), Hispanic). Interviews were conducted on Zoom and transcripts were coded and analyzed with Dedoose.

KEY RESULTS

Compared to NHW participants, Hispanic and NHB participants more often endorsed weight loss barriers of limited time to make lifestyle changes due to long work and commute hours, inconvenient DPP class locations and offerings, and limited disposable income for extra weight loss activities. Conversely, facilitators of weight loss regardless of race and ethnicity included retirement or having flexible work schedules; being able to identify convenient DPP classes; having a strong, positive support system; and purchasing supplementary resources to support lifestyle change (e.g., gym memberships, one-on-one activity classes).

CONCLUSIONS

We found that NHB and Hispanic SDM participants report certain barriers to weight loss more commonly than NHW participants, particularly barriers related to limited disposable income and/or time constraints. Our findings suggest that increased lifestyle change support and flexible program delivery options may be needed to ensure equity in DPP reach, participant engagement, and outcomes.

Effectiveness of Incentives for Improving Diabetes-Related Health Indicators in Chronic Disease Lifestyle Modification Programs: a Systematic Review and Meta-Analysis

INTRODUCTION

We examined the effectiveness of providing incentives to participants in lifestyle modification programs to improve diabetes-related health indicators: body weight, body mass index (BMI), blood pressure, cholesterol, and hemoglobin A1C (HbA1C). We also examined the potential effect of 4 different incentive domains (ie, type, monetary value, attainment certainty, and schedule) on those indicators.

METHODS

We searched Medline, Embase, PsycINFO, and Cochrane Library to identify relevant studies published from January 2008 through August 2021. We used a random-effects model to pool study results and examine between-study heterogeneity by using the I2 statistic and the Cochran Q test. We also conducted moderator analyses by using a mixed-effects model to examine differences between subgroups of incentive domains (eg, incentive type [cash vs other types]).

RESULTS

Our search yielded 10,965 articles, of which 19 randomized controlled trials met our selection criteria. The random-effects model revealed that, relative to the control group, the incentive group had significant reductions in weight (-1.85kg; 95% CI, -2.40 to -1.29; P < .001), BMI (-0.47kg/m2; 95% CI, -0.71 to -0.22; P < .001), and both systolic blood pressure (-2.59 mm HG; 95% CI, -4.98 to -0.20; P = .03) and diastolic blood pressure (-2.62 mm Hg; 95% CI, -4.61 to -0.64; P = .01). A reduction in cholesterol level was noted but was not significant (-2.81 mg/dL; 95% CI, -8.89 to -3.28; P = .37). One study found a significant reduction in hemoglobin A1c (-0.17%; 95% CI, -0.30% to -0.05%; P < .05). The moderator analyses showed that the incentive effect did not vary significantly between the subgroups of the incentive domains, except on weight loss for the attainment certainty domain, suggesting that a variety of incentive subgroups could be equally useful.

CONCLUSION

Providing incentives in lifestyle modification programs is a promising strategy to decrease weight, BMI, and blood pressure.

Use and Impact of Type 2 Diabetes Prevention Interventions

INTRODUCTION

RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes.

METHODS

The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program.

RESULTS

Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients.

CONCLUSIONS

Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

Risk Factors and Lifestyle Interventions

There are many nonmodifiable and modifiable risk factors for type 2 diabetes. Nonmodifiable risk factors include age, genetics, epigenetics, and social determinants of health (including education level, socioeconomic status, and noise and arsenic exposure). Modifiable risk factors include obesity, the microbiome, diet, cigarette smoking, sleep duration, sleep quality, and sedentary behavior. Major lifestyle interventions to prevent and treat diabetes relate to these risk factors. Weight loss is the lifestyle intervention with the largest benefit for both preventing and treating diabetes. Exercise, even without weight loss, significantly reduces the incidence of type 2 diabetes.

Discovering Engagement Personas in a Digital Diabetes Prevention Program

Digital health technologies are shaping the future of preventive health care. We present a quantitative approach for discovering and characterizing engagement personas: longitudinal engagement patterns in a fully digital diabetes prevention program. We used a two-step approach to discovering engagement personas among n = 1613 users: (1) A univariate clustering method using two unsupervised k-means clustering algorithms on app- and program-feature use separately and (2) A bivariate clustering method that involved comparing cluster labels for each member across app- and program-feature univariate clusters. The univariate analyses revealed five app-feature clusters and four program-feature clusters. The bivariate analysis revealed five unique combinations of these clusters, called engagement personas, which represented 76% of users. These engagement personas differed in both member demographics and weight loss. Exploring engagement personas is beneficial to inform strategies for personalizing the program experience and optimizing engagement in a variety of digital health interventions.

Barriers to participation and lifestyle change among lower versus higher income participants in the National Diabetes Prevention Program: lifestyle coach perspectives

Individuals from socioeconomically disadvantaged groups have lesser participation and success in the National Diabetes Prevention Program (NDPP). Barriers to NDPP participation and lifestyle change were examined from the perspective of Lifestyle Coaches serving lower versus higher income participants. Lifestyle Coaches (n = 211) who serve lower income (n = 82) or higher income (n = 129) participants reported on observed barriers to NDPP participation and lifestyle change and ranked the three most significant barriers to (a) NDPP participation and (b) lifestyle change. Group differences in number/type of barriers were examined using t-tests and chi-square analyses, and ranking differences were examined using multilevel cumulative logit models. Lifestyle Coaches of lower income (versus higher income) participants reported two additional barriers on average. Ranked barriers to participation were similar between groups, and notably included physical/emotional barriers. However, for lifestyle change, those serving lower income groups were more likely to rank lack of access to healthy grocery stores, but less likely to rank low motivation and lack of family support. Lifestyle Coaches of lower income participants were less likely to rank long wait period prior to enrollment as the most significant barrier to participation, and to rank lack of time off from work as the most significant barrier to lifestyle change. Despite more barriers observed among lower versus higher income participants, overlap in the most significant barriers highlights the potential utility of widely addressing common barriers among NDPP participants. In particular, physical and emotional barriers have been overlooked, yet deserve greater attention in future research and practice.

Feasibility and Effectiveness of a Preventive Care Program during the Compound Humanitarian Crisis and COVID-19 Pandemic in Venezuela

Effective preventive care programs are urgently needed during humanitarian crises, as has been especially obvious during the COVID-19 pandemic. A pragmatic trial was designed: hybridized intervention (Diabetes Prevention Program [DPP] + medical nutrition therapy + liquid diet [LD]; LD group) vs. DPP only (DPP group). The participants were adults who were overweight/obese and at high risk of type 2 diabetes mellitus (T2DM). The LD consisted of a “homemade” milk- and fruit-juice-based beverage. Pandemic restrictions delayed the program by nine months, tripled the amount of time required for screening, and reduced the total sample to 60%. Eventually, 127 participants were randomized, and 94/127 participants (74.0%) completed the first phase. Participant dropout was influenced by migration, COVID-19 symptoms, education level, and socioeconomic status. In two months, the LD group lost 2.9 kg (p < 0.001) and the DPP group, 2.2 kg (p < 0.001) (between-group p = 0.170), with improvements in their cardiometabolic risk factors. At this stage, the DPP was shown to be feasible and effective, demonstrating weight loss with the improvement of cardiometabolic risk factors in a primary setting in Venezuela, a middle-income country with a chronic humanitarian crisis, during the COVID-19 pandemic.

A Smartphone App-Based Lifestyle Change Program for Prediabetes (D'LITE Study) in a Multiethnic Asian Population: A Randomized Controlled Trial

Introduction

Landmark studies have established that lifestyle interventions focused on weight loss, diet modification and physical activity can prevent diabetes progression. However, the effectiveness of mobile health application among Asians with prediabetes remains largely unexamined. We aimed to assess whether a smartphone app-based lifestyle intervention program would lead to weight loss, normoglycemia and improved metabolic indices in a multiethnic Asian population with prediabetes.

Research Design and Methods

This multicentre prediabetes RCT is part of the Diabetes Lifestyle Intervention using Technology Empowerment (D'LITE) trial. Adults (n = 148) with prediabetes and BMI ≥ 23 kg/m² were randomly allocated either to the intervention group (n = 72) empowered by self-monitoring features of the Nutritionist Buddy Diabetes app with in-app dietitian coaching for 6 months, or the control group (n = 76) receiving standard diet counseling at baseline. Primary outcome was defined as change in body weight at 6 months, while secondary outcomes included glycemic control and other metabolic indices analyzed using Generalized Linear Mixed Model analysis with intention-to-treat approach.

Results

Intervention group achieved a significantly greater weight loss of 4.2 vs. 1.3 kg [mean difference of −3.1 kg (95% CI −4.5 to −1.7), p < 0.001], and a 4.3-fold increased likelihood of achieving ≥ 5% weight loss, as compared to the control group at 6 months. The likelihood of achieving normoglycemia (defined as HbA_1c < 5.7%) was 2.1 times higher in intervention group than in the control group (p < 0.018). Changes to blood pressure, total and LDL cholesterol were not statistically significant.

Conclusion

An app-based lifestyle program led to clinically significant weight loss and improved glycemia, and can potentially augment current standard care in the prevention of diabetes among an Asian multiethnic population.

Clinical Trial Registration

anzctr.org.au, identifier: ACTRN12617001112358.

Patient Retention in Pediatric Weight Management Programs in the United States: Analyses of Data from the Pediatrics Obesity Weight Evaluation Registry

Objective: Meeting recommended provider contact hours in multicomponent pediatric weight management (PWM) programs is difficult when patient retention is low. Our objective was to examine associations between individual patient characteristics, program characteristics, and patient retention. Methods: Using the Pediatric Obesity Weight Evaluation Registry, a prospective longitudinal study of 32 PWM programs, we included children (≤18 years; n = 6502) enrolled for a full year. We examined associations between retention (any follow-up visit) and patient and program characteristics using multivariable models with site-clustering random effects. Results: Sixty-seven percent of children had at least one follow-up visit, whereas 12% had four or more visits. Compared with non-Hispanic white children, non-Hispanic black children were less likely to have a follow-up visit [adjusted odds ratio (aOR) = 0.79], whereas Hispanic children (any race) were more likely (aOR = 1.22). Children with Medicaid had similar retention to those with private insurance. Retention did not differ by age, gender, weight status, or comorbidities, nor by program characteristics. Conclusions: Few characteristics of PWM programs are clearly associated with retention, indicating that a variety of formats can support continued treatment and likely reflect the influence of unmeasured characteristics. Clearer ways to identify and overcome barriers for individual patients will be needed to improve retention in PWM.

3. Prevention or Delay of Type 2 Diabetes and Associated Comorbidities: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Delivering the National Diabetes Prevention Program: Assessment of Enrollment in In-Person and Virtual Organizations

The aim of the US Centers for Disease Control and Prevention's (CDC) National Diabetes Prevention Program (National DPP) is to make an evidence-based lifestyle change program widely available to the more than 88 million American adults at risk for developing type 2 diabetes. The National DPP allows for program delivery using four delivery modes: in person, online, distance learning, and combination. The objective of this study was to analyze cumulative enrollment in the National DPP by delivery mode. We included all participants who enrolled in CDC-recognized organizations delivering the lifestyle change program between January 1, 2012, and December 31, 2019, and whose data were submitted to CDC's Diabetes Prevention Recognition Program. During this time, the number of participants who enrolled was 455,954. Enrollment, by delivery mode, was 166,691 for in-person; 269,004 for online; 4,786 for distance-learning; and 15,473 for combination. In-person organizations enrolled the lowest proportion of men (19.4%) and the highest proportions of non-Hispanic Black/African American (16.1%) and older (65+ years) participants (28.2%). Online organizations enrolled the highest proportions of men (27.1%), younger (18-44 years) participants (41.5%), and non-Hispanic White participants (70.3%). Distance-learning organizations enrolled the lowest proportion of Hispanic/Latino participants (9.0%). Combination organizations enrolled the highest proportions of Hispanic/Latino participants (37.3%) and participants who had obesity (84.1%). Most in-person participants enrolled in organizations classified as community-centered entities (41.4%) or medical providers (31.2%). Online and distance-learning participants were primarily enrolled (93.3% and 70.2%, respectively) in organizations classified as for-profit businesses or insurers. Participants in combination programs were enrolled almost exclusively in organizations classified as medical providers (89%). The National DPP has reached nearly half a million participants since its inception in 2012, but continued expansion is critical to stem the tide of type 2 diabetes among the many Americans at high risk.

Using Community Health Workers to Address Barriers to Participation and Retention in Diabetes Prevention Program: A Concept Paper

Objective:

The PreventionLink of Southern Maryland is a 5-year project to eliminate barriers to participation and retention in the National Diabetes Prevention Program (DPP) lifestyle change program to prevent or delay the onset of type 2 diabetes in adults with prediabetes. This is the study to identify the obstacles to participation and retention in the DPP lifestyle change program among high burden populations and learn how CHWs have reduced the identified barriers to participation and retention for high burden populations.

Methods:

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to conduct this literature review. We have used the Scopus and PubMed, including all types of studies and peer-reviewed documents published in English between 2010 and 2020.

Results:

From 131 identified articles, 18 articles were selected for qualitative synthesis. The reviewed literature documented following as main barriers to participate in a DPP lifestyle change program: time, cost, lack of transportation, cost of transportation, commute distance, technology access, access to facilities and community programs, caregiver responsibilities, lack of health literacy and awareness, and language. CHWs can address these barriers to participation and retention, they were involved in educating and supporting roles; they worked as bridges between healthcare providers and participants and as intervention team members.

Conclusions:

Diabetes prevention program participants with social determinant risk factors who most need CHW services are unlikely to have financial resources to pay for CHW services out-of-pocket. Hence, the public and private health plans that pay for their prediabetes care should consider paying for these CHW services and there is a need to trust more to CHW and have them as a “community health teams” member.

Impact of a Prescription Produce Program on Diabetes and Cardiovascular Risk Outcomes

OBJECTIVE

To evaluate the impact of a fruit and vegetable prescription program on diabetes and cardiovascular risk outcomes.

DESIGN

Single-arm pre-post study.

SETTING

Primary care clinic in a community-based hospital.

PARTICIPANTS

Adults with type 2 diabetes (n = 97), aged > 18 years, with hemoglobin A1c (HbA1c) ≥ 7.0%, and a body mass index (BMI) of ≥ 25 kg/m².

INTERVENTION

Over 7 months, participants received monthly group-based diabetes self-management education (DSME) and monthly vouchers ($28-$140/month) redeemable for fruits and vegetables at local markets.

ANALYSIS

Biomarker changes (HbA1c, BMI, and blood pressure) were assessed with paired t tests. Voucher distribution and redemption were tracked, and voucher redemption rates were calculated. Linear mixed-effect regression models tested associations between biomarkers, voucher redemption rates, and participant characteristics.

RESULTS

There was a -1.3% (P < 0.001) postprogram change in HbA1c. Reduced HbA1c was associated with higher voucher redemption rates (P = 0.032) and a change in diabetes medications (P = 0.003). There were no associations with BMI, but blood pressure was positively associated with voucher redemption.

CONCLUSIONS AND IMPLICATIONS

Fruit and vegetable prescription programs may improve diabetes outcomes by incentivizing DSME uptake and retention. Future randomized trials are warranted to identify strategies to improve DSME engagement and voucher redemption rates and assess mechanisms through which these programs influence health outcomes.

Affective disorders, weight change, and patient engagement in a rural behavioral weight loss trial

BACKGROUND

Adults in rural areas have a higher prevalence of obesity and some mental health conditions. The degree to which mental health influences weight loss among rural residents remains unclear. This study evaluated changes in body weight, physical activity, diet, and program engagement outcomes in a cohort of participants with vs. without an affective disorder in a behavioral weight loss trial.

METHODS

A sample of 1407 adults with obesity were recruited from rural U.S. primary care practices to participate in a weight loss trial. In this secondary analysis, participants were stratified by those with vs. without an affective disorder at baseline. Mixed models were used to estimate changes in outcomes over 24 months.

RESULTS

One-third of participants (n = 468) had an affective disorder. After covariate adjustment, both groups experienced significant weight loss over 24 months, but weight loss was significantly less among those with an affective disorder at all follow-up times (all p's < 0.001; 24-month weight loss -2.7 ± 0.4 vs. -4.8 ± 0.3 kg). Compared to those without an affective disorder, participants with an affective disorder also had significantly less improvement in physical activity and fruit/vegetable consumption, lower attendance at weight loss sessions, and less engagement in setting weight loss goals and strategies.

CONCLUSION

Participants with an affective disorder lost less body weight and less improvement in lifestyle measures over 24 months. These trends paralleled reduced engagement in critical intervention activities such as weight loss session attendance. Future interventions should consider additional methods to minimize disengagement in adults with underlying affective disorders.

Patient-Centered Goal-Setting in the National Diabetes Prevention Program: A Pilot Study

OBJECTIVE

Difficulty achieving preset goals (e.g., ≥5% weight loss, ≥150 min of weekly physical activity) in the yearlong National Diabetes Prevention Program (NDPP) can prompt dropout and diminish benefits. We piloted a more patient-centered NDPP adaptation (NDPP-Flex) that promotes a variety of attainable and individually tailored goals to reduce diabetes risks, along with flexibility to adjust goals each week as needed.

RESEARCH DESIGN AND METHODS

Retention, physical activity, weight, and glycated hemoglobin (HbA_1c) were evaluated among diverse participants with diabetes risks who received our pilot of NDPP-Flex beginning in January and July 2018 (n = 95), with a planned comparison with standard NDPP delivery in preceding cohorts that launched between September 2016 and October 2017 (n = 245). Both the standard NDPP and NDPP-Flex interventions were 1 year in duration and implemented in phases (i.e., nonrandomized).

RESULTS

Average adjusted retention (e.g., 158.90 ± 15.20 vs. 166.71 ± 9.38 days; P = 0.674), physical activity (157.97 ± 11.91 vs. 175.64 ± 7.54 weekly min; P = 0.231), and weight loss (1.46 ± 0.38% vs. 1.90 ± 0.24%; P = 0.396) were similar between NDPP-Flex versus standard NDPP. However, NDPP-Flex participants had greater HbA_1c reduction on average (0.22 ± 0.05% vs. 0.06 ± 0.03%; P = 0.018) and were more likely to have normoglycemia at follow-up (odds ratio 4.62; P = 0.013 [95% CI 1.38-15.50]) than participants in the standard NDPP.

CONCLUSIONS

An adapted, more patient-centered NDPP that focuses on flexible, self-selected goals may be a promising strategy to improve glycemia even in the absence of substantial weight loss.

Effect of ICT-Based Self-Management System DialBeticsLite on Treating Abdominal Obesity in the Specific Health Guidance in Japan: Randomized Controlled Trial. (Preprint)

Background

Mobile health (mHealth) interventions, a more cost-effective approach compared with traditional methods of delivering lifestyle coaching in person, have been shown to improve physical parameters and lifestyle behavior among overweight populations. In Japan, the Specific Health Checkups and Specific Health Guidance (SHG) started in 2008 to treat obesity and abdominal obesity. However, the effectiveness of SHG is limited owing to its in-person counseling. The effect of mHealth on SHG has yet to be demonstrated.

Objective

This study aims to determine whether a mobile self-management app (DialBeticsLite) could make the SHG more beneficial among patients with abdominal obesity to achieve a reduction in visceral fat area (VFA).

Methods

This study was an open-label, 2-arm, parallel-design randomized controlled trial. We recruited 122 people in September 2017 and randomly assigned them into either the intervention or control group. All participants attended an educational group session that delivered information regarding diet and exercise. In addition, participants in the intervention group were asked to use DialBeticsLite for 3 months. DialBeticsLite facilitated the daily recording of several physical parameters and lifestyle behavior and provided feedback to encourage an improvement in behavior. The primary outcome was the change in VFA from baseline to the 3-month follow-up. Secondary outcomes included changes in both physical and metabolic parameters from baseline to the 3-month follow-up. The Welch 2-tailed t test was conducted to analyze the effects of DialBeticsLite on both the primary and secondary outcomes.

Results

Of the 122 participants recruited, 75 (61.5%) were analyzed because 47 (38.5%) were excluded: 37 (30.3%) because of ineligibility and 10 (8.2%) because of withdrawal of consent. The mean age was 49.3 (SD 6.1) years in the intervention group (41/75, 55%) and 48.5 (SD 5.3) years in the control group (34/75, 45%), and all participants were men, although unintentionally. The baseline characteristics did not differ significantly between the intervention and control groups, except for VFA. The average change of VFA was −23.5 (SD 20.6) cm² in the intervention group and +1.9 (SD 16.2) cm² in the control group (P<.001). Statistically significant differences were also found for the change of body weight, BMI, and waist circumference. These findings did not change after adjusting for VFA at the baseline. The intervention had no significant effect on any of the metabolic parameters. An exploratory analysis showed significant associations between the change in VFA and steps per day and between the change in VFA and calorie intake per day within the intervention group.

Conclusions

Our findings indicate that an mHealth intervention facilitating the daily monitoring of several physical parameters and lifestyle behavior can be highly effective in inducing visceral fat loss and weight loss among adults eligible for SHG.

Trial Registration

UMIN Clinical Trials Registry UMIN000042045; https://tinyurl.com/4vat3v53

Prevention of Type 2 Diabetes

The global diabetes burden is staggering, and prevention efforts are needed to reduce the impact on individuals and populations. There is strong evidence from efficacy trials showing that lifestyle interventions promoting increased physical activity, improvements in diet, and/or weight loss significantly reduce diabetes incidence and improve cardiometabolic risk factors. Implementation research assessing the feasibility, effectiveness, and cost-effectiveness of delivering these proven programs at the community level has shown success, but more research is needed to overcome barriers to implementation in different settings globally. New avenues of research should be considered to combat this public health issue.

Anti-obesity Medication Use Among Adults with Overweight and Obesity in the United States: 2015-2018

OBJECTIVE

To estimate utilization of FDA-approved prescription anti-obesity medications (AOMs) and identify factors associated with AOM use in the United States.

METHODS

Respondents >18 years-old meeting AOM eligibility criteria in 2015-2016 and 2017-2018 National Health and Nutrition Examination Survey (NHANES) and 2016 Medical Expenditure Panel Survey (MEPS) were included in the study. AOM eligibility was defined as having a body mass index (BMI) >30 kg/m², or a BMI between 27 to 29.9 kg/m² and at least one obesity-related comorbidity. Demographic, socioeconomic, and clinical characteristics, economic outcomes and health-related quality of life were summarized and compared between AOM users and non-users. Multivariable logistic regression was used to identify factors associated with AOM use.

RESULTS

Only 0.80% of eligible adults reported use of AOMs in the past 30 days in 2015-2016 and 2017-2018 NHANES. A greater proportion of current AOM users previously tried dietary changes compared to non-users. They also reported an average weight loss of 6.8 lbs. (3.1 kg) over the previous year compared to a 3.3 lbs. (1.5 kg) gain among non-users. Total healthcare costs trended higher among AOM users, driven mostly by higher outpatient healthcare costs. A BMI ≥30 kg/m², depression, dyslipidemia, and infertility predicted AOM use, whereas Medicare and being at risk of sleep apnea were associated with lower odds of AOM use.

CONCLUSION

Despite availability of newer AOMs and inclusion of AOMs in medical treatment guidelines, AOM utilization remains low. This may reflect under-prescribing of and/or restricted patient access to approved evidence-based pharmacotherapy for obesity.

An ounce of prevention is worth a pound of cure: considerations for pharmacists delivering the National Diabetes Prevention Program

Prediabetes is highly prevalent in the United States affecting over 88 million adults. In 2010, the Centers for Disease Control and Prevention (CDC) established the National Diabetes Prevention Program (NDPP), an intensive lifestyle program consisting of a 16-lesson curriculum focused on diet, exercise, and behavior modification, with the ultimate goal to reduce progression from prediabetes to diabetes. Despite tens of millions of adults potentially qualifying to participate in the program, the uptake of the NDPP has been exceedingly low. As a result, the CDC has focused its efforts on engaging with local health departments and community partners, including community pharmacies, across the United States to scale-up enrollment in the NDPP. In this commentary we discuss factors affecting implementation of the NDPP in community pharmacies and other settings where pharmacists practice, including training, space, personnel, recruitment and enrollment, retention, and sustainability.

Barriers and Facilitators to Enrollment and Retention in the National Diabetes Prevention Program: Perspectives of Women and Clinicians Within a Health System

Background: More than 10% of US adults are living with type 2 diabetes. The Centers for Disease Control and Prevention established the National Diabetes Prevention Program (National DPP) in 2010 in an effort to delay or prevent this disease among individuals at high risk. Unfortunately, enrollment and retention rates are low. This qualitative study aims to understand barriers and facilitators to enrolling and completing the National DPP among women, and to provide recommendations for improvement.

Methods: Semistructured interviews were conducted with the following: (1) women who were eligible for the National DPP, but declined to enroll (n=11); (2) women who enrolled in the National DPP, but did not complete the program (n=12); and (3) clinicians who treat women eligible for the National DPP (n=12). Transcripts of the interviews were coded using content analysis.

Results: The 35 interviews (23 patients and 12 clinicians) provided further insight into known barriers, such as the cost of the program, the time that it takes, and inconvenient locations. The study also identified previously undiscovered barriers, including the program not meeting participants' expectations and facilitating referrals. Furthermore, improved communication between clinicians, patients, and National DPP staff could ensure that both clinicians and National DPP staff are aware of patients' goals and their individual barriers to success.

Conclusions: Enrollment and retention in the National DPP may be improved with additional communication, more training for National DPP staff to work more closely with participants, adding better incentives to participation, and making the program more accessible through flexibility in time and/or locations.

Type 2 Diabetes Prevention Focused on Normalization of Glycemia: A Two-Year Pilot Study

The purpose of this study is to assess the effects of an alternative approach to type 2 diabetes prevention. Ninety-six patients with prediabetes (age 52 (10) years; 80% female; BMI 39.2 (7.1) kg/m2) received a continuous remote care intervention focused on reducing hyperglycemia through carbohydrate restricted nutrition therapy for two years in a single arm, prospective, longitudinal pilot study. Two-year retention was 75% (72 of 96 participants). Fifty-one percent of participants (49 of 96) met carbohydrate restriction goals as assessed by blood beta-hydroxybutyrate concentrations for more than one-third of reported measurements. Estimated cumulative incidence of normoglycemia (HbA1c <5.7% without medication) and type 2 diabetes (HbA1c ≥6.5% or <6.5% with medication other than metformin) at two years were 52.3% and 3%, respectively. Prevalence of metabolic syndrome, class II or greater obesity, and suspected hepatic steatosis significantly decreased at two years. These results demonstrate the potential utility of an alternate approach to type 2 diabetes prevention, carbohydrate restricted nutrition therapy delivered through a continuous remote care model, for normalization of glycemia and improvement in related comorbidities.

Preventing Type 2 Diabetes in Women with Previous Gestational Diabetes: Reviewing the Implementation Gaps for Health Behavior Change Programs

Gestational diabetes mellitus (GDM) places a woman at high risk of developing subsequent type 2 diabetes mellitus (T2DM), particularly in the first 5 years postpartum. Engaging women in health behavior change during this period is challenging and current diabetes prevention programs were developed for middle-aged adults, all of which have limited the evidence on successful implementation for this high-risk population. In this review, we will first summarize the effects of existing diabetes prevention programs in women with a history of GDM. Second, we suggest that the programs need to be modified according to the facilitators and barriers faced by this population. Third, we propose that improving program penetration, fidelity, and participation is critical for population-level success. Finally, we outline the research priorities to improve the implementation of diabetes prevention programs for postpartum women with a history of GDM.

3. Prevention or Delay of Type 2 Diabetes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Weight Loss Disparities Among Hispanic and Underserved Participants, Colorado, 2015-2018

INTRODUCTION

The National Diabetes Prevention Program (DPP) is an evidence-based strategy to prevent the development of type 2 diabetes in adults at high risk through education and behavior modifications that promote weight loss. This evaluation aimed to determine if National DPP participants' weight-related outcomes varied across demographic subgroups, including sex, age, race/ethnicity, and insurance status, after controlling for program attendance and physical activity.

METHODS

Our cross-site evaluation used participant-level data from 11 organizations during July 2015 through June 2018. A modified Poisson regression model was used to examine the relationship between demographic subgroups, controlling for physical activity (minutes per week) and program attendance.

RESULTS

A total of 1,007 National DPP participants were included in the analyzed sample. Participants lost an average of 4% of their initial body weight, approximately 8 pounds. About one-third of participants achieved greater than 5% weight loss. In the unadjusted estimates, participants who were Hispanic, non-Hispanic Black, young, and uninsured were significantly less likely to achieve 5% or greater weight loss. Demographic differences in achieving 5% or greater weight loss, however, were not significant after adjusting for program attendance and physical activity level.

CONCLUSIONS

Disparities in National DPP weight-related outcomes were not observed across demographic groups after adjusting for program attendance and physical activity levels. However, non-Hispanic Black participants had lower attendance and Hispanic participants reported less physical activity than participants of other races/ethnicities. Strategies to improve National DPP participation and increase physical activity, therefore, should be prioritized among Hispanic and non-Hispanic Black participants.

Mobile Virtual reality vs. Mobile 360 Video to Promote Enrollment in the Diabetes Prevention Program Amongst Hispanic Adults (Preprint)

Background

Hispanic adults are at increased risk of developing type 2 diabetes. The Diabetes Prevention Program (DPP) reduces the risk of developing type 2 diabetes; however, the rate of enrollment is very low.

Objective

The goal of this pilot project was to determine whether presenting brief motivational mobile videos in virtual reality vs 360° video has differential effects on risk perceptions and enrollment in the DPP.

Methods

Adults with prediabetes were recruited at a clinic serving a low-income Hispanic community. After consenting, the participants completed a baseline survey that collected information about demographics and risk perceptions. All participants then viewed 2 videos. Per random assignment, the videos were presented either using the participant’s smartphone alone (360° video) or were viewed with their smartphone in a virtual reality (VR) cardboard headset. Two weeks later, a follow-up survey collected measures of enrollment in the DPP, risk perceptions, health literacy, the importance of contextual factors related to the decision of whether to enroll in the DPP (eg, distance to the class), and qualitative feedback on the interventions. We used logistic regression to determine whether enrollment in the DPP differed by intervention mode, while accounting for health literacy and contextual factors related to the DPP. We used unpaired t tests to examine differences in change in risk perceptions between groups. Paired t tests were used to examine within-subject changes in risk perceptions.

Results

A total of 116 participants provided complete data. Most participants were middle-aged (mean age 44.6 years; SD 11.9) Hispanic (114/116), female (79/116), with low health literacy (mean score 12.3/20; SD 3.4). Enrollment in the DPP was 44/116 (37.9%) overall but did not differ by group (odds ratio for enrolling in VR group 1.78, 95% CI 0.75-4.3; P=.19). Individuals who rated the distance needed to travel to attend the DPP as more important were less likely to enroll in the DPP (odds ratio 0.56, 95% CI 0.33-0.92; P=.03). Risk perceptions did not differ by group (mean change in 360° video group -0.07, mean change in VR group 0.03, t=0.6, P=.54) and did not change within subjects (mean 0.02, t=0.21, P=.83). Participant feedback suggested that the videos are emotionally engaging and educational.

Conclusions

The videos presented in 360° video and mobile VR had equal efficacy in promoting enrollment in the DPP. Future work to rigorously evaluate this intervention, its mechanism of action, and potential moderators of the efficacy are discussed.

Implementation outcomes of a culturally adapted diabetes self-management education intervention for Native Hawaiians and Pacific islanders

BACKGROUND

Native Hawaiians and Pacific Islanders (NHPIs) experience a disproportionate burden of type 2 diabetes and related complications. Although diabetes self-management education and support (DSMES) interventions have generally yielded positive results, few NHPIs have been included in these studies, and even fewer studies have been evaluated using a randomized controlled trial design and/or implementation research methods. The purpose of this pilot study was to evaluate implementation outcomes of a culturally adapted diabetes self-management education intervention delivered by peer educators to Native Hawaiians and Pacific Islanders residing in Honolulu, Hawai'i.

METHODS

In three study sites, the peer educators and 48 participants randomized to the intervention were invited to participate in the mixed methods implementation research. We used a convergent parallel design to collect implementation data including fidelity, feasibility, acceptability, appropriateness, adoption, and sustainability. Data were collected from class observations, participants' class feedback, and post-intervention focus groups with participants and peer educators.

RESULTS

In 314 end-of-class feedback surveys, 97% of respondents expressed that they were satisfied or highly satisfied with the class content and activities, 98% reported that the classes and materials were very useful, 94% reported very applicable, and 93% reported materials were culturally appropriate. Respondents identified several aspects of the program as especially enjoyable: interactions with peer educators, meeting in groups, learning about other participants' experiences with diabetes, and the information presented in each class. Major themes that emerged from the end-of-intervention focus groups were the relevance of the educational materials, strategies to manage blood glucose, hands-on activities, cultural aspects of the program, including the stories and analogies used to convey information, and appreciation of the group format and peer educators.

CONCLUSIONS

Results from this research support a culturally tailored, peer educator approach to DSMES among NHPIs. Delivery of the Partners in Care program is feasible in health care and community settings and is a reimbursable DSMES program.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01093924 prospectively registered 01.20.09.

Intervention Delivery Matters: What Mothers at High Risk for Type 2 Diabetes Want in a Diabetes Prevention Program-Results from a Comparative Effectiveness Trial

Participants in the ENCOURAGE Healthy Families Study, a family-focused, modified Diabetes Prevention Program, reported challenges to and preferences for engaging in a diabetes prevention program. Challenges with flexible intervention delivery, accessibility, the traditional group-based format, and Coronavirus Disease 2019 (COVID-19) exposure risk can be mitigated by participant preferences for one-on-one, virtual/online intervention delivery.Trial Registration: ClinicalTrials.gov identifier, NCT01823367.