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

Interventions to achieve long-term weight loss in obese older people: a systematic review and meta-analysis

PURPOSE

the prevalence of obesity is rapidly increasing in older adults. Information is required about what interventions are effective in reducing obesity and influencing health outcomes in this age group.

DESIGN

systematic review and meta-analysis.

DATA SOURCES

thirteen databases were searched, earliest date 1966 to December 2008, including Medline, CINAHL, PsycINFO, the Cochrane database and EMBASE.

STUDY SELECTION

we included studies with participants' mean age > or = 60 years and mean body mass index > or = 30 kg/m(2), with outcomes at a minimum of 1 year. Data were independently extracted by two reviewers and differences resolved by consensus.

DATA EXTRACTION

nine eligible trials were included. Study interventions targeted diet, physical activity and mixed approaches. Populations included patients with coronary artery disease, diabetes mellitus and osteoarthritis.

RESULTS

meta-analysis (seven studies) demonstrated a modest but significant weight loss of 3.0 kg [95% confidence interval (CI) 5.1-0.9] at 1 year. Total cholesterol (four studies) did not show a significant change: -0.36 mmol/l (95% CI -0.75 to 0.04). There was no significant change in high-density lipoprotein, low-density lipoprotein or triglycerides. In one study, recurrence of hypertension or cardiovascular events was significantly reduced (hazard ratio 0.65, 95% CI 0.50-0.85). Six-minute walk test did not significantly change in one study. Health-related quality of life significantly improved in one study but did not improve in a second study.

CONCLUSIONS

although modest weight reductions were observed, there is a lack of high-quality evidence to support the efficacy of weight loss programmes in older people.

Web-based weight loss in primary care: a randomized controlled trial

Evidence is lacking regarding effective and sustainable weight loss approaches for use in the primary care setting. We conducted a 12-week randomized controlled trial to evaluate the short-term efficacy of a web-based weight loss intervention among 101 primary care patients with obesity and hypertension. Patients had access to a comprehensive website that used a moderate-intensity weight loss approach designed specifically for web-based implementation. Patients also participated in four (two in-person and two telephonic) counseling sessions with a health coach. Intent-to-treat analysis showed greater weight loss at 3 months (-2.56 kg; 95% CI -3.60, -1.53) among intervention participants (-2.28 +/- 3.21 kg), relative to usual care (0.28 +/- 1.87 kg). Similar findings were observed among intervention completers (-3.05 kg; 95% CI -4.24, -1.85). High rates of participant retention (84%) and website utilization were observed, with the greatest weight loss found among those with a high frequency of website logins (quartile 4 vs. 1: -4.16 kg; 95% CI -1.47, -6.84). The intervention's approach promoted moderate weight loss at 12 weeks, though greater weight loss was observed among those with higher levels of website utilization. Efficacious web-based weight loss interventions can be successfully offered in the primary care setting.

The effects of a nurse case manager and a community health worker team on diabetic control, emergency department visits, and hospitalizations among urban African Americans with type 2 diabetes mellitus: a randomized controlled trial

BACKGROUND

Although African American adults bear a disproportionate burden from diabetes mellitus (DM), few randomized controlled trials have tested culturally appropriate interventions to improve DM care.

METHODS

We randomly assigned 542 African Americans with type 2 DM enrolled in an urban managed care organization to either an intensive or minimal intervention group. The intensive intervention group consisted of all components of the minimal intervention plus individualized, culturally tailored care provided by a nurse case manager (NCM) and a community health worker (CHW), using evidence-based clinical algorithms with feedback to primary care providers (eg, physicians, nurse practitioners, or physician assistants). The minimal intervention consisted of mailings and telephone calls every 6 months to remind participants about preventive screenings. Data on diabetic control were collected at baseline and at 24 months by blind observers; data emergency department (ER) visits and hospitalizations were assessed using administrative data.

RESULTS

At baseline, participants had a mean age of 58 years, 73% were women, and 50% were living in poverty. At 24 months, compared with the minimal intervention group, those in the intensive intervention group were 23% less likely to have ER visits (rate difference [RD], -14.5; adjusted rate ratio [RR], 0.77; 95% confidence interval [CI], 0.59-1.00). In on-treatment analyses, the rate reduction was strongest for patients who received the most NCM and CHW visits (RD, -31.0; adjusted RR, 0.66; 95% CI, 0.43-1.00; rate reduction downward arrow 34%).

CONCLUSION

These data suggest that a culturally tailored intervention conducted by an NCM/CHW team reduced ER visits in urban African Americans with type 2 DM.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00022750.

Randomized trial of a behavioral weight loss intervention for low-income women: the Weight Wise Program

Low-income women in the United States have the highest rates of obesity, yet they are seldom included in weight loss trials. To address this research gap, components of two evidence-based weight loss interventions were adapted to create a 16-week intervention for low-income women (Weight Wise Program), which was evaluated in a randomized trial with the primary outcome of weight loss at 5-month follow-up. Participants were low-income women (40-64 years) with a BMI of 25-45. Of 143 participants, 72 were randomized to the Weight Wise Program (WWP) and 71 to the Control Group (CG). Five-month follow-up data were obtained from 64 (89%) WWP and 62 (87%) CG participants. With baseline values carried forward for missing data, WWP participants had a weight change of -3.7 kg compared to 0.7 kg in the CG (4.4 kg difference, 95% confidence interval (CI), 3.2-5.5, P<0.001). For systolic blood pressure (SBP), change in the WWP was -6.5 mm Hg compared to -0.4 mm Hg among controls (6.2 mm Hg difference, 95% CI, 1.7-10.6, P=0.007); for diastolic BP (DBP), changes were -4.1 mm Hg for WWP compared to -1.3 mm Hg for controls (2.8 mm Hg difference, 95% CI, 0.0-5.5, P=0.05). Of the 72 WWP participants, 64, 47, and 19% lost at least 3, 5, and 7% of their initial body weight, respectively. In conclusion, the WWP was associated with statistically significant and clinically important short-term weight loss.

The effect of weight reduction interventions for persons with type 2 diabetes: a meta-analysis from a self-regulation perspective

PURPOSE

The main purpose of this article was to investigate the value of a self-regulation approach for weight reduction interventions in patients with type 2 diabetes. In addition, the potentially moderating effect of other intervention characteristics was explored.

METHODS

In a meta-analysis of 34 studies, overall effect sizes were calculated for weight and A1C. The focus of the analysis was, however, on the moderating effect of intervention characteristics, especially whether interventions that score high on self-regulation produce stronger effects.

RESULTS

The overall effect sizes (d) for weight loss in the short term (<6 months) were low and even lower in the longer term (>6 months). The overall effect sizes for A1C outcomes were higher and remained stable in the longer term. Interventions that scored high on self-regulation characteristics produced significantly better effects on both weight and A1C outcomes. Furthermore, "goal reformulation" increased the effect on weight outcomes whereas "emotion regulation" increased the effect on A1C. With respect to the other intervention characteristics, only the "inclusion of a patient's partner or relative" increased the effect on weight loss.

CONCLUSIONS

This meta-analysis underlines the importance of a self-regulation approach for weight reduction interventions in diabetes patients, in particular, for A1C outcomes. However, more research is needed to fully understand the relationship among self-regulation, weight, and A1C.

The First Step First Bite Program: guidance to increase physical activity and daily intake of low-glycemic index foods

Practical lifestyle interventions are needed to help people with type 2 diabetes increase their physical activity and follow nutrition therapy guidelines. This study examined whether combining instructions to walk more and to eat more low-glycemic index (GI) foods (First Step First Bite Program) improved hemoglobin A1c and anthropometric and cardiovascular health outcomes in people with type 2 diabetes vs the First Step Program (instruction only on walking). Subjects were randomly assigned to the First Step Program or First Step First Bite Program (n=22 in each group) and attended four weekly group meetings with minimal follow-up during weeks 5 to 16. All subjects monitored steps per day throughout the study; First Step First Bite Program subjects also monitored daily intake of low-GI foods. At week 16 (n=19 per group), both groups had increased steps per day by approximately 3,000 compared with baseline (P<0.01). In the First Step Program vs First Step First Bite Program groups, respectively, waist girth decreased by 5.9+/-0.9 cm vs 3.7+/-0.5 cm and hip decreased by 3.7+/-0.6 cm vs 2.2+/-0.5 cm (P<0.01 over time, both groups). There was no significant difference between groups at week 16 for anthropometric or metabolic variables measured, including hemoglobin A1c. Both the First Step First Bite Program and First Step Program resulted in increased physical activity; First Step First Bite Program also increased daily intake of low-GI foods. Both groups experienced similar significant reductions in waist and hip girth. Thus, adding a low-GI component to a walking program in people with type 2 diabetes in good glycemic control did not improve anthropometric or metabolic outcomes. A great number and/or longer duration of low-GI foods may be required to observe improved clinical outcomes.

Translating the Diabetes Prevention Program into practice: a review of community interventions

PURPOSE

The purpose of this review is to summarize community interventions based on the National Institutes of Health (NIH) Diabetes Prevention Program (DPP) curriculum and to describe differences in curriculum and its effect on outcome measurements.

METHODS

A keyword search of PubMed and review of citation lists of relevant articles yielded 161 articles. Primary outcomes of interest were achievement of the DPP study goals: 5% to 7% loss of body weight and increased moderate physical activity to at least 150 minutes per week. A secondary outcome of improvement in metabolic syndrome components was also included. Inclusion criteria included application of a DPP-based curriculum to a community setting and publication in English.

RESULTS

Seven articles were included in the review. Interventions were conducted across a variety of settings. All showed a significant amount of weight loss immediately following a DPP-based curriculum, varying in length from 6 to 24 weeks. Three held significance by 12 months. Two articles reported on physical activity improvements. Two articles reported improvement in metabolic syndrome components.

CONCLUSION

Although the most effective intervention for type 2 diabetes prevention may not yet be identified, DPP-based interventions show promise for long-term sustainability. The DPP intervention is effective in treating overweight and obesity across a variety of settings and thus may prevent chronic diseases in which overweight and obesity are risk factors. Public health practitioners can use this successful intervention to help individuals lead healthier lives.

Weight loss through living well: translating an effective lifestyle intervention into clinical practice

PURPOSE

To translate the Diabetes Prevention Program (DPP) lifestyle intervention into a clinical setting and evaluate its effectiveness.

METHODS

The authors implemented a group-based version of the DPP lifestyle curriculum in a large academic medicine practice. It is delivered by a nurse educator over 12 weekly sessions with optional reenrollment, available on a self-pay basis, and implemented using existing clinical resources (eg, electronic medical record referrals, scheduling, conference rooms, communication technology). The program was evaluated using a controlled before-after design, including all patients referred between April 1, 2005, and February 1, 2007. Patients with a body mass index (BMI) >or=25 kg/m(2) were eligible if their primary care providers felt the program was medically appropriate and safe. Change in weight (kg) and frequency of achieving >or=7% weight loss were examined.

RESULTS

Referred patients were primarily female (84%), with an average age of 49.91 years (SE, 1.46) and average BMI of 39.65 kg/m(2) (SE, 0.73). Among eligible patients, 93% of enrollees and 80% of nonenrollees had follow-up weights recorded within the evaluation window. Over 1 year, mean weight change was -5.19 kg (95% confidence interval [CI], -7.71 to -2.68) among enrollees and +0.21 kg (CI, -1.0 to 1.93) among nonenrollees (P < .001). A >or=7% loss was found for 27% of enrollees and 6% of nonenrollees (P = .001).

CONCLUSIONS

An evidence-based lifestyle intervention can be effectively translated into the clinical setting. Use of existing resources may facilitate patient flow and minimize cost. This provider-integrated preventive care approach may provide a model for incorporating knowledge from behavioral science into clinical care.

Community-based participatory research in developing an obesity intervention in a rural county

This research includes a study of body mass index (BMI) measurement for 11-year-old students (n = 174) within a rural county during the 2005-2006 academic year. School entry assessments were used to determine students' individual BMIs longitudinally and determine prevalence of risk of overweight (weighted for gender and age). Results were provided to county school districts and communities, which used the data to determine policy and curriculum changes related to school wellness program planning and development, develop wellness activities, and pursue funding support. This study has implications for data collection and school health program development within a rural setting.

Are behavioural approaches feasible and effective in the treatment of type 2 diabetes? A propensity score analysis vs. prescriptive diet

BACKGROUND AND AIMS

Lifestyle changes are considered first line treatment in type 2 diabetes, but very few data are available in the "real world" of diabetes units. We aimed to measure the effectiveness of moderate and high intensity interventions on weight loss, metabolic control and insulin use. We report a prospective cohort study, carried out in 822 consecutive subjects with type 2 diabetes, first seen in a 4-year period in a diabetes unit of an academy hospital.

METHODS AND RESULTS

Subjects were treated with either a sole prescriptive diet (Diet), or received an additional short-course Elementary Nutritional Education (4 group sessions-ENE) or an intensive Cognitive Behavioural Therapy (12-15 group sessions-CBT). The results were adjusted for the propensity score to be assigned different treatments, derived from logistic regression on the basis of age, gender, BMI, HbA1c, diabetes duration and insulin use at baseline. Main outcome measures were weight loss and weight loss maintenance, metabolic control, and secondary failure to insulin use. Both structured programmes produced a larger weight loss, and the adjusted probability of achieving the 7% weight loss target was increased. Similarly, both programmes favoured metabolic control, irrespective of insulin use. After adjustment for propensity score, both ENE (hazard ratio, 0.48; 95% CI, 0.27-0.84) and CBT (hazard ratio, 0.36; 95% CI, 0.16-0.83) were associated with a reduced risk of de novo insulin treatment.

CONCLUSION

Structured behavioural programmes aimed at lifestyle changes are feasible and effective in the "real world" setting of a diabetes unit for the treatment of type 2 diabetes.

Impact of surgical and nonsurgical weight loss on diabetes resolution and cardiovascular risk reduction

Weight loss favorably modifies most cardiovascular risk factors, in particular the diagnostic criteria for metabolic syndrome, type 2 diabetes mellitus, and hypertension. Treating the spectrum of diabetes by promoting disease control or resolution invariably improves cardiovascular outcomes. However, in clinical trials and routine medical practice, long-term weight loss has been difficult to achieve due to wavering patient motivation, inadequate resources, ineffective medical treatments, lack of psychosocial support, recidivism, or combinations thereof. The issue is not information but rather methods, motivation, and behavioral changes. This article reviews surgical and nonsurgical methods of weight loss and their impact on cardiovascular risk factors, especially the resolution of type 2 diabetes mellitus, and the implications for cardiovascular event reduction in patients with morbid obesity.

Individual patient education for people with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes is a common and costly chronic disease which is associated with significant premature mortality and morbidity. Although patient education is an integral component of diabetes care, there remain uncertainties regarding the effectiveness of different methods and modes of education.

OBJECTIVES

To evaluate the effectiveness of individual patient education on metabolic control, diabetes knowledge and psychosocial outcomes.

SEARCH STRATEGY

Multiple electronic bibliographic databases were searched, including The Cochrane Library, MEDLINE, Premedline, ERIC, Biosis, AMED, Psychinfo, EMBASE, CINAHL, APAIS-health, Australian Medical Index, Web of Science, dissertation abstracts and Biomed Central.

SELECTION CRITERIA

Randomized controlled and controlled clinical trials which evaluated individual education for adults with type 2 diabetes. The intervention was individual face-to-face patient education while control individuals received usual care, routine treatment or group education. Only studies that assessed outcome measures at least six months from baseline were included.

DATA COLLECTION AND ANALYSIS

Information was extracted by two reviewers who summarized both study characteristics and outcome statistics. A meta-analysis using a fixed-effect model was performed if there were adequate studies with a specified outcome of sufficient homogeneity. For outcomes where there were too few studies or the assessment measurements were not standardized or variable, the results were summarised qualitatively.

MAIN RESULTS

Nine studies involving 1359 participants met the inclusion criteria. Six studies compared individual education to usual care and three compared individual education to group education (361 participants). There were no long-term studies and overall the quality of the studies was not high. In the six studies comparing individual face-to-face education to usual care, individual education did not significantly improve glycaemic control (weighted mean difference (WMD) in HbA1c -0.1% (95% confidence interval (CI) -0.3 to 0.1, P = 0.33) over a 12 to 18 month period. However, there did appear to be a significant benefit of individual education on glycaemic control in a subgroup analysis of three studies involving participants with a higher mean baseline HbA1c greater than 8% (WMD -0.3% (95% CI -0.5 to -0.1, P = 0.007). In the two studies comparing individual to group education, there was no significant difference in glycaemic control between individual or group education at 12 to 18 months with a WMD in HbA1c of 0.03% (95% CI -0.02 to 0.1, P = 0.22). There was no significant difference in the impact of individual versus usual care or group education on body mass index systolic or diastolic blood pressure. There were too few studies to perform a meta-analysis on the effect of individual education on dietary self management, diabetes knowledge, psychosocial outcomes and smoking habits. No data were available on the other main outcome measures of diabetes complications or health service utilization and cost analysis in these studies.

AUTHORS' CONCLUSIONS

This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. However, overall there did not appear to be a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months. Additional studies are needed to delineate these findings further.

A meta-analysis of psycho-behavioral obesity interventions among US multiethnic and minority adults

OBJECTIVE

The present review examines efficacious psycho-behavioral interventions in preventing weight gains or reducing weight among US multiethnic and minority adults as few studies were conducted to review such interventions to date.

METHODS

Data were examined from 24 controlled intervention studies, representing 23 programs and involving 13,326 adults. Studies were identified through manual and online search of databases that include MEDLINE, Academic Search Premier, ERIC, PsycARTICLES, SPORTDiscus, and CINAHL Plus.

RESULTS

Whereas one-component (n=5, d=0.08, 90% CI=-0.04, 0.35) and two-component interventions (n=13, d=0.22, 90% CI=0.05, 0.40) showed a low mean effect size, three-component interventions (n=6, d=0.52, 90% CI=0.39, 0.65) showed a moderate effect size. Interventions conducted in individual sessions (n=15, d=0.40, 90% CI=0.24, 0.56) showed a higher mean effect size than group interventions (n=9, d=0.08, 90% CI=-0.04, 0.30) although the confidence intervals overlapped.

CONCLUSIONS

The study results indicate that future obesity prevention interventions targeting multiethnic and minority adults might benefit from incorporating individual sessions, family involvement, and problem solving strategies into multi-component programs that focus on lifestyle changes.

Obesity Reduction Black Intervention Trial (ORBIT): design and baseline characteristics

BACKGROUND

Obesity is associated with many chronic diseases, and weight loss can reduce the risk of developing these diseases. Obesity is highly prevalent among Black women, but weight loss treatment for black women has been understudied until recently. The Obesity Reduction black Intervention Trial (ORBIT) is a randomized controlled trial designed to assess the efficacy of a culturally proficient weight loss and weight loss maintenance program for black women. This paper describes the design of the trial, the intervention, and baseline characteristics of the participants.

METHODS

Two hundred thirteen obese black women aged 30-65 years were randomized to the intervention group or a general health control group. The intervention consists of a 6-month weight loss program followed by a 1-year maintenance program. Weight, dietary intake, and energy expenditure are measured at baseline, 6 months, and 18 months.

RESULTS

More than 40% of participants had a baseline body mass index (BMI) >40 kg/m(2) (class III obesity). Intake of fat and saturated fat was higher and consumption of fruit, vegetables, and fiber was lower than currently recommended guidelines. Self-reported moderate to vigorous physical activity was high (median 85 min/day). However, objectively measured physical activity among a subgroup of participants was lower (median 15 min/day).

CONCLUSIONS

Weight loss among obese black women has received inadequate attention in relation to the magnitude of the problem. Factors that contribute to successful weight loss and more importantly, weight loss maintenance need to be identified.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Individually randomized group treatment trials: a critical appraisal of frequently used design and analytic approaches

OBJECTIVES

We reviewed published individually randomized group treatment (IRGT) trials to assess researchers' awareness of within-group correlation and determine whether appropriate design and analytic methods were used to test for treatment effectiveness.

METHODS

We assessed sample size and analytic methods in IRGT trials published in 6 public health and behavioral health journals between 2002 and 2006.

RESULTS

Our review included 34 articles; in 32 (94.1%) of these articles, inappropriate analytic methods were used. In only 1 article did the researchers claim that expected intraclass correlations (ICCs) were taken into account in sample size estimation; in most articles, sample size was not mentioned or ICCs were ignored in the reported calculations.

CONCLUSIONS

Trials in which individuals are randomly assigned to study conditions and treatments administered in groups may induce within-group correlation, violating the assumption of independence underlying commonly used statistical methods. Methods that take expected ICCs into account should be used in reexamining past studies and planning future studies to ensure that interventions are not judged effective solely on the basis of statistical artifacts. We strongly encourage investigators to report ICCs from IRGT trials and describe study characteristics clearly to aid these efforts.

Tailoring a Diabetes Self-Care Intervention for Use With Older, Rural African American Women

Purpose The purpose of this study was to tailor a diabetes management intervention to the cultural and age-related needs and preferences of older, rural African American women.

Methods Findings from exploratory research, clinical experience, and review of the literature were used to inform the development of a culture- and function-specific intervention. Findings informed the design of the intervention, format of intervention delivery, format of intervention materials, and training provided to interventionists. Intervention materials were reviewed by a community advisory board, and the intervention was pilot tested with 43 women.

Results The intervention's delivery was tailored to the needs of older African American women through the use of 1-hour, in-home sessions that used a storytelling format to share information. The design of the intervention individualized its content to each woman's symptom experience, self-care practices, and coping strategies. Extensive training sensitized intervention nurses to coping strategies (spirituality, church, family) and barriers to self-care (functional limitations, stress, the multi-caregiver role) that are common among older African American women. Intervention materials were culturally sensitive and in large-print format.

Conclusions African American women's cultural background may have a strong influence on health behaviors and beliefs. Older women's health behaviors are further influenced by changes in their functional abilities. Therefore, the authors tailored a diabetes self-care management inter- vention to be specific to older African American women's cultural and functional differences. An initial pilot of the intervention found high levels of participant satisfaction with the intervention, improvements in dia- betes self-care practices, and a trend toward greater metabolic control.

Diabetes Care and Education in Rural Regions

Purpose The purpose of this study was to examine what is cur- rently known about diabetes education and care in rural geographical regions. Residents of rural areas are less likely to have access to health care providers, health insurance, or specialty care and are more likely to experience health care disparities as a result. Persons living in rural areas are likely to have greater burdens of chronic disease, including uncontrolled diabetes, and perceive their health as poorer than their urban counterparts.

Methods A conventional literature review focused on type 1 and type 2 diabetes was completed using the search terms rural, diabetes, and education. The databases searched were CINAHL, EBSCO, Pub Med, and Medline. In all, 22 research articles that fit the inclusion criteria were identified.

Results Findings indicated that diabetes education for rural regions can be enhanced by a focus on family, culture, interdisciplinary teams, and technology.

Conclusions Future rural research about diabetes care should carefully define rural, include gender-related studies that describe findings in terms of men and women, and focus on primary prevention.

Is weight loss beneficial for reduction of morbidity and mortality? What is the controversy about?

The increase of obesity and type 2 diabetes on a global scale has increased the interest in how to counteract this epidemic. Improved lifestyle in general is a fundamental approach, but other remedies such as specific weight reduction or diabetes preventive drugs and surgery have also been tested. One problem to understand is what really happens after weight loss. Ongoing studies will try to address this question, such as the Swedish Obese Subjects (SOS) surgery study, the Look AHEAD (Action for Health in Diabetes) trial in the U.S. (recruiting obese type 2 diabetic patients), and the Comprehensive Rimonabant Evaluation Study of Cardiovascular End Points and Outcomes (CRESCENDO) trial (by use of rimonabant versus placebo). This is very important, since previously, several observational studies in large population-based cohorts have indicated some detrimental effects of weight loss, even after intentional weight loss, with increased morbidity and mortality rates.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Diabetes health disparities: a systematic review of health care interventions

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.

Behavioural interventions for preventing and treating obesity in adults

The purpose of this study was to review existing behavioural interventions for preventing and treating obesity in adult population that were published between 2000 and September 2006. A total of 23 interventions were found. Most of these interventions targeted both physical activity and nutrition behaviours. Majority of the interventions were not based on any explicit behavioural theory. In terms of duration, the interventions ranged from 3 weeks to 9 years. Approximately half of the interventions were less than 6 months in duration. Most of the interventions were implemented by the researchers themselves. However, some interventions were implemented by nurse educators, nutritionists, trained public health nurses, dietitians, healthcare providers, fitness workers and certified diabetic educators. Most of the interventions used group sessions as the predominant method to deliver the programme. Three of the interventions used media. Majority of the interventions were implemented in patient care settings with some in community settings. The most common determinant for measuring impact of the interventions has been body mass index. Fifteen interventions showed positive change in adiposity indices while six showed no change in adiposity indices. Recommendations for enhancing the effectiveness of behavioural interventions for prevention of obesity are presented.

Translating efficacious behavioral principles for diabetes prevention into practice

This case study describes the process of translating efficacy-based Diabetes Prevention Program principles into a practical format for delivery within a managed care organization. Using Rogers' innovation-decision process model, the authors tracked the adoption, implementation, and short-term effectiveness of a clinical program. Effectiveness was documented using a pre-post design to detect changes in physical activity and dietary habits. Participants (N = 298) were Kaiser Permanente of Colorado patients enrolled in diabetes-prevention classes. Changes were analyzed using paired-samples t tests and one-way analysis of variance. Participants significantly increased reported minutes of moderate (p < .001, mu = 84.52, CI: 58.44-110.61) and vigorous (t = 2.220, p = .028, mu = 19.05, CI: 2.10-36.00) physical activity and their daily servings of fruits and vegetables (p < .001, mu = 0.20, CI: 0.13-0.27). By identifying the underlying strategies that led to efficacy, professionals can implement sound diabetes-prevention programs that fit within their context.

Motivational interviewing improves weight loss in women with type 2 diabetes

OBJECTIVE

We sought to determine whether adding motivational interviewing to a behavioral weight control program improves weight loss outcomes and glycemic control for overweight women with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted a randomized, controlled, clinical trial in which participants all received an 18-month, group-based behavioral obesity treatment and were randomized to individual sessions of motivational interviewing or attention control (total of five sessions) as an adjunct to the weight control program. Overweight women with type 2 diabetes treated by oral medications who could walk for exercise were eligible. Primary outcomes were weight and A1C, assessed at 0, 6, 12, and 18 months.

RESULTS

A total of 217 overweight women (38% African American) were randomized (93% retention rate). Women in motivational interviewing lost significantly more weight at 6 months (P = 0.01) and 18 months (P = 0.04). Increased weight losses with motivational interviewing were mediated by enhanced adherence to the behavioral weight control program. African-American women lost less weight than white women overall and appeared to have a diminished benefit from the addition of motivational interviewing. Significantly greater A1C reductions were observed in those undergoing motivational interviewing at 6 months (P = 0.02) but not at 18 months.

CONCLUSIONS

Motivational interviewing can be a beneficial adjunct to behavioral obesity treatment for women with type 2 diabetes, although the benefits may not be sustained among African-American women.

Psychosocial and behavioral interventions for chronic medical conditions

PURPOSE OF REVIEW

This paper critically reviews recent studies that have used behavioral or psychosocial interventions aimed at preventing type 2 diabetes mellitus, cardiovascular disease and HIV/AIDS as well as the psychosocial management of cardiovascular disease, HIV and cancer.

RECENT FINDINGS

Behavioral (lifestyle) interventions can decrease risk of type 2 diabetes mellitus and cardiovascular disease. Psychosocial interventions have proven efficacy for alleviating distress in patients medically treated for cancer, cardiovascular disease and HIV/AIDS. These interventions may also help to prevent HIV infection, and improve medication adherence in HIV/AIDS.

SUMMARY

Behavioral and psychosocial interventions are useful in preventing some chronic diseases and for alleviating distress in patients who have been medically treated for diseases such as cancer, cardiovascular disease and HIV/AIDS. Findings regarding the effects of psychosocial interventions on disease processes, morbidity and mortality are not yet well established and require appropriate clinical trials.

Lifestyle Intervention for Prevention and Treatment of Type 2 Diabetes

Evidence exists that lifestyle interventions in the prevention and treatment of type 2 diabetes are effective. The present challenge is to translate the evidence into policies and practices that maximize the potential health benefits for the largest number of individuals. Translational efforts are urgently needed to identify how best to identify individuals for lifestyle prevention efforts, prepare health care systems for treatment delivery, and design public health policies that support healthy weight through healthy opportunities for eating and physical activity.

Obesity in older adults: a systematic review of the evidence for diagnosis and treatment

OBJECTIVE

Although obesity is increasing in older U.S. adults, treatment is controversial in this age group. We sought to examine evidence concerning obesity's health-related risks, diagnostic methods, and treatment outcomes in older individuals.

RESEARCH METHODS AND PROCEDURES

We searched MEDLINE and Cochrane Library databases, consulted with experts, and examined bibliographies for English language studies discussing obesity in older adults (mean age > or = 60), published between January 1980 and November 2005. Inclusion criteria were met by 32 longitudinal analyses, seven diagnostic studies, and 17 randomized controlled trial articles. At least two authors independently reviewed and abstracted study design, population, results, and quality information.

RESULTS

Correlations between body fat and three anthropometric measures (BMI, waist circumference, waist-to-hip ratio) decrease with age but remain clinically significant. Obesity contributes to risk for several cardiovascular endpoints, some cancers, and impaired mobility but protects against hip fracture. The association between obesity and mortality declines as age increases. Intensive counseling strategies incorporating behavioral, dietary, and exercise components promote a weight loss of 3 to 4 kg over 1 to 3.3 years. The loss is linked with improved glucose tolerance, improved physical functioning, reduced incidence of diabetes and a combined hypertension and cardiovascular endpoint, and reduced bone density.

DISCUSSION

In older adults, obesity can be diagnosed with standard clinical measures. Intensive counseling can promote modest sustained weight loss, but data are insufficient to evaluate surgical or pharmacological options. Obesity treatment is most likely to benefit individuals with high cardiovascular risk. Limited data suggest possible functional improvement. Treatment should incorporate measures to avoid bone loss.

Development of an obesity prevention and management program for children and adolescents in a rural setting

This study applied theory-based health behavior change constructs to childhood obesity prevention. Constructs such as goal setting, self-efficacy, and readiness for change were used within a rural community-based program designed to be developmentally appropriate for 6th graders. The project included 2 studies across 12 months. The 1st assessed the scope of the obesity problem within a 3-county area with key stakeholders in health and education. The 2nd implemented a pilot community intervention program within a rural middle school. Participants in the intervention included 65 middle-school students and the families of 25 of these students. Qualitative and quantitative analyses were conducted to assess the effectiveness of the intervention. Changes from pre- to postintervention on relevant measures were statistically significant for families but not for students. Issues related to family versus individual behavior change are discussed, along with implications for managing behaviorally based activity and nutrition interventions within a rural community.