Translating efficacious behavioral principles for diabetes prevention into practice

A randomized controlled trial to test the effectiveness of two technology-enhanced diabetes prevention programs in primary care: The DiaBEAT-it study

Objective

To evaluate the effectiveness of two technology-enhanced interventions for diabetes prevention among adults at risk for developing diabetes in a primary care setting.

Methods

The DiaBEAT-it study employed a hybrid 2-group preference (Choice) and 3-group randomized controlled (RCT) design. This paper presents weight related primary outcomes of the RCT arm. Patients from Southwest Virginia were identified through the Carilion Clinic electronic health records. Eligible participants (18 and older, BMI ≥ 25, no Type 2 Diabetes) were randomized to either Choice (n = 264) or RCT (n = 334). RCT individuals were further randomized to one of three groups: (1) a 2-h small group class to help patients develop a personal action plan to prevent diabetes (SC, n = 117); (2) a 2-h small group class plus automated telephone calls using an interactive voice response system (IVR) to help participants initiate weight loss through a healthful diet and regular physical activity (Class/IVR, n = 110); or (3) a DVD with same content as the class plus the same IVR calls over a period of 12 months (DVD/IVR, n = 107).

Results

Of the 334 participants that were randomized, 232 (69%) had study measured weights at 6 months, 221 (66%) at 12 months, and 208 (62%) at 18 months. Class/IVR participants were less likely to complete weight measures than SC or DVD/IVR. Intention to treat analyses, controlling for gender, race, age and baseline BMI, showed that DVD/IVR and Class/IVR led to reductions in BMI at 6 (DVD/IVR -0.94, p < 0.001; Class/IVR -0.70, p < 0.01), 12 (DVD/IVR -0.88, p < 0.001; Class/IVR-0.82, p < 0.001) and 18 (DVD/IVR -0.78, p < 0.001; Class/IVR -0.58, p < 0.01) months. All three groups showed a significant number of participants losing at least 5% of their body weight at 12 months (DVD/IVR 26.87%; Class/IVR 21.62%; SC 16.85%). When comparing groups, DVD/IVR were significantly more likely to decrease BMI at 6 months (p < 0.05) and maintain the reduction at 18 months (p < 0.05) when compared to SC. There were no differences between the other groups.

Conclusions

The DiaBEAT-it interventions show promise in responding to the need for scalable, effective methods to manage obesity and prevent diabetes in primary care settings that do not over burden primary care clinics and providers.

Registration

https://clinicaltrials.gov/ct2/show/NCT02162901, identifier: NCT02162901.

Effects of a Digital Diabetes Prevention Program: An RCT

INTRODUCTION

In light of the need to expand the reach and access of clinically proven digital Diabetes Prevention Programs (d-DPPs) and the need for rigorous evidence of effectiveness, the purpose of this study was to determine the effectiveness of a digital Diabetes Prevention Program for improving weight, HbA1c, and cardiovascular risk factors among people with prediabetes compared to enhanced standard care plus waitlist control.

STUDY DESIGN

This was a single-blind RCT among participants at risk of developing type 2 diabetes and included 12 months of follow-up.

SETTING/PARTICIPANTS

A total of 599 volunteer patients with prediabetes were recruited primarily through electronic medical records and primary care practices.

INTERVENTION

Participants were randomized to either a d-DPP (n=299) or a single-session small-group diabetes-prevention education class (n=300) focused on action planning for weight loss. The d-DPPs consisted of 52 weekly sessions, lifestyle coaching, virtual peer support, and behavior tracking tools.

MAIN OUTCOME MEASURES

The primary outcome was a change in HbA1c from baseline to 12 months using intent-to-treat analyses. On the basis of multiple comparisons of endpoints, 95% CIs are presented and 2-sided p<0.025 was required for statistical significance. Secondary outcomes included body weight and cardiovascular disease risk factors.

RESULTS

Among 599 randomized participants (mean age=55.4 years, 61.4% women), 483 (80%) completed the study. The d-DPPs produced significantly greater reductions in HbA1c (0.08%, 95% CI= -0.12, -0.03) and percentage change in body weight (-5.5% vs -2.1%, p<0.001) at 12 months. A greater proportion of the d-DPPs group achieved a clinically significant weight loss ≥5% (43% vs 21%, p<0.001), and more participants shifted from prediabetes to normal HbA1c range (58% vs 48%, p=0.04). Engagement in d-DPPs was significantly related to improved HbA1c and weight loss.

CONCLUSIONS

This d-DPPs demonstrated clinical effectiveness and has significant potential for widespread dissemination and impact, particularly considering the growing demand for telemedicine in preventive healthcare services.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov (ClinicalTrials.gov Identifier: NCT03312764).

Using Integrated Research-Practice Partnerships to Move Evidence-Based Principles Into Practice

The implementation of evidence-based physical activity interventions is improved when integrated research-practice partnerships are used. These partnerships consider both research- and practice-based evidence that moves beyond only assessing program efficacy. Our novel hypothesis is that integrated research-practice partnerships may lead to interventions that are practical and effective, reach more participants, and are more likely to be sustained in practice.

Effectiveness of Program Modification Strategies of the Diabetes Prevention Program: A Systematic Review

PURPOSE

The purpose of this study is to review the effectiveness of commonly used program modifications classified under cultural adaptation and program translational strategies for the Diabetes Prevention Program (DPP) in terms of risk reduction for type 2 diabetes.

METHODS

Authors extracted data about weight, body mass index (BMI), and 5 areas of program modification strategies from 28 interventions and analyzed them in SPSS software. Bivariate analyses examined the odds of achieving a significant reduction in outcomes by each modification of the DPP and by presence of a maintenance component, as well as the mean reduction of weight and BMI by more versus fewer modifications and by the presence of a maintenance component.

RESULTS

There were no statistically significant differences in achieving a significant reduction in weight or BMI by any type of modification or by the presence of a maintenance component. Programs with fewer modifications reported significantly greater reduction in mean weight at 12 months postintervention and the furthest time point extracted. Programs with a maintenance component achieved significantly greater reduction in mean weight measured at the furthest time point extracted.

CONCLUSIONS

The DPP appears to be programmatically robust to a variety of cultural adaptation and translational strategies. Potentially cost-saving modifications do not seem to reduce effectiveness, which should encourage implementation on a broader scale. Program planners should, however, make efforts to include maintenance components because they appear to significantly reduce risk for acquiring type 2 diabetes.

FUEL Your Life: A Translation of the Diabetes Prevention Program to Worksites

Purpose.

To evaluate the effectiveness of FUEL Your Life, a translation of the Diabetes Prevention Program for worksites.

Design.

A randomized control group design was conducted in five worksites of a large transportation company. Measures were collected pretest, posttest (6 months), and follow-up (12 months).

Setting.

Railroad maintenance facilities of Union Pacific Railroad.

Subjects.

Participants consisted of 362 workers (227 treatment, 135 control).

Intervention.

FUEL Your Life was translated from the Diabetes Prevention Program to better fit within the context of the worksite. The primary difference was the use of peer health coaches to provide social support and reinforcement and an occupational nurse to provide lesson content (six sessions of 10 minutes) to participants instead of the lifestyle coaches employed by the Diabetes Prevention Program, resulting in a less structured meeting schedule.

Measures.

The primary outcomes were weight and body mass index (BMI), with secondary outcomes including eating behaviors, physical activity, and social support.

Analysis.

Latent growth modeling was used to measure changes in the outcomes over time.

Results.

Participants in the intervention group maintained weight/BMI (–.1 pounds/–.1 BMI), whereas the control participants gained weight/BMI (+2.6 pounds/+.3 BMI), resulting in a statistically significant difference between groups. Fifty-five percent of intervention participants lost some weight, whereas only 35% of the control group lost weight.

Conclusions.

FUEL Your Life, a low intensity intervention, was not effective for promoting weight loss, but was effective for helping workers maintain weight over a 12-month period.

From margarine to butter: predictors of changing bread spread in an 11-year population follow-up

OBJECTIVE

Finland is known for a sharp decrease in the intake of saturated fat and cardiovascular mortality. Since 2000, however, the consumption of butter-containing spreads - an important source of saturated fats - has increased. We examined social and health-related predictors of the increase among Finnish men and women.

DESIGN

An 11-year population follow-up.

SETTING

A representative random sample of adult Finns, invited to a health survey in 2000.

SUBJECTS

Altogether 5414 persons aged 30-64 years at baseline in 2000 were re-invited in 2011. Of men 1529 (59 %) and of women 1853 (66 %) answered the questions on bread spreads at both time points. Respondents reported the use of bread spreads by choosing one of the following alternatives: no fat, soft margarine, butter-vegetable oil mixture and butter, which were later categorized into margarine/no spread and butter/butter-vegetable oil mixture (= butter). The predictors included gender, age, marital status, education, employment status, place of residence, health behaviours, BMI and health. Multinomial regression models were fitted.

RESULTS

Of the 2582 baseline margarine/no spread users, 24.6% shifted to butter. Only a few of the baseline sociodemographic or health-related determinants predicted the change. Finnish women were more likely to change to butter than men. Living with a spouse predicted the change among men.

CONCLUSIONS

The change from margarine to butter between 2000 and 2011 seemed not to be a matter of compliance with official nutrition recommendations. Further longitudinal studies on social, behavioural and motivational predictors of dietary changes are needed.

A review of diabetes prevention program translations: use of cultural adaptation and implementation research

The Diabetes Prevention Program (DPP) has been shown to prevent type 2 diabetes through lifestyle modification. The purpose of this study was to describe the literature on DPP translation, synthesizing studies using cultural adaptation and implementation research. A systematic search was conducted. Original studies evaluating DPP implementation and/or cultural adaptation were included. Data about cultural adaptation, implementation outcomes, and translation strategies was abstracted. A total of 44 were included, of which 15 reported cultural adaptations and 38 explored implementation. Many studies shortened the program length and reported a group format. The most commonly reported cultural adaptation (13 of 15) was with content. At the individual level, the most frequently assessed implementation outcome (n = 30) was adoption. Feasibility was most common (n = 32) at the organization level. The DPP is being tested in a variety of settings and populations, using numerous translational strategies and cultural adaptations. Implementation research that identifies, evaluates, and reports efforts to translate the DPP into practice is crucial.

Design and methods of "diaBEAT-it!": a hybrid preference/randomized control trial design using the RE-AIM framework

BACKGROUND

Diabetes prevention is a public health priority that is dependent upon the reach, effectiveness, and cost of intervention strategies. However, understanding each of these outcomes within the context of randomized controlled trials is problematic.

PURPOSE

To describe the methods and design of a hybrid preference/randomized control trial using the RE-AIM framework.

METHODS

The trial, which was developed using the RE-AIM framework, will contrast the effects of 3 interventions: (1) a standard care, small group, diabetes prevention education class (SG), (2) the small group intervention plus 12 months of interactive voice response telephone follow-up (SG-IVR), and (3) a DVD version of the small group intervention with the same IVR follow-up (DVD-IVR). Each intervention includes personal action planning with a focus on key elements of the lifestyle intervention from the Diabetes Prevention Program (DPP). Adult patients at risk for diabetes will be randomly assigned to either choice or RCT. Those assigned to choice (n=240) will have the opportunity to choose between SG-IVR and DVD-IVR. Those assigned to RCT group (n=360) will be randomly assigned to SG, SG-IVR, or DVD-IRV. Assessment of primary (weight loss, reach, & cost) and secondary (physical activity, & dietary intake) outcomes will occur at baseline, 6, 12, and 18 months.

CONCLUSION

This will be the first diabetes prevention trial that will allow the research team to determine the relationships between reach, effectiveness, and cost of different interventions.

Mitochondrial alteration in type 2 diabetes and obesity: an epigenetic link

The growing epidemic of type 2 diabetes mellitus (T2DM) and obesity is largely attributed to the current lifestyle of over-consumption and physical inactivity. As the primary platform controlling metabolic and energy homeostasis, mitochondria show aberrant changes in T2DM and obese subjects. While the underlying mechanism is under extensive investigation, epigenetic regulation is now emerging to play an important role in mitochondrial biogenesis, function, and dynamics. In line with lifestyle modifications preventing mitochondrial alterations and metabolic disorders, exercise has been shown to change DNA methylation of the promoter of PGC1α to favor gene expression responsible for mitochondrial biogenesis and function. In this article we discuss the epigenetic mechanism of mitochondrial alteration in T2DM and obesity, and the effects of lifestyle on epigenetic regulation. Future studies designed to further explore and integrate the epigenetic mechanisms with lifestyle modification may lead to interdisciplinary interventions and novel preventive options for mitochondrial alteration and metabolic disorders.

Translational health research: perspectives from health education specialists

The phrase "from bench to bedside to curbside" is a common definition of translational research among health disparities researchers. Health Education Specialists can make important contributions to the field of clinical translational medicine, particularly in light of U.S. health care reform and a renewed emphasis on medical home or health care home models.Health Education Specialists have the training and experience to engage in and facilitate translational research, as well as the opportunity to learn from the translational efforts of other professions and enhance our research, practice, and community partnerships through translational efforts. In this paper, a Translational Health Education Research framework for health education researchers is suggested to foster increased translational efforts within our profession as well as to promote interdisciplinary collaborations to translate a variety of health-related research. A conceptual framework adapted from translational health disparities research that highlights the level and scope of translational research necessary for changes in practice and policy is also provided.

The Live Well, Be Well study: a community-based, translational lifestyle program to lower diabetes risk factors in ethnic minority and lower-socioeconomic status adults

OBJECTIVES

We evaluated a community-based, translational lifestyle program to reduce diabetes risk in lower-socioeconomic status (SES) and ethnic minority adults.

METHODS

Through an academic-public health department partnership, community-dwelling adults at risk for diabetes were randomly assigned to individualized lifestyle counseling delivered primarily via telephone by health department counselors or a wait-list control group. Primary outcomes (6 and 12 months) were fasting glucose level, triglycerides, high- and low-density lipoprotein cholesterol, weight, waist circumference, and systolic blood pressure. Secondary outcomes included diet, physical activity, and health-related quality of life.

RESULTS

Of the 230 participants, study retention was 92%. The 6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P=.03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P=.02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P=.05) and more fruits and vegetables (P=.02) than did control participants.

CONCLUSIONS

Despite challenges designing effective translational interventions for lower-SES and minority communities, this program modestly improved some diabetes risk factors. Thus, individualized, telephone-based models may be a promising alternative to group-based interventions.

Evaluation of a rural community pharmacy-based Waist Management Project: bringing the program to the people

Time constraints and lack of awareness of risk factors for future chronic disease development prevent many young adults from accessing lifestyle programs offered by local health services. This study aimed to determine the effectiveness of a rural pharmacy-based multidisciplinary healthy lifestyle pilot program on reducing risk factors for chronic disease development among young adults. Individuals under the age of 50 with chronic disease risk factors were referred to the program. All subjects were provided with free after-hours nutritional counselling from a dietitian at the local community pharmacy, a comprehensive medication review conducted by the pharmacist, gym membership and access to cooking classes and supermarket tours. Selected participants also received bulk-billed GP appointments and assistance with establishing a home vegetable garden. Body weight, waist circumference, fruit and vegetable consumption and physical activity were assessed at baseline and after program conclusion. Forty participants regularly attended the program between March 2009 and March 2010. At program conclusion, mean body weight was reduced by 3.8 ± 6.7 kg (P < 0.001) and waist circumference reduced by 3.9 ± 6.5 cm (P < 0.001). Fruit consumption increased by 1.2 ± 0.2 serves/day (P < 0.001) and vegetable intake increased by 1.6 ± 1.0 serves/day (P < 0.001). Participants also spent an average of 88.0 ± 47.7 more min/week (P < 0.001) engaged in physical activity on completion of the program. The community pharmacy provided an accessible location for the delivery of a successful chronic disease risk reduction program targeting young adults in a rural area.

Description of an academic community partnership lifestyle program for lower income minority adults at risk for diabetes

PURPOSE

Translating strategies and approaches from the successful clinically based Diabetes Prevention Program's lifestyle intervention to community settings is a key next step. This article describes a lifestyle program developed in partnership by researchers at a major university and public health professionals at a local health department.

METHODS

The Live Well, Be Well (LWBW) program was designed to meet the needs of lower income, minority, and low-literacy adults at risk for diabetes. It was adapted from interventions with demonstrated efficacy and delivered in Spanish and English by health department staff. The program consisted of a 6-month active phase and a 6-month maintenance phase and was primarily telephone based, with one in-person planning session and several group workshops. In-person and group sessions were held in convenient community-based settings. Counselors provided education and skills training to modify diet and increase physical activity. Self-selected and attainable goal-setting and action plans were emphasized to enhance self-efficacy. LWBW is the intervention component of a randomized trial with primary outcomes of fasting glucose, weight, and other clinical measures.

CONCLUSIONS

The program provides a unique translational model for implementing diabetes risk reduction programs for underserved populations. Individually tailored and nonprescriptive, it utilized existing health department infrastructure, focused on telephone counseling, used culturally appropriate, low-literacy materials, and was delivered in local, community-based facilities.

How should the clinician most effectively prevent type 2 diabetes in the obese person at high risk?

The dramatic increase in newly diagnosed cases of type 2 diabetes (T2D) has developed into a major public health concern worldwide. Conversely, several clinical studies have demonstrated that preventive efforts can significantly reduce the risk of developing diabetes. There is a clear consensus that action is needed to develop targeted community-based prevention programs and strategies for T2D. Currently, numerous prevention management concepts that can be implemented into clinical practice exist in various countries. Finland is the pioneer country in implementing community-wide diabetes prevention programs. Nevertheless, population-based nationwide strategies are still lacking in virtually all countries. We report on intervention strategies to prevent T2D in people with increased diabetes risk, as well as strategies on how to implement diabetes prevention programs into the real world of public health or clinical care. The implementation of managed prevention concepts will realistically help to improve the ability to prevent T2D in the public health framework.