Psychosocial Predictors of Weight Loss among American Indian and Alaska Native Participants in a Diabetes Prevention Translational Project

Delivering the National Diabetes Prevention Program: Assessment of Retention, Physical Activity, and Weight Loss Outcomes by Participant Characteristics and Delivery Modes

Type 2 diabetes disproportionately affects older adults, persons from racial and ethnic minority groups, and persons of low socioeconomic status. It can be prevented or delayed through evidence-based interventions such as the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP). This analysis is aimed at evaluating the outcomes (i.e., retention, physical activity, and weight loss) associated with participation in the National DPP LCP by participant characteristics and delivery mode (i.e., in-person, online, distance learning, and combination) using the 2012-2018 Diabetes Prevention Recognition Program (DPRP) data. Across all delivery modes, there were generally no substantial differences in retention between male and female participants, but male participants tended to have higher physical activity and weight loss (e.g., average weight loss for in-person delivery: 5.0% for males and 4.3% for females). Older participants had better retention rates than younger participants in all delivery modes and mostly higher physical activity and weight loss except for distance learning delivery (e.g., average weight loss for in-person delivery: 5.1% for those aged 65+ and 3.3% for those aged 18-34). Among the seven racial and ethnic groups studied, retention was generally highest for non-Hispanic/Latino (NH)-White participants and lowest for Hispanic/Latino participants. Physical activity varied by racial and ethnic groups and delivery mode. NH-White participants generally had the most weight loss except for distance learning delivery, and NH-Black/African American participants had the least (e.g., average weight loss for in-person delivery: 5.1% for NH-White participants, 3.3% for both NH-Black/African American and NH-American Indian/Alaska Native participants, and other racial and ethnic minority groups ranged from 3.4% to 4.9%). Monitoring and identifying disparities across demographics and delivery modes, particularly across multiple racial and ethnic groups, provides information that can be used to improve the implementation of the National DPP LCP by tailoring the intervention to reduce disparities.

The Medicine Wheel as a public health approach to lifestyle management interventions for indigenous populations in North America

This analytic essay intends to elevate Medicine Wheel, or generally "four directions" teachings, to encourage a more comprehensive alignment of lifestyle intervention components with traditional ecological knowledge systems of Indigenous cultures in North America. North American Medicine Wheels provided people with a way to orient themselves both within their traditional belief systems and to the seasonal changes in their areas, improving survivability. The wheel or circle is a sacred symbol, indicating the continuity and perpetuity of all of life. The four directions are iconized in many Indigenous cultures across North America with different directions representing different aspects of our world and of ourselves, different seasons of the year and of our lives, different beings of the earth and tribes of humans with a balance among those necessary for health and wellbeing. In the context of public health, teachings of the four directions warn that a lack of balance limits our ability to achieve optimal health. While there is much public health success in lifestyle interventions, existing practice is limited by a siloed and one size fits all approach. Medicine Wheel teachings lay out a path toward more holistic and Indigenous-based lifestyle intervention that is modifiable depending on tribal teachings and needs, may appeal to a variety of Indigenous communities and is in alignment with health behavior change theory. It is a public health imperative that lifestyle management interventions are fully optimized to rigorously determine what can be achieved when interventions are implemented in a holistic and Indigenous-based manner, and in alignment with an Indigenous model of health. This more complete alignment would allow for a stronger foundation to further explore and develop social determinants (i.e., housing, employment, etc.) and structural intervention enhancements to inform public health practice and promote health equity.

Patients' and family members' knowledge, attitudes and perceived family support for SMBG in type 2 diabetes: a fuzzy-set qualitative comparative analysis

AIMS AND OBJECTIVES

To examine the combined effects of the patient's and family members' knowledge, attitudes and perceived family support on self-monitoring of blood glucose (SMBG) behaviour of patients with type 2 diabetes.

DESIGN

A cross-sectional design using the framework of knowledge-attitude-behaviour (KAB) combined with family support.

SETTING

Shanghai, China.

PARTICIPANTS

Seventy type 2 diabetes patient-family member dyads recruited from 26 residential committees in Shanghai were investigated. Twenty-three health providers were interviewed.

PRIMARY OUTCOME MEASURES

The knowledge, attitudes and perceived family support of patients' and their family members' data were measured through scales. Combined effects were analysed by a fuzzy-set qualitative comparative analysis (fsQCA) using fsQCA V.3.0. Other analyses and calculations were performed by STATA V.14.0.

RESULTS

SMBG was very poor (20%), and behaviour was characterised by 'multiple complications,' and 'all paths lead to the same destination' for patients. There were two solution paths toward patients' SMBG (solution coverage=0.4239, solution consistency=0.7604). One path was the combination of 'patients with low risk perception, the patients' and family members' perceived negative support', the other was the combination of 'patients with high risk perception, the patients' perceived negative support'. In both paths, basic knowledge serves as an auxiliary condition.

CONCLUSION

The study revealed that for patients with high and low risk perceptions that are relatively difficult to change, we could strengthen family support to achieve the desired SMBG behaviour. Knowledge is not a prerequisite to achieving SMBG. Moreover, negative family support plays a crucial role. Perceived family support by patients is more important than perceived family support by family members, which suggests that family members should improve support for patients so that the patients can perceive more family support.

Social Support and Diabetes Management Among Older American Indians

Objective

Greater understanding how relationships that can facilitate or impede type 2 diabetes (T2D) management and control among older American Indian people is an overlooked, yet urgently needed strategy. Thus, we examined social support among older American Indian people in relation to their T2D management.

Methods

During the fall 2015, we conducted qualitative interviews with 28 participants aged ≥ 60 years who were members of a federally-recognized tribe. Drawing upon the buffering and direct effects theoretical models of how social support affects health, we examined transcribed audio recordings of the interviews with a systematic text analysis approach. We used a low-inference qualitative descriptive design to provide a situated understanding of participants' life experiences using their naturalistic expressions.

Results

The mean age of our participants was 73.0 ± 6.4 years with a mean HbA1c of 7.3 ± 1.5. Main social support sources were family, clinicians/formal services, community/culture, and spiritual/God. All four common social support types were represented, namely emotional, instrumental, informational, and appraisal support with most being instrumental in nature. A prominent gender difference was seen with respect to men receiving more instrumental support family/friends support than women.

Discussion

Value orientations among American Indian people often reflect extended social systems and interdependence. A deeper understanding is needed of how social relationships can be better leveraged to aid in effective T2D management among older American Indian people. The development and implementation of evidence-based social network interventions with an assets-based orientation that build upon the cultural value of reciprocity hold promise to improve T2D outcomes of older American Indian people.

Advancing Diabetes Prevention and Control in American Indians and Alaska Natives

As with many Indigenous populations globally, American Indians and Alaska Natives (AI/ANs) experience high rates of type 2 diabetes. Prevention efforts, ongoing medical care, patient self-management education, and support to prevent and reduce the risk of long-term complications must be developed to limit the impact of diabetes on individuals, families, and communities. Diabetes prevention and control require both individual- and community-level efforts as well as policies that attempt to mitigate contributing adverse socioeconomic factors. Congressional funding since 1998 continues to address the epidemic of diabetes in AI/AN groups with the Special Diabetes Program for Indians (SDPI), which has resulted in significant outcomes and key lessons that can inform new efforts to prevent diabetes in other populations and communities. The purpose of this review is to understand the context behind the epidemic of diabetes in AI/ANs, review the impact of the SDPI on prevention and control of diabetes as well as the translation of these strategies into clinical practice and their influence on health practice, and identify lessons learned for future efforts to address this ongoing challenge for AI/AN and other communities suffering from type 2 diabetes.

A longitudinal study of the stress of poor glucose control and diabetes distress

Poor glucose control can be viewed as a stressor, possibly promulgating diabetes distress. We examined the relationship between perceived blood glucose control and diabetes distress over time using a partially controlled cross-lagged path analysis model. After controlling for demographics, control at 6 months was directly related to change in distress at 12 months. Subsequently, distress at 12 months was directly related to change in control at 18 months. Both 6-month control and distress had significant indirect effects on 18-month control and distress. This demonstrates the nuanced bi-directional relationship between the stress of poor perceived control and diabetes distress.

An Expert Opinion on "Glycemic Happiness": Delineating the Concept and Determinant Factors for Persons with Type 2 Diabetes Mellitus

The importance of the psychological impact of diabetes is globally well-documented. Evidence suggests that there is a high level of psychosocial burden of diabetes in India. Moreover, there is a lack of relevant knowledge among the patients and caregivers regarding the psychological impact of diabetes and how to cope with it, as compared to the majority of other countries. “Happiness of the patient” is an essential component of diabetes management, which potentially affects the treatment outcome, treatment adherence, self-care, and lifelong management of diabetes. Although several validated tools and scales exist for measuring psychological outcomes both in patients and physicians, tools to assess “happiness in diabetes care” are still lacking. With this background, an expert group meeting was held in India in September 2019, involving nine expert diabetologists and endocrinologists across the country to discuss the concept of “glycemic happiness”. This article summarizes the expert opinion on the factors affecting psychological outcomes in diabetes, introduces the concept of glycemic happiness, describes available scales and tools to measure general happiness, and delineates the five sets of questionnaires developed with questions that may help correlate with “glycemic happiness”. The questionnaires are based on a five-point Likert method. The experts also discussed and decided upon the study design for a proposed observational survey to assess glycemic happiness of persons with type 2 diabetes mellitus (T2DM) based on the developed five sets of questionnaires. Given the huge burden of diabetes in India, the introduction of the concept of glycemic happiness will help in the optimization of diabetes care in the country.

Perceived Family Social Support for Healthy Eating Is Related to Healthy Dietary Patterns for Native Americans: A Cross-sectional Examination

Native Americans continue to suffer health disparities ameliorated by healthy dietary patterns. The study objective was to determine moderating effects of perceived family social support on the relationship between ethnicity and diet behaviors. Dependent variables included dietary variables, and independent variable was family social support for healthy eating. Analyses included Pearson χ and correlation, one-way analysis of variance, and regression tests. Higher social support was related to lower consumption of added sugars, sugar-sweetened beverages, and red/processed meats for Native Americans. More research is needed to confirm the moderating effect of family social support on dietary behaviors.

Culture, Social Support, and Diabetes Empowerment Among American Indian Adults Living With Type 2 Diabetes

OBJECTIVE | Type 2 diabetes represents a major health disparity for many American Indian/Alaska Native (AIAN) communities, in which prevalence rates are more than double that of the general U.S. population. Diabetes is a major indicator for other comorbidities, including the leading cause of death for AIANs (i.e., cardiovascular disease). This study investigated associations between protective factors (social support and cultural factors) and self-reported empowerment to manage illness. DESIGN AND METHODS | Participants were drawn from a random sample of tribal clinic records. Data included results from computer-assisted personal interviews with 192 American Indian adults with a diagnosis of type 2 diabetes living on or near a reservation. Community Research Councils, developed at each of the five partnering Anishinaabe reservations, oversaw protocols and procedures in this community-based participatory research collaboration. RESULTS | Multiple ordinary least squares regression models determined that general social support and diabetes-specific social support are positively related to diabetes empowerment. These associations persisted when both social support measures were added to the model, indicating independent effects of different types of social support. Cultural identity and cultural practices were positively related to diabetes empowerment in bivariate analyses; however, both measures dropped from statistical significance after accounting for all other covariates. An interaction term revealed a moderation effect through which cultural identity amplified the positive relationship between social support and diabetes empowerment. CONCLUSION | Results moderately support policy and risk-reduction efforts aiming at expanding social support networks into multiple domains and reinforcing cultural identity and cultural practices.

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.

Examining protective and buffering associations between sociocultural factors and adverse childhood experiences among American Indian adults with type 2 diabetes: a quantitative, community-based participatory research approach

OBJECTIVES

The purpose of this study was to determine the frequency of select adverse childhood experiences (ACEs) among a sample of American Indian (AI) adults living with type 2 diabetes (T2D) and the associations between ACEs and self-rated physical and mental health. We also examined associations between sociocultural factors and health, including possible buffering processes.

DESIGN

Survey data for this observational study were collected using computer-assisted survey interviewing techniques between 2013 and 2015.

SETTING

Participants were randomly selected from AI tribal clinic facilities on five reservations in the upper Midwestern USA.

PARTICIPANTS

Inclusion criteria were a diagnosis of T2D, age 18 years or older and self-identified as AI. The sample includes n=192 adults (55.7% female; mean age=46.3 years).

PRIMARY MEASURES

We assessed nine ACEs related to household dysfunction and child maltreatment. Independent variables included social support, diabetes support and two cultural factors: spiritual activities and connectedness. Primary outcomes were self-rated physical and mental health.

RESULTS

An average of 3.05 ACEs were reported by participants and 81.9% (n=149) said they had experienced at least one ACE. Controlling for gender, age and income, ACEs were negatively associated with self-rated physical and mental health (p<0.05). Connectedness and social support were positively and significantly associated with physical and mental health. Involvement in spiritual activities was positively associated with mental health and diabetes-specific support was positively associated with physical health. Social support and diabetes-specific social support moderated associations between ACEs and physical health.

CONCLUSIONS

This research demonstrates inverse associations between ACEs and well-being of adult AI patients with diabetes. The findings further demonstrate the promise of social and cultural integration as a critical component of wellness, a point of relevance for all cultures. Health professionals can use findings from this study to augment their assessment of patients and guide them to health-promoting social support services and resources for cultural involvement.

PREVIEW study-influence of a behavior modification intervention (PREMIT) in over 2300 people with pre-diabetes: intention, self-efficacy and outcome expectancies during the early phase of a lifestyle intervention

PURPOSE

Onset of type 2 diabetes (T2D) is often gradual and preceded by impaired glucose homeostasis. Lifestyle interventions including weight loss and physical activity may reduce the risk of developing T2D, but adherence to a lifestyle change is challenging. As part of an international T2D prevention trial (PREVIEW), a behavior change intervention supported participants in achieving a healthier diet and physically active lifestyle. Here, our aim was to explore the influence of this behavioral program (PREMIT) on social-cognitive variables during an 8-week weight loss phase.

METHODS

PREVIEW consisted of an initial weight loss, Phase I, followed by a weight- maintenance, Phase II, for those achieving the 8-week weight loss target of ≥ 8% from initial bodyweight. Overweight and obese (BMI ≥25 kg/m2) individuals aged 25 to 70 years with confirmed pre-diabetes were enrolled. Uni- and multivariate statistical methods were deployed to explore differences in intentions, self-efficacy, and outcome expectancies between those who achieved the target weight loss ("achievers") and those who did not ("non-achievers").

RESULTS

At the beginning of Phase I, no significant differences in intentions, self-efficacy and outcome expectancies between "achievers" (1,857) and "non-achievers" (163) were found. "Non-achievers" tended to be younger, live with child/ren, and attended the PREMIT sessions less frequently. At the end of Phase I, "achievers" reported higher intentions (healthy eating χ2(1)=2.57; P <0.008, exercising χ2(1)=0.66; P <0.008), self-efficacy (F(2; 1970)=10.27, P <0.005), and were more positive about the expected outcomes (F(4; 1968)=11.22, P <0.005).

CONCLUSION

Although statistically significant, effect sizes observed between the two groups were small. Behavior change, however, is multi-determined. Over a period of time, even small differences may make a cumulative effect. Being successful in behavior change requires that the "new" behavior is implemented time after time until it becomes a habit. Therefore, having even slightly higher self-efficacy, positive outcome expectancies and intentions may over time result in considerably improved chances to achieve long-term lifestyle changes.

Influence of a New Diabetes Diagnosis on the Health Behaviors of the Patient's Partner

PURPOSE

When a person is given a diagnosis of diabetes, the changes in his or her health behaviors may influence the behaviors of his or her partner. The diabetes diagnosis may affect household members' perceptions of their own health risks, which could trigger behavioral change. The purpose of this study was to assess whether partners of persons with newly diagnosed diabetes changed their health behaviors compared with partners of persons without diabetes.

METHODS

The study population consisted of Kaiser Permanente Northern California health plan members from 2007 to 2011. This cohort study assessed differences in change of 8 health behaviors. The study compared coresiding partners of persons with newly diagnosed diabetes before and after a diabetes diagnosis with a 5 to 1 matched sample of coresiding partners of persons without diabetes.

RESULTS

A total of 180,910 couples were included in the analysis. After adjusting for baseline characteristics, partners of persons with newly diagnosed diabetes had significantly higher rates of participation in weight management-related health education classes (risk ratio [RR] = 1.50; 95% CI, 1.39-1.63); smoking cessation medication use (RR = 1.25; 95% CI, 1.05-1.50); glucose screening (RR = 1.07; 95% CI, 1.05-1.08); clinically meaningful weight loss (RR = 1.06; 95% CI, 1.02-1.11); lipid screening (RR = 1.05; 95% CI, 1.04-1.07); influenza vaccination (RR = 1.03; 95% CI, 1.02-1.04); and blood pressure screening (RR = 1.02; 95% CI, 1.02-1.03) compared with partners of persons without diabetes.

CONCLUSIONS

There were small but significant differences in health-related behavioral changes among partners of persons with newly diagnosed diabetes compared with partners of persons without diabetes, even when no intervention occurred. This finding suggests a diabetes diagnosis within a family may be a teachable moment to improve health behaviors at the household level.

Apathy and Type 2 Diabetes among American Indians: Exploring the Protective Effects of Traditional Cultural Involvement

In this study we examine relationships between traditional cultural factors, apathy, and health-related outcomes among a sample of American Indian adults with type 2 diabetes. Participants completed cross-sectional interviewer-assisted paper and pencil surveys. We tested a proposed model using latent variable path analysis in order to understand the relationships between cultural participation, apathy, frequency of high blood sugar symptoms, and health-related quality of life. The model revealed significant direct effects from cultural participation to apathy, and apathy to both health-related outcomes. No direct effect of cultural participation on either health-related outcome was found; however, cultural participation had a negative indirect effect through apathy on high blood sugar and positive indirect effects on health-related quality of life. This study highlights a potential pathway of cultural involvement to positive diabetes outcomes.

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

Diabetes is highly prevalent, affecting over 25 million adults in the US, yet it can be effectively prevented through lifestyle interventions, including the well-tested Diabetes Prevention Program (DPP). American Indian/Alaska Native (AIAN) adults, the majority of whom live in urban settings, are more than twice as likely to develop diabetes as non-Hispanic whites. Additionally, prevalent mental health issues and psychosocial stressors may facilitate progression to diabetes and hinder successful implementation of lifestyle interventions for AIAN adults. This 2-phased study first engaged community stakeholders to develop culturally-tailored strategies to address mental health concerns and psychosocial stressors. Pilot testing (completed) refined those strategies that increase engagement in an enhanced DPP for urban AIAN adults. Second, the enhanced DPP will be compared to a standard DPP in a randomized controlled trial (ongoing) with a primary outcome of body mass index (BMI) and a secondary outcome of quality of life (QoL) over 12months. Obese self-identified AIAN adults residing in an urban setting with one or more components of the metabolic syndrome (excluding waist circumference) will be randomized to the enhanced or standard DPP (n=204). We hypothesize that addressing psychosocial barriers within a culturally-tailored DPP will result in clinical (BMI) and superior patient-centered (QoL) outcomes as compared to a standard DPP. Exploratory outcomes will include cardiometabolic risk factors (e.g., waist circumference, blood pressure, fasting glucose) and health behaviors (e.g., diet, physical activity). Results of this trial may be applicable to other urban AIAN or minority communities or even diabetes prevention in general.

Satisfação com o Suporte Social e Perda de Peso — Estudo Transversal

Objetivo

Potencial moderador e mediador da eficácia nas intervenções para perda de peso bem-sucedida (PPBS), o suporte social é poucas vezes avaliado neste contexto. Pretende-se averiguar a relação entre a percentagem de peso perdido e variáveis sociodemográficas e psicológicas, incluindo satisfação com o suporte social, em pessoas que realizaram uma PPBS.

Método

No total, 105 adultos com PPBS (ou seja, perda igual ou superior a 7% do peso inicial, com manutenção mínima de 12 meses) preencheram a Escala de Satisfação com o Suporte Social e um questionário para recolha de informação sociodemográfica, estado de saúde psicológica e estilos de vida.

Resultados

O modelo estrutural com as dimensões de satisfação com a família e intimidade apresentou um bom ajustamento (χ²/gl = 1,343; CFI = 0,943; GFI = 0,924; RMSEA = 0,057, p < 0,001; C.I. 90% = ]0,000; 0,093[); a satisfação com o suporte familiar (β = 0,193;p= 0,081) e a existência de uma relação afetivo-sexual (β = -0,184; p = 0,082) foram as únicas variáveis a predizer marginalmente a percentagem de peso perdido.

Conclusão

Participantes mais satisfeitos com o suporte familiar (no mínimo, um ano após a PPBS) perderam uma maior percentagem de peso; assim, a satisfação com suporte social da família poderá ser uma variável relevante no processo de perda de peso. Todavia, a natureza do estudo (tipo de estudo e de amostra) torna necessária mais investigação na área para confirmar este resultado.

The Impact of a Home-Based Diabetes Prevention and Management Program on High-Risk American Indian Youth

PURPOSE

The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth.

METHODS

Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth's psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment.

RESULTS

A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth's quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036).

CONCLUSIONS

The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.