Development and evaluation of an enhanced diabetes prevention program with psychosocial support for urban American Indians and Alaska natives: A randomized controlled trial

"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

Breaking down silos: the multifaceted nature of obesity and the future of weight management

The continued global increase in the prevalence of obesity prompted a meeting at the Royal Society of London investigating causal mechanisms of the disease, 'Causes of obesity: theories, conjectures, and evidence' in October 2022. Evidence presented indicates areas of obesity science where there have been advancements, including an increased understanding of biological and physiological processes of weight gain and maintenance, yet it is clear there is still debate on the relative contribution of plausible causes of the modern obesity epidemic. Consensus was reached that obesity is not a reflection of diminished willpower, but rather the confluence of multiple, complex factors. As such, addressing obesity requires multifactorial prevention and treatment strategies. The accumulated evidence suggests that a continued focus primarily on individual-level contributors will be suboptimal in promoting weight management at the population level. Here, we consider individual biological and physiological processes within the broader context of sociodemographic and sociocultural exposures as well as environmental changes to optimize research priorities and public health efforts. This requires a consideration of a systems-level approach that efficiently addresses both systemic and group-specific environmental determinants, including psychosocial factors, that often serve as a barrier to otherwise efficacious prevention and treatment options. This article is part of a discussion meeting issue 'Causes of obesity: theories, conjectures and evidence (Part I)'.

Systemic and Environmental Contributors to Obesity Inequities in Marginalized Racial and Ethnic Groups

Obesity is a multifactorial disease that disproportionally affects diverse racial and ethnic groups. Structural racism influences racial inequities in obesity prevalence through environmental factors, such as racism and discrimination, socioeconomic status, increased levels of stress, and bias in the health care delivery system. Researchers, clinicians, and policy makers must work to address the environmental and systematic barriers that contribute to health inequities in the United States. Specifically, clinicians should quantitatively and qualitatively assess environmental and social factors and proactively engage in patient-centered care to tailor available treatments based on identified needs and experiences.

Stress and Cardiometabolic Disease Risk for Indigenous Populations throughout the Lifespan

BACKGROUND

Indigenous people experience the greatest cardiometabolic disease disparity in the Unites States, yet high cardiometabolic disease risk factors do not fully explain the extent of the cardiometabolic disease disparity for Indigenous people. Stress, trauma, and racism occur at high rates within Indigenous communities and have not been well explored as significant contributors to cardiometabolic disease disparities despite emerging literature, and therefore will be described here.

METHODS

This descriptive study explores the relationship between cardiometabolic disease risks and Indigenous-specific stressors (e.g., early childhood stress and trauma, adulthood stress and trauma, and historical and intergenerational trauma) using current literature. Indigenous-specific protective factors against cardiometabolic disease are also reviewed.

RESULTS

Increasing research indicates that there is a relationship between Indigenous-specific stressful and traumatic life experiences and increased cardiometabolic disease risk. Mental health and psychophysiology play an important role in this relationship. Effective interventions to reduce cardiometabolic disease risk in Indigenous communities focus on ameliorating the negative effects of these stressors through the use of culturally specific health behaviors and activities.

CONCLUSIONS

There is increasing evidence that cultural connection and enculturation are protective factors for cardiometabolic disease, and may be galvanized through Indigenous-led training, research, and policy change.

Negative emotions in community-dwelling adults with prediabetes and hypertension

Objective

The purpose of this study was to investigate negative emotions and factors related to the risk of mental disorders in individuals with prediabetes and hypertension.

Methods

A total of 504 community-dwelling adult men and women in Suzhou, China, were enrolled and questionnaires used to obtain sociodemographic data, anxiety and depression scores, and current status of common metabolic indicators, including blood glucose level and blood pressure.

Results

Anxiety and depression scores in participants with prediabetes and hypertension were significantly higher than those in participants with normal blood glucose levels and normal blood pressure. Correlation analysis revealed that age, sex, smoking, duration of disease, physical activity, blood pressure and fasting plasma glucose levels were key factors accelerating the progression to both anxiety and depression in all participants.

Conclusions

More attention should be paid to negative emotions in individuals with prediabetes and hypertension. These findings could help to inform health providers in developing interventions for this population.

Comparing enhanced versus standard Diabetes Prevention Program among indigenous adults in an urban setting: a randomized controlled trial

Background

Indigenous people in the United States are at high risk for diabetes. Psychosocial stressors like historical trauma may impede success in diabetes prevention programs.

Methods

A comparative effectiveness trial compared a culturally tailored diabetes prevention program (standard group) with an enhanced one that addressed psychosocial stressors (enhanced group) in 2015 to 2017. Participants were 207 Indigenous adults with a body mass index (BMI) of ≥30 and one additional criterion of metabolic syndrome, and were randomized to the standard or enhanced group. Both groups received a culturally tailored behavioral diabetes prevention program. Strategies to address psychosocial stressors were provided to the enhanced group only. Change in BMI over 12 months was the primary outcome. Secondary outcomes included change in quality of life, and clinical, behavioral, and psychosocial measures at 6 and 12 months.

Results

The two groups did not significantly differ in BMI change at 12 months. The two groups also did not differ in any secondary outcomes at 6 or 12 months, with the exception of unhealthy food consumption; the standard group reported a larger mean decrease (95% CI) in consumption of unhealthy food compared with the enhanced group (− 4.6 [− 6.8, − 2.5] vs. -0.7 [− 2.9, 1.4], p = 0.01). At 6 months, significant improvements in weight and the physical component of the quality of life measure were observed for both groups compared with their baseline level. Compared with baseline, at 12 months, the standard group showed significant improvement in BMI (mean [95% CI], − 0.5 [− 1.0, − 0.1]) and the enhanced group showed significant improvement in the physical component of the quality of life (2.9 [0.7, 5.2]).

Conclusions

Adding strategies to address psychosocial barriers to a culturally tailored diabetes prevention program was not successful for improving weight loss among urban Indigenous adults.

Trial Registration

(if applicable): NCT02266576. Registered October 17, 2014 on clinicaltrials.gov. The trial was prospectively registered.

Academic and Government Partnerships to Address Diabetes in the USA: a Narrative Review

PURPOSE OF REVIEW

Multi-sector partnerships are broadly considered to be of value for diabetes prevention and management. The purpose of this article is to summarize academic and government collaborations focused on diabetes prevention and management.

RECENT FINDINGS

Using a narrative review approach, we identified 17 articles describing 10 academic and government partnerships for diabetes management and surveillance. Challenges and gaps in the literature include complexity of diabetes management vis a vis current healthcare infrastructure; a paucity of racial/ethnic diversity in translational efforts; and the time/effort needed to maintain strong relationships across partner institutions. Academic and government partnerships are of value for diabetes prevention and management activities. Acknowledgment that the key priorities of government programming are often costs and feasibility is critical for collaborations to be successful. Future translational efforts of diabetes prevention and management programs should focus on the following: (1) expansion of partnerships between academia and local health departments; (2) increased utilization of implementation science for enhanced and efficient implementation and dissemination; and (3) harnessing of technological advances for data analysis, patient communication, and report generation.