Special diabetes program for Indians: retention in cardiovascular risk reduction

Change in physical activity, food choices and hemoglobin A1c among American Indians and Alaska Natives with type 2 diabetes

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At baseline, physically active participants with higher healthy food scores had lower HbA1c levels than non-active participants.

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Over the three-year period, women who increased physical activity and/or healthy food consumption had slightly decreased HbA1c.

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Changes in physical activity and HbA1c differed by gender.

The prevalence of diabetes among American Indian and Alaska Native (AI/AN) adults is the highest of all United States racial/ethnic groups. Health behaviors, including regular physical activity and healthy food choices, are important components in the management of diabetes. We estimated the cross-sectional association between physical activity and healthy food scores, separately, and combined (PAHF) with hemoglobin A1c (HbA1c) over three years of the Special Diabetes Program for Indians-Healthy Heart demonstration project (SDPI-HH) intervention. The relationship between physical activity and food choices was also examined. Among 3,039 SDPI-HH participants at baseline, those reporting being physically active and having high healthy food scores had statistically significant lower HbA1c (mean = 7.67 ± 2.01) compared to inactive participants with low healthy food scores (7.90 ± 1.92). Among the 1,150 SDPI-HH participants who attended the three-year follow-up visit, participants who increased physical activity, consumption of healthy foods, or both had a larger decrease in HbA1c (β = -0.29, P = 0.03) over the study period compared to participants with no improvement in physical activity or increase in consuming healthy foods. This association was statistically significant among women (β = -0.35, P = 0.04) but not among men (β = -0.08, P = 0.70). Our findings indicated that an increase in healthier behaviors, including physical activity and healthy food choices, was associated with a small improvement in HbA1c in the subset of women who participated in the SDPI-HH through the three-year follow up. Although the decrease in HbA1c was small, physical activity and healthy food choices are important behaviors to incorporate into everyday life among AI/AN adults, particularly those with diabetes.

Aging and Health of American Indians and Alaska Natives: Contributions from the Native Investigator Development Program

Objectives: To describe recent advances in our knowledge regarding the health and illness of older American Indians and Alaska Natives, and factors underlying why this special population lives 5.5 years less than the 78.5 years of U.S. all races. Methods: The articles in this supplemental issue, authored by participants in a National Institutes of Health-sponsored early research career development program, examine high priority health concerns that contribute to the increased risk of Native elders for chronic disease and resulting impairment that compromise their life expectancy. Results: Important insights into the roles that racial discrimination, food security, hypertension, alcohol consumption, memory problems, and military service play in the health and well-being of older American Indians and Alaska Natives. Discussion: Early career faculty development programs focused on increasing the diversity of the scientific workforce not only promote greater racial and ethnic minority representation in the field of aging, but can simultaneously add to the knowledge base regarding the health status and function of often ignored, vulnerable older members of communities that suffer significant health disparities.

Perceived Discrimination, Retention, and Diabetes Risk Among American Indians and Alaska Natives in a Diabetes Lifestyle Intervention

Objectives: To examine the association of perceived discrimination with participant retention and diabetes risk among American Indians and Alaska Natives. Methods: Data were drawn from the Special Diabetes Program for Indians-Diabetes Prevention Demonstration Project (N = 2553). Results: Perceived discrimination was significantly and negatively associated with short-term and long-term retention and diabetes risk without adjusting. After controlling for socioeconomic characteristics and clinical outcomes, perceived discrimination was not associated with retention but was significantly associated with less improvement in body mass index (BMI) and high-density lipoprotein (HDL) cholesterol. Every unit increase in the perceived discrimination score was associated with 0.14 kg/m2 less BMI reduction (95% CI: [0.02, 0.26], p = 0.0183) and 1.06 mg/dl lower HDL at baseline (95% CI: [0.36, 1.76], p = 0.0028). Discussion: Among racialized groups, improving retention and health in lifestyle interventions may require investigating perceived discrimination and the broader context of structural racism and colonialism.

Parental Ethnic Identity and Its Influence on Children's Oral Health in American Indian Families

Objectives: To examine the relationship between ethnic identity and oral health knowledge, beliefs, behavior, and outcomes in American Indian families. Methods: Secondary data were analyzed for 579 parent–child dyads in a randomized controlled trial aimed at reducing early childhood caries in a Northern Plains tribal community. Data included demographic characteristics; parental ethnic identity; oral health knowledge, beliefs, and behavior; and parental/pediatric oral health outcomes. Ethnic identity was assessed using two measures: perceived importance of tribal identity and tribal language proficiency. We examined the association of baseline ethnic identity with baseline and longitudinal oral health measures. Results: At baseline, importance of tribal identity was significantly associated with several oral health beliefs, and one’s locus of control measure (external-chance). Baseline scores on importance of tribal identity were also associated with one’s oral heath belief (perceived severity), the same locus of control measure, and oral health knowledge and behavior over the three years of study follow up. Tribal language proficiency was not associated with any study measures at baseline, although it was associated with parental oral health status over the three years. Conclusions: Ethnic identity was associated with a range of oral health constructs expected to influence American Indian children’s oral health.

The Prevalence of Cardiovascular Disease and Other Comorbidities Among American Indian and Alaska Native Adults with Diabetes

AIMS

American Indians and Alaska Native (AI/ANs) peoples experience significant health disparities compared to the U.S. general population. We report comorbidities among AI/ANs with diabetes to guide efforts to improve their health status.

METHODS

Drawing upon data for over 640,000 AI/ANs who used services funded by the Indian Health Service, we identified 43,518 adults with diabetes in fiscal year 2010. We reported the prevalence of comorbidities by age and cardiovascular disease (CVD) status. Generalized linear models were estimated to describe associations between CVD and other comorbidities.

RESULTS

Nearly 15% of AI/AN adults had diabetes. Hypertension, CVD and kidney disease were comorbid in 77.9%, 31.6%, and 13.3%, respectively. Nearly 25% exhibited a mental health disorder; 5.7%, an alcohol or drug use disorder. Among AI/ANs with diabetes absent CVD, 46.9% had 2 or more other chronic conditions; the percentage among adults with diabetes and CVD was 75.5%. Hypertension and tobacco use disorders were associated with a 71% (95% CI for prevalence ratio: 1.63 - 1.80) and 33% (1.28 - 1.37) higher prevalence of CVD, respectively, compared to adults without these conditions.

CONCLUSION

Detailed information on the morbidity burden of AI/ANs with diabetes may inform enhancements to strategies implemented to prevent and treat CVD and other comorbidities.

Association of Ethnic Identity with Oral Health Knowledge, Attitudes, Behavior, and Outcomes on the Navajo Nation

American Indians and Alaska Natives (AI/ANs) experience poor oral health. Children and adults living on the Navajo Nation have a particularly high rate of dental decay. The literature suggests that health outcomes are often associated with the strength of one's ethnic identity. We investigated the association of ethnic identity among Native parents with oral health knowledge, attitudes, behavior, and outcomes. Analyses used baseline data from a randomized controlled trial designed to reduce dental decay among AI/AN preschoolers enrolled in the Navajo Nation Head Start Program. Greater perceived importance of ethnic identity was associated with better oral health knowledge and attitudes but was unassociated with oral health behavior and was linked to worse oral health status. Parents who were better able to speak their tribal language had greater confidence in their ability to manage their children's oral health, engaged in better oral health behavior, and reported better parental oral health status.

Patient-provider relationship and perceived provider weight bias among American Indians and Alaska Natives

Objective

The objective of this study was to examine patient-provider relationships among American Indians and Alaska Native (AI/AN) patients by examining associations between patient activation, perceived provider weight bias and working alliance. Patient activation is generally defined as having the knowledge, skills and confidence to manage one's health.

Methods

Among a sample of 87 AI/AN adults presenting for general medical care at an urban clinic in the north-west region of the USA, ordinary least squares regression analysis was completed to examine associations.

Results

Better working alliance scores were associated with increased patient activation, while perceived provider weight bias was associated with reduced patient activation. In addition, those with class II obesity had decreased patient activation.

Conclusion

These findings point to the importance of a positive patient-provider relationship in AI/ANs. Optimal patient engagement and subsequent health outcomes warrant additional consideration of patients' perceptions of provider weight bias within the context of health promotion and interventions.

Derivation and Evaluation of a Risk-Scoring Tool to Predict Participant Attrition in a Lifestyle Intervention Project

Participant attrition in clinical trials and community-based interventions is a serious, common, and costly problem. In order to develop a simple predictive scoring system that can quantify the risk of participant attrition in a lifestyle intervention project, we analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), an evidence-based lifestyle intervention to prevent diabetes in 36 American Indian and Alaska Native communities. SDPI-DP participants were randomly divided into a derivation cohort (n = 1600) and a validation cohort (n = 801). Logistic regressions were used to develop a scoring system from the derivation cohort. The discriminatory power and calibration properties of the system were assessed using the validation cohort. Seven independent factors predicted program attrition: gender, age, household income, comorbidity, chronic pain, site's user population size, and average age of site staff. Six factors predicted long-term attrition: gender, age, marital status, chronic pain, site's user population size, and average age of site staff. Each model exhibited moderate to fair discriminatory power (C statistic in the validation set: 0.70 for program attrition, and 0.66 for long-term attrition) and excellent calibration. The resulting scoring system offers a low-technology approach to identify participants at elevated risk for attrition in future similar behavioral modification intervention projects, which may inform appropriate allocation of retention resources. This approach also serves as a model for other efforts to prevent participant attrition.

Assessing the Everyday Discrimination Scale among American Indians and Alaska Natives

The Everyday Discrimination Scale (EDS) has been used widely as a measure of subjective experiences of discrimination. The usefulness of this measure for assessments of perceived experiences of discrimination by American Indian and Alaska Native (AI/AN) peoples has not been explored. Data derived from the Special Diabetes Program for Indians--Healthy Heart Demonstration Project (SDPI-HH), a large-scale initiative to reduce cardiovascular risk among AI/ANs with Type 2 diabetes. Participants (N = 3,039) completed a self-report survey that included the EDS and measures of convergent and divergent validity. Missing data were estimated by multiple imputation techniques. Reliability estimates for the EDS were calculated, yielding a single factor with high internal consistency (α = .92). Younger, more educated respondents reported greater perceived discrimination; retired or widowed respondents reported less. Convergent validity was evidenced by levels of distress, anger, and hostility, which increased as the level of perceived discrimination increased (all p < .001). Divergent validity was evidenced by the absence of an association between EDS and resilient coping. Resilient coping and insulin-specific diabetes knowledge were not significantly associated with perceived discrimination (p = .61 and 0.16, respectively). However, general diabetes-related health knowledge was significantly associated with perceived discrimination (p = .02). The EDS is a promising measure for assessing perceived experiences of discrimination among those AI/ANs who participated in the SDPI-HH.

Participant and site characteristics related to participant retention in a diabetes prevention translational project

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50 % of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

Socioeconomic Disparities in Weight and Behavioral Outcomes Among American Indian and Alaska Native Participants of a Translational Lifestyle Intervention Project

OBJECTIVE

To investigate possible socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native (AI/AN) participants in a translational diabetes prevention project.

RESEARCH DESIGN AND METHODS

We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, an evidence-based lifestyle intervention to prevent diabetes in 36 AI/AN grantee sites. A total of 2,553 participants started the 16-session Lifestyle Balance Curriculum between 1 January 2006 and 31 July 2008. Linear mixed models were used to evaluate the relationships of participant and staff socioeconomic characteristics with weight and behavioral outcomes at the end of the curriculum.

RESULTS

A strong, graded association existed between lower household income and less BMI reduction, which remained significant after adjusting for other socioeconomic characteristics. Compared with others, participants with annual income <$15,000 also had less improvement in physical activity and unhealthy food consumption in bivariate models, but the relationships were only marginally significant in multivariate regressions. Furthermore, grantee sites with fewer professionally prepared staff were less successful at improving participant BMI and healthy food consumption than the other sites. The strong association between income and BMI reduction was reduced by 20-30% in the models with changes in diet variables but was unrelated to changes in physical activity.

CONCLUSIONS

Significant socioeconomic disparities exist in weight outcomes of lifestyle intervention at both participant and site staff levels. Helping low-income participants choose more affordable healthy foods and increasing the proportion of professionally trained staff might be practical ways to maximize the effectiveness of lifestyle interventions implemented in "real-world" settings.

The role of session zero in successful completion of chronic disease self-management program workshops

BACKGROUND

The Chronic Disease Self-Management Program (CDSMP) has been widely disseminated among various racial and ethnic populations. In addition to the six required CDSMP workshop sessions, the delivery sites have the option to offer a Session Zero (or zero class), an information session offered prior to Session One as a marketing tool. Despite assumptions that a zero class is helpful, little is known about the prevalence of these additional sessions or their impact on retaining participants in CDSMP workshops. This study aims to describe the proportion of CDSMP workshops that offered Session Zero and examine the association between Session Zero and workshop completion rates.

METHODS

Data were analyzed from 80,987 middle-aged and older adults collected during a two-year national dissemination of CDSMP. Generalized estimating equation regression analyses were conducted to assess the association between Session Zero and successful workshop completion (attending four or more of the six workshop sessions).

RESULTS

On average, 21.04% of the participants attended workshops that offered Session Zero, and 75.33% successfully completed the CDSMP workshop. The participants of the workshops that offered Session Zero had significantly higher odds of completing CDSMP workshops than those who were not offered Session Zero (OR = 1.099, P = <0.001) after controlling for participants' demographic characteristics, race, ethnicity, living status, household income, number of chronic conditions, and workshop delivery type.

CONCLUSION

As one of the first studies reporting the importance of an orientation session for participant retention in chronic disease management intervention projects, our findings suggest offering an orientation session may increase participant retention in similar translational efforts.

Serious Psychological Distress and Diabetes Management among American Indians and Alaska Natives

OBJECTIVE

Our study examined associations between serious psychological distress and blood glucose level (HbA1c) and body mass index (BMI) among American Indian and Alaska Native (AI/AN) participants in a cardiovascular disease prevention program.

DESIGN

Using linear regression, we assessed the relationships between serious psychological distress and HbA1c and BMI at baseline and one year later. SETTING, PARTICIPANTS, AND INTERVENTION: AI/AN participants were aged 18 years, diagnosed with type 2 diabetes, and enrolled in the Special Diabetes Project for Indians Healthy Heart Project.

MAIN OUTCOME MEASURES

Outcomes were percentage of HbA1c and BMI, measured at enrollment and first annual exam. Both outcomes were continuous measures in all analyses.

RESULTS

Serious psychological distress was associated at baseline with increased HbA1c in the unadjusted and adjusted models (adjusted b = .17%, P < 0.01). Serious psychological distress also was associated at baseline with increased BMI (.635 kg/m2, P = .01) and at one year with increased BMI (0.174 kg/m2, P = .01) in the unadjusted model. After adjustment for demographic and health characteristics, these relationships were no longer significant.

CONCLUSIONS

Cross-sectional baseline findings are consistent with existing literature. One-year findings suggest need for further inquiry into mediators of psychological distress and examination of additional diabetes-specific health outcomes. Additional years of observation may be needed to disentangle relationships between serious psychological distress and BMI.

Case management to reduce cardiovascular disease risk in American Indians and Alaska Natives with diabetes: results from the Special Diabetes Program for Indians Healthy Heart Demonstration Project

OBJECTIVES

We evaluated cardiovascular disease (CVD) risk factors in American Indians/Alaska Natives (AI/ANs) with diabetes in the Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project.

METHODS

Multidisciplinary teams implemented an intensive case management intervention among 30 health care programs serving 138 tribes. The project recruited 3373 participants, with and without current CVD, between 2006 and 2009. We examined data collected at baseline and 1 year later to determine whether improvements occurred in CVD risk factors and in Framingham coronary heart disease (CHD) risk scores, aspirin use, and smoking status.

RESULTS

A1c levels decreased an average of 0.2% (P < .001). Systolic and diastolic blood pressure, low-density lipoprotein (LDL) cholesterol, and triglyceride levels decreased, with the largest significant reduction in LDL cholesterol (∆ = -5.29 mg/dL; P < .001). Average Framingham CHD risk scores also decreased significantly. Aspirin therapy increased significantly, and smoking decreased. Participants with more case management visits had significantly greater reductions in LDL cholesterol and A1c values.

CONCLUSIONS

SDPI-HH successfully translated an intensive case management intervention. Creative retention strategies and an improved understanding of organizational challenges are needed for future Indian health translational efforts.

Community-responsive interventions to reduce cardiovascular risk in American Indians

American Indian and Alaska Native (AI/AN) populations bear a heavy burden of cardiovascular disease (CVD), and they have the highest rates of risk factors for CVD, such as cigarette smoking, obesity, and diabetes, of any U.S. population group. Yet, few randomized controlled trials have been launched to test potential preventive interventions in Indian Country. Five randomized controlled trials were initiated recently in AI/AN communities to test the effectiveness of interventions targeting adults and/or children to promote healthy behaviors that are known to impact biological CVD risk factors. This article provides a context for and an overview of these five trials. The high burden of CVD among AI/AN populations will worsen unless behaviors and lifestyles affecting CVD risk can be modified. These five trials, if successful, represent a starting point in addressing these significant health disparities.

Translating Findings from Lifestyle Intervention Trials of Cardiovascular Disease and Diabetes to the Primary Care Setting

Preventing or delaying type 2 diabetes and cardiovascular disease is a key public health issue. Large, randomized, clinical trials have shown that intensive lifestyle interventions can be used to prevent or delay type 2 diabetes and to improve cardiovascular disease risk factors, but the key question that remains is how to best translate the results from these large, clinical trials into interventions that can be effectively delivered in primary care and community-based settings. Several effective approaches have been identified and tested. New research examining specific physical activity or dietary behaviors also has identified new behavioral targets for interventions.

Advancing the science of recruitment and retention of ethnically diverse populations

We highlight several critical challenges that must be addressed to accelerate the advancement of the science on recruitment and retention of ethnically diverse older adults into health research. These include the relative lack of attention by researchers to methodological issues related to recruitment and retention of ethnically diverse populations and the inadequacy of funding to advance systematically this field. We describe strategies used by the Resource Centers on Minority Aging Research and other National Institute of Aging-funded programs to advance the science of recruitment of ethnically diverse older adults. Finally, we propose a set of broad recommendations designed to generate a body of evidence on successful methods of recruitment and retention of ethnically diverse populations in health research. To eliminate health disparities and better understand aging processes in ethnically diverse populations, much more research is needed on effective strategies for increasing minority enrollment in health research. Comparative effectiveness research on more intensive recruitment and retention methods, which are often needed for including diverse populations, will require dedicated funding and concerted efforts by investigators.

Introduction to the science of recruitment and retention among ethnically diverse populations

Recruitment and retention of research participants is evolving with the changing demographics of the American population, in particular its growing diversity. The cultural-historical background and sociopolitical conditions of each diverse group poses unique challenges in developing successful recruitment and retention methods and strategies. This critical collection of articles demonstrates important theoretical and conceptual frameworks that seek to address the shortcomings of previous models of recruiting diverse populations. Understanding the key components of cultural distinctions, such as values and beliefs, community cohesion, and collective history, has proven to be instrumental in reaching out to these diverse groups. This important strategy has allowed researchers to overcome the barriers that have been fostered in the past and has built the trust necessary to move forward into an inclusive approach to aging research. Not to be overlooked, an important factor to achieving success in recruitment and retention of diverse populations is having access to resources that allow for ongoing connection with research participants.