An active strategy to identify individuals eligible for type 2 diabetes prevention by lifestyle intervention in Dutch primary care: the APHRODITE study

Cultural adaptation of a peer-led lifestyle intervention program for diabetes prevention in India: the Kerala diabetes prevention program (K-DPP)

BACKGROUND

Type 2 diabetes mellitus (T2DM) is now one of the leading causes of disease-related deaths globally. India has the world's second largest number of individuals living with diabetes. Lifestyle change has been proven to be an effective means by which to reduce risk of T2DM and a number of "real world" diabetes prevention trials have been undertaken in high income countries. However, systematic efforts to adapt such interventions for T2DM prevention in low- and middle-income countries have been very limited to date. This research-to-action gap is now widely recognised as a major challenge to the prevention and control of diabetes. Reducing the gap is associated with reductions in morbidity and mortality and reduced health care costs. The aim of this article is to describe the adaptation, development and refinement of diabetes prevention programs from the USA, Finland and Australia to the State of Kerala, India.

METHODS

The Kerala Diabetes Prevention Program (K-DPP) was adapted to Kerala, India from evidence-based lifestyle interventions implemented in high income countries, namely, Finland, United States and Australia. The adaptation process was undertaken in five phases: 1) needs assessment; 2) formulation of program objectives; 3) program adaptation and development; 4) piloting of the program and its delivery; and 5) program refinement and active implementation.

RESULTS

The resulting program, K-DPP, includes four key components: 1) a group-based peer support program for participants; 2) a peer-leader training and support program for lay people to lead the groups; 3) resource materials; and 4) strategies to stimulate broader community engagement. The systematic approach to adaptation was underpinned by evidence-based behavior change techniques.

CONCLUSION

K-DPP is the first well evaluated community-based, peer-led diabetes prevention program in India. Future refinement and utilization of this approach will promote translation of K-DPP to other contexts and population groups within India as well as other low- and middle-income countries. This same approach could also be applied more broadly to enable the translation of effective non-communicable disease prevention programs developed in high-income settings to create context-specific evidence in rapidly developing low- and middle-income countries.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909 . Registered 10 March 2011.

Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether diet, physical activity or both can prevent or delay T2DM and its associated complications in at-risk people is unknown.

OBJECTIVES

To assess the effects of diet, physical activity or both on the prevention or delay of T2DM and its associated complications in people at increased risk of developing T2DM.

SEARCH METHODS

This is an update of the Cochrane Review published in 2008. We searched the CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, ICTRP Search Portal and reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was January 2017. We continuously used a MEDLINE email alert service to identify newly published studies using the same search strategy as described for MEDLINE up to September 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of two years or more.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology for data collection and analysis. We assessed the overall quality of the evidence using GRADE.

MAIN RESULTS

We included 12 RCTs randomising 5238 people. One trial contributed 41% of all participants. The duration of the interventions varied from two to six years. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains.Eleven trials compared diet plus physical activity with standard or no treatment. Nine RCTs included participants with impaired glucose tolerance (IGT), one RCT included participants with IGT, impaired fasting blood glucose (IFG) or both, and one RCT included people with fasting glucose levels between 5.3 to 6.9 mmol/L. A total of 12 deaths occurred in 2049 participants in the diet plus physical activity groups compared with 10 in 2050 participants in the comparator groups (RR 1.12, 95% CI 0.50 to 2.50; 95% prediction interval 0.44 to 2.88; 4099 participants, 10 trials; very low-quality evidence). The definition of T2DM incidence varied among the included trials. Altogether 315 of 2122 diet plus physical activity participants (14.8%) developed T2DM compared with 614 of 2389 comparator participants (25.7%) (RR 0.57, 95% CI 0.50 to 0.64; 95% prediction interval 0.50 to 0.65; 4511 participants, 11 trials; moderate-quality evidence). Two trials reported serious adverse events. In one trial no adverse events occurred. In the other trial one of 51 diet plus physical activity participants compared with none of 51 comparator participants experienced a serious adverse event (low-quality evidence). Cardiovascular mortality was rarely reported (four of 1626 diet plus physical activity participants and four of 1637 comparator participants (the RR ranged between 0.94 and 3.16; 3263 participants, 7 trials; very low-quality evidence). Only one trial reported that no non-fatal myocardial infarction or non-fatal stroke had occurred (low-quality evidence). Two trials reported that none of the participants had experienced hypoglycaemia. One trial investigated health-related quality of life in 2144 participants and noted that a minimal important difference between intervention groups was not reached (very low-quality evidence). Three trials evaluated costs of the interventions in 2755 participants. The largest trial of these reported an analysis of costs from the health system perspective and society perspective reflecting USD 31,500 and USD 51,600 per quality-adjusted life year (QALY) with diet plus physical activity, respectively (low-quality evidence). There were no data on blindness or end-stage renal disease.One trial compared a diet-only intervention with a physical-activity intervention or standard treatment. The participants had IGT. Three of 130 participants in the diet group compared with none of the 141 participants in the physical activity group died (very low-quality evidence). None of the participants died because of cardiovascular disease (very low-quality evidence). Altogether 57 of 130 diet participants (43.8%) compared with 58 of 141 physical activity participants (41.1%) group developed T2DM (very low-quality evidence). No adverse events were recorded (very low-quality evidence). There were no data on non-fatal myocardial infarction, non-fatal stroke, blindness, end-stage renal disease, health-related quality of life or socioeconomic effects.Two trials compared physical activity with standard treatment in 397 participants. One trial included participants with IGT, the other trial included participants with IGT, IFG or both. One trial reported that none of the 141 physical activity participants compared with three of 133 control participants died. The other trial reported that three of 84 physical activity participants and one of 39 control participants died (very low-quality evidence). In one trial T2DM developed in 58 of 141 physical activity participants (41.1%) compared with 90 of 133 control participants (67.7%). In the other trial 10 of 84 physical activity participants (11.9%) compared with seven of 39 control participants (18%) developed T2DM (very low-quality evidence). Serious adverse events were rarely reported (one trial noted no events, one trial described events in three of 66 physical activity participants compared with one of 39 control participants - very low-quality evidence). Only one trial reported on cardiovascular mortality (none of 274 participants died - very low-quality evidence). Non-fatal myocardial infarction or stroke were rarely observed in the one trial randomising 123 participants (very low-quality evidence). One trial reported that none of the participants in the trial experienced hypoglycaemia. One trial investigating health-related quality of life in 123 participants showed no substantial differences between intervention groups (very low-quality evidence). There were no data on blindness or socioeconomic effects.

AUTHORS' CONCLUSIONS

There is no firm evidence that diet alone or physical activity alone compared to standard treatment influences the risk of T2DM and especially its associated complications in people at increased risk of developing T2DM. However, diet plus physical activity reduces or delays the incidence of T2DM in people with IGT. Data are lacking for the effect of diet plus physical activity for people with intermediate hyperglycaemia defined by other glycaemic variables. Most RCTs did not investigate patient-important outcomes.

Type-2 diabetes primary prevention program implemented in routine primary care: a process evaluation study

Background

Process evaluation studies are recommended to improve our understanding of underlying mechanisms related to clinicians, patients, context and intervention delivery that may impact on trial or program results and on their potential transferability to practice. This paper aims to document the translation of a type-2 diabetes (T2D) prevention program into the routine context of several primary care centers, assessing process indicators related to clinician adoption, patient recruitment, exposure to the intervention components and baseline characteristics.

Methods

An observational descriptive process evaluation study was conducted of the 2.5-year implementation of the Prevention of Diabetes in Euskadi cluster randomized trial in 14 primary care centers of the Basque Health Service (Osakidetza). The clinical intervention consisted of three components: (1) risk screening, (2) an educational intervention promoting healthy lifestyles, and (3) remote support (follow-up). A passive dissemination strategy of providing training and materials was used to translate the intervention into practice. All non-diabetic patients aged 45 to 70 years who were identified as being at high risk of developing T2D were eligible for study inclusion. The RE-AIM framework guided the process evaluation.

Results

Overall, 31.4 % of family physicians and 57.6 % of nurses participated in the study, while 4170 out of 67,293 (6.2 %) targeted patients who attended the centers during the implementation period were reached through the screening. Around half of the screened patients were identified as being at high risk of developing T2D (FINDRISC score ≥14). The rate of refusal to participate and the proportion of women were higher in the intervention group. Finally, 634 and 454 non-diabetic 45- to 70-year-old patients who were at high risk of T2D were included in the control and intervention group centers (intervention reach = 48 %). Significant variability in most process indicators was observed at center level.

Conclusion

The passive dissemination strategy has produced modest process indicators related to the adoption, reach and implementation of the intervention program, and reduced the possibility of its standardized application in heterogeneous contexts. The resulting different procedures and strategies used by the centers were associated with process outcomes. Context-specific variability and possible confounding will require rigorous procedures for analysis of the intervention effects.

Trial registration

The trial was registered in ClinicalTrials.gov (identifier: NCT01365013). Registered on June 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1379-0) contains supplementary material, which is available to authorized users.

A systematic review of real-world diabetes prevention programs: learnings from the last 15 years

Background

The evidence base for the prevention of type 2 diabetes mellitus (T2DM) has progressed rapidly from efficacy trials to real-world translational studies and practical implementation trials over the last 15 years. However, evidence for the effective implementation and translation of diabetes programs and their population impact needs to be established in ways that are different from measuring program effectiveness. We report the findings of a systematic review that focuses on identifying the critical success factors for implementing diabetes prevention programs in real-world settings.

Methods

A systematic review of programs aimed at diabetes prevention was undertaken in order to evaluate their outcomes using the penetration, implementation, participation, and effectiveness (PIPE) impact metric. A search for relevant articles was carried out using PubMed (March 2015) and Web of Science, MEDLINE, CENTRAL, and EMBASE. A quality coding system was developed and included studies were rated independently by three researchers.

Results

Thirty eight studies were included in the review. Almost all (92 %) provided details on participation; however, only 18 % reported the coverage of their target population (penetration). Program intensity or implementation—as measured by frequency of contacts during first year and intervention duration—was identified in all of the reported studies, and 84 % of the studies also reported implementation fidelity; however, only 18 % of studies employed quality assurance measures to assess the extent to which the program was delivered as planned. Sixteen and 26 % of studies reported ‘highly’ or ‘moderately’ positive changes (effectiveness) respectively, based on weight loss. Six (16 %) studies reported ‘high’ diabetes risk reduction but ‘low’ to ‘moderate’ weight loss only.

Conclusion

Our findings identify that program intensity plays a major role in weight loss outcomes. However, programs that have high uptake—both in terms of good coverage of invitees and their willingness to accept the invitation—can still have considerable impact in lowering diabetes risk in a population, even with a low intensity intervention that only leads to low or moderate weight loss. From a public health perspective, this is an important finding, especially for resource constrained settings. More use of the PIPE framework components will facilitate increased uptake of T2DM prevention programs around the world.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-015-0354-6) contains supplementary material, which is available to authorized users.

Response and participation of underserved populations after a three-step invitation strategy for a cardiometabolic health check

Background

Ethnic minority and native Dutch groups with a low socioeconomic status (SES) are underrepresented in cardiometabolic health checks, despite being at higher risk. We investigated response and participation rates using three consecutive inexpensive-to-costly culturally adapted invitation steps for a health risk assessment (HRA) and further testing of high-risk individuals during prevention consultations (PC).

Methods

A total of 1690 non-Western immigrants and native Dutch with a low SES (35–70 years) from six GP practices were eligible for participation. We used a ‘funnelled’ invitation design comprising three increasingly cost-intensive steps: (1) all patients received a postal invitation; (2) postal non-responders were approached by telephone; (3) final non-responders were approached face-to-face by their GP. The effect of ethnicity, ethnic mix of GP practice, and patient characteristics (gender, age, SES) on response and participation were assessed by means of logistic regression analyses.

Results

Overall response was 70 % (n = 1152), of whom 62 % (n = 712) participated in the HRA. This was primarily accomplished through the postal and telephone invitations. Participants from GP practices in the most deprived neighbourhoods had the lowest response and HRA participation rates. Of the HRA participants, 29 % (n = 207) were considered high-risk, of whom 59 % (n = 123) participated in the PC. PC participation was lowest among native Dutch with a low SES.

Conclusions

Underserved populations can be reached by a low-cost culturally adapted postal approach with a reminder and follow-up telephone calls. The added value of the more expensive face-to-face invitation was negligible. PC participation rates were acceptable. Efforts should be particularly targeted at practices in the most deprived areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2139-x) contains supplementary material, which is available to authorized users.

Predictive modeling for incident and prevalent diabetes risk evaluation

With half of individuals with diabetes undiagnosed worldwide and a projected 55% increase of the population with diabetes by 2035, the identification of undiagnosed and high-risk individuals is imperative. Multivariable diabetes risk prediction models have gained popularity during the past two decades. These have been shown to predict incident or prevalent diabetes through a simple and affordable risk scoring system accurately. Their development requires cohort or cross-sectional type studies with a variable combination, number and definition of included risk factors, with their performance chiefly measured by discrimination and calibration. Models can be used in clinical and public health settings. However, the impact of their use on outcomes in real-world settings needs to be evaluated before widespread implementation.

'Check it out!' Decision-making of vulnerable groups about participation in a two-stage cardiometabolic health check: a qualitative study

OBJECTIVE

Exploring determinants influencing vulnerable groups regarding (non-) participation in the Dutch two-stage cardiometabolic health check, comprising a health risk assessment (HRA) and prevention consultations (PCs) for high-risk individuals.

METHODS

Qualitative study comprising 21 focus groups with non-Western (Surinamese, Turkish, Moroccan) immigrants aged 45-70, adult children from one of these descents, native Dutch with a lower socioeconomic status, and healthcare professionals working with these groups.

RESULTS

Reasons for not completing the HRA included (flawed) risk perceptions, health negligence, (health) illiteracy, and language barriers. A face-to-face invitation from a reliable source and community outreach to raise awareness were perceived as facilitating participation. Reasons for not attending the PCs overlapped with completing the HRA but additionally included risk denial, fear about the outcome, its potential consequences (lifestyle changes and medication prescription), and disease-related stigma.

CONCLUSION

Reasons for not completing the HRA were mainly cognitive, whereas reasons for not attending the PCs were also affective.

PRACTICE IMPLICATIONS

When designing a two-stage health check, choice of invitation method seems important, as does training healthcare professionals in techniques to effectively handle patients' (flawed) risk perceptions and attitudinal ambivalence. Focus should be on promoting informed choices by providing accurate information.

Willingness to participate in prevention programs for cardiometabolic diseases

Background

Cardiometabolic diseases are the leading cause of death worldwide and result in decreased quality of life for patients and increased healthcare costs. Population-based prevention programs may prevent the onset and development of cardiometabolic diseases. The effectiveness of these programs depends on participation rates. This study identified factors related to willingness to participate in health checks and lifestyle intervention programs to prevent cardiometabolic diseases.

Methods

A questionnaire was sent to 1,500 Dutch adults, participating in the Dutch Health Care Consumer Panel of NIVEL. The questionnaire was developed by NIVEL. Predictors of willingness to participate were identified with logistic regression analyses. Predictors investigated were socio-demographic variables, risk factors for cardiometabolic diseases and motivational aspects.

Results

The response rate was 63%. 56% of the participants in our study were willing to participate in a health check. Higher age was associated with increased willingness to participate, as was the desire to know the actual risk for cardiometabolic diseases (OR = 4.6). Becoming unnecessarily worried was identified as a barrier (OR = 0.3). 47% were willing to participate in a lifestyle intervention program. People aged 39–65 were most willing to participate. Attention for prevention relapse behavior (OR = 3.3), informing the general practitioner about results (OR = 2.6) and conducting the program in a group (OR = 2.0) were positively associated with willingness to participate in lifestyle interventions.

Conclusions

Willingness to participate in a health check depended on personal beliefs, whereas social aspects contributed most to willingness to participate in a lifestyle intervention program. This information can be used to optimize and tailor the promotion of prevention programs.

10-year risk estimation for type 2 diabetes mellitus and coronary heart disease in Kuwait: a cross-sectional population-based study

BACKGROUND

Type 2 diabetes mellitus (T2DM), coronary heart disease (CHD) and metabolic syndrome (MetS) are major healthcare problems in Kuwait. The present study was designed to determine the prevalence of MetS, and to estimate the 10-year risk for developing T2DM and CHD among the general population in Kuwait.

METHODS

A descriptive, cross-sectional survey was undertaken in 1800 individuals without diabetes or a history of cardiovascular disease (CVD). They were selected from six governorates using two stage convenience sampling. The questionnaire was developed using the Finnish Diabetes Risk Score (FINDRISK), Framingham Risk Score [FRS] and the 2009 Joint Statement criteria for diagnosis of MetS as a framework. Descriptive and multivariate logistic regression analyses were used.

RESULTS

The response rate was 89.4%. More than half (60.8%; 95% CI: 58.4-63.2) of responders were either overweight or obese. One hundred and ninety seven (12.2%) subjects had blood pressure (BP) ≥ 140/90 mm Hg. Almost three-in-ten (28.3%: 26.2-30.6) subjects had fasting plasma glucose (FPG) levels ≥ 5.6 mmol/l, of whom 86.0% and 14.0% had impaired fasting glucose (IFG) and screen detected T2DM, respectively. MetS was present in 512 (31.8%; 29.5-34.2) respondents. Just under one third (n = 481; 29.9%; 27.7-32.2) of participants were at moderate, high, or very high risk of developing T2DM, while 283 (17.6%: 15.8-19.6) were at moderate/high 10-year risk of developing CHD. Approximately one-in-ten (8.5%; 7.2-9.9) subjects were at moderate/high/very high 10-year risk of developing both T2DM/CHD. T2DM risk was higher for females compared to males (p < 0.001); however, the pattern was reversed in terms of the risk of developing CHD or T2DM/CHD. The risk of developing T2DM, CHD, or T2DM/CHD was greater among those aged ≥ 45 years, and those having MetS (p<0.001).

CONCLUSIONS

The current findings highlight the need for multifaceted interventions for prevention.

Behavior change in a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention content

BACKGROUND

Despite the favorable effects of behavior change interventions on diabetes risk, lifestyle modification is a complicated process. In this study we therefore investigated opportunities for refining a lifestyle intervention for type 2 diabetes prevention, based on participant perceptions of behavior change progress.

METHODS

A 30 month intervention was performed in Dutch primary care among high-risk individuals (FINDRISC-score ≥ 13) and was compared to usual care. Participant perceptions of behavior change progress for losing weight, dietary modification, and increasing physical activity were assessed after18 months with questionnaires. Based on the response, participants were categorized as 'planners', 'initiators' or 'achievers' and frequencies were evaluated in both study groups. Furthermore, participants reported on barriers for lifestyle change.

RESULTS

In both groups, around 80% of all participants (intervention: N = 370; usual care: N = 322) planned change. Except for reducing fat intake (p = 0.08), the number of initiators was significantly higher in the intervention group than in usual care. The percentage of achievers was high for the dietary and exercise objectives (intervention: 81-95%; usual care: 83-93%), but was lower for losing weight (intervention: 67%; usual care: 62%). Important motivational barriers were 'I already meet the standards' and 'I'm satisfied with my current behavior'. Temptation to snack, product taste and lack of time were important volitional barriers.

CONCLUSIONS

The results suggest that the intervention supports participants to bridge the gap between motivation and action. Several opportunities for intervention refinement are however revealed, including more stringent criteria for participant inclusion, tools for (self)-monitoring of health, emphasis on the 'small-step-approach', and more attention for stimulus control.

TRIAL REGISTRATION

Netherlands Trial Register: NTR1082.

Health care providers' perspective on using family history in the prevention of type 2 diabetes: a qualitative study including different disciplines

BACKGROUND

Family history (FH) is considered an important factor to detect individuals at increased risk developing type 2 diabetes (T2D). Moreover, FH information could be used to personalise risk messages, which are assumed to increase risk-reducing behaviours. In this study, we aimed to explore Dutch health care professionals' attitudes regarding current or future uptake of a more extensive use of FH information and the family system in diabetes prevention.

METHODS

Semi-structured interviews were conducted with nineteen health care professionals from six general practices and four outpatient diabetes clinics. The use of FH information in opportunistic screening for T2D was explored, as well as the usability of a direct versus patient-mediated targeting strategy to reach persons with a FH of T2D. Three researchers analysed the interview transcripts separately.

RESULTS

Dutch health care professionals considered FH an important risk factor in opportunistic screening for T2D. However, none of them used FH to promote risk-reducing behaviours. Directly targeting and educating patients known to have a FH of T2D was desirable for most primary care professionals, but not considered feasible. Findings indicated that FH information was not systematically gathered in primary care settings and electronic medical records were not equipped to retrieve persons with T2D running in their family. The idea of asking patients to pass on risk and preventive information was new to all interviewees, but was considered an acceptable strategy to reach persons with a FH of diabetes. Nevertheless, there were concerns about the accuracy of the messages delivered by the patients to their relatives. Practical barriers with regard to time, expertise, and financial reimbursement were also mentioned.

CONCLUSIONS

There is great interest among healthcare professionals in primary as well as secondary care about the use of FH to prevent T2D, but there are significant barriers against such use. The removal of these barriers would depend on evidence showing the cost-effectiveness of FH-based strategies designed to prevent T2D.

Non-participation in population-based disease prevention programs in general practice

BACKGROUND

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

METHODS

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

RESULTS

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

CONCLUSIONS

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Non-participation in population-based disease prevention programs in general practice

Background

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

Methods

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

Results

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

Conclusions

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Implementation of a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention delivery

Background

As in clinical practice resources may be limited compared to experimental settings, translation of evidence-based lifestyle interventions into daily life settings is challenging. In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care. Based on this evaluation we discuss opportunities for refining intervention delivery.

Methods

A 2.5-year intervention was performed in 14 general practices in the Netherlands among individuals at high risk for type 2 diabetes (FINDRISC-score ≥ 13) (n = 479) and was compared to usual care (n = 446). Intervention consisted of individual lifestyle counselling by nurse practitioners (n = 24) and GPs (n = 48) and group-consultations. Drop-out and attendance were registered during the programme. After the intervention, satisfaction with the programme and perceived implementation barriers were assessed with questionnaires.

Results

Drop-out was modest (intervention: 14.6 %; usual care: 13.2 %) and attendance at individual consultations was high (intervention: 80-97 %; usual care: 86-94 %). Providers were confident about diabetes prevention by lifestyle intervention in primary care. Participants were more satisfied with counselling from nurse practitioners than from GPs. A major part of the GPs reported low self-efficacy regarding dietary guidance. Lack of counselling time (60 %), participant motivation (12 %), and financial reimbursement (11 %) were regarded by providers as important barriers for intervention implementation.

Conclusions

High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling. Results support a role for the nurse practitioner as the key player in guiding lifestyle modification. Further research is needed on strategies that could increase cost-effectiveness, such as more stringent criteria for participant inclusion, group-counselling, more tailor-made counselling and integration of screening and / or interventions for different disorders.

A lifestyle intervention to reduce Type 2 diabetes risk in Dutch primary care: 2.5-year results of a randomized controlled trial

AIMS

To determine the effectiveness of a 2.5-year lifestyle intervention for Type 2 diabetes prevention in Dutch general practice compared with usual care.

METHODS

A randomized controlled trial of 925 individuals at high risk for Type 2 diabetes (FINDRISC-score ≥ 13) in 14 general practices in the Netherlands. Intervention consisted of lifestyle counselling from the nurse practitioner and the general practitioner. Usual care consisted of oral and written information at the start of the study. Study groups were compared over 2.5 years regarding changes in clinical and lifestyle measures.

RESULTS

Both groups showed modest changes in body weight, glucose concentrations, physical activity and dietary intake [weight: intervention group, -0.8 (5.1) kg, usual care group, -0.4 (4.7) kg, (P=0.69); fasting plasma glucose: intervention group, -0.17 (0.4) mmol/l, usual care group, -0.10 (0.5) mmol/l, (P=0.10)]. Differences between groups were significant only for total physical activity and fibre intake. In the intervention group, self-efficacy was significantly higher in individuals successful at losing weight compared with unsuccessful individuals. No significant differences in participant weight loss were found between general practitioners and nurse practitioners with different levels of motivation or self-efficacy.

CONCLUSIONS

Diabetes risk factors could significantly be reduced by lifestyle counselling in Dutch primary care. However, intervention effects above the effects attributable to usual care were modest. Higher participant self-efficacy seemed to facilitate weight loss. Lack of motivation or self-efficacy of professionals did not negatively influence participant guidance.

Risk models and scores for type 2 diabetes: systematic review

OBJECTIVE

To evaluate current risk models and scores for type 2 diabetes and inform selection and implementation of these in practice.

DESIGN

Systematic review using standard (quantitative) and realist (mainly qualitative) methodology. Inclusion criteria Papers in any language describing the development or external validation, or both, of models and scores to predict the risk of an adult developing type 2 diabetes.

DATA SOURCES

Medline, PreMedline, Embase, and Cochrane databases were searched. Included studies were citation tracked in Google Scholar to identify follow-on studies of usability or impact.

DATA EXTRACTION

Data were extracted on statistical properties of models, details of internal or external validation, and use of risk scores beyond the studies that developed them. Quantitative data were tabulated to compare model components and statistical properties. Qualitative data were analysed thematically to identify mechanisms by which use of the risk model or score might improve patient outcomes.

RESULTS

8864 titles were scanned, 115 full text papers considered, and 43 papers included in the final sample. These described the prospective development or validation, or both, of 145 risk prediction models and scores, 94 of which were studied in detail here. They had been tested on 6.88 million participants followed for up to 28 years. Heterogeneity of primary studies precluded meta-analysis. Some but not all risk models or scores had robust statistical properties (for example, good discrimination and calibration) and had been externally validated on a different population. Genetic markers added nothing to models over clinical and sociodemographic factors. Most authors described their score as "simple" or "easily implemented," although few were specific about the intended users and under what circumstances. Ten mechanisms were identified by which measuring diabetes risk might improve outcomes. Follow-on studies that applied a risk score as part of an intervention aimed at reducing actual risk in people were sparse.

CONCLUSION

Much work has been done to develop diabetes risk models and scores, but most are rarely used because they require tests not routinely available or they were developed without a specific user or clear use in mind. Encouragingly, recent research has begun to tackle usability and the impact of diabetes risk scores. Two promising areas for further research are interventions that prompt lay people to check their own diabetes risk and use of risk scores on population datasets to identify high risk "hotspots" for targeted public health interventions.

Lifestyle counseling for type 2 diabetes risk reduction in Dutch primary care: results of the APHRODITE study after 0.5 and 1.5 years

OBJECTIVE To study the overall effect of the Active Prevention in High-Risk Individuals of Diabetes Type 2 in and Around Eindhoven (APHRODITE) lifestyle intervention on type 2 diabetes risk reduction in Dutch primary care after 0.5 and 1.5 years and to evaluate the variability between general practices. RESEARCH DESIGN AND METHODS Individuals at high risk for type 2 diabetes (Finnish Diabetes Risk Score ≥13) were randomly assigned into an intervention group (n = 479) or a usual-care group (n = 446). Comparisons were made between study groups and between general practices regarding changes in clinical and lifestyle measures over 1.5 years. Participant, general practitioner, and nurse practitioner characteristics were compared between individuals who lost weight or maintained a stable weight and individuals who gained weight. RESULTS Both groups showed modest changes in glucose values, weight measures, physical activity, energy intake, and fiber intake. Differences between groups were significant only for total physical activity, saturated fat intake, and fiber intake. Differences between general practices were significant for BMI and 2-h glucose but not for energy intake and physical activity. In the intervention group, the nurse practitioners' mean years of work experience was significantly longer in individuals who were successful at losing weight or maintaining a stable weight compared with unsuccessful individuals. Furthermore, successful individuals more often had a partner. CONCLUSIONS Risk factors for type 2 diabetes could be significantly reduced by lifestyle counseling in Dutch primary care. The small differences in changes over time between the two study groups suggest that additional intervention effects are modest. In particular, the level of experience of the nurse practitioner and the availability of partner support seem to facilitate intervention success.