Considerations for diabetes translational research in real-world settings

Adopting and implementing an innovative model to organize diabetes care within First Nations communities: A qualitative assessment

Background

Diabetes care remains suboptimal in First Nations populations. Innovative and culturally relevant approaches are needed to promote systematic and proactive organization of diabetes care for people living with diabetes on-reserve in Canada. The RADAR model is one strategy to improve care: an integrated disease registry paired with an electronic health record for local community healthcare providers with remote care coordination. We qualitatively assessed adoption and implementation of RADAR in First Nations communities in Alberta to inform its potential spread in the province.

Methods

We used the RE-AIM framework to evaluate adoption and implementation of RADAR in 6 First Nations communities. Using purposeful sampling, we recruited local healthcare providers and remote care coordinators involved in delivering RADAR to participate in telephone or in-person interviews at 6- and 24-months post-implementation. Interviews were digitally recorded, transcribed, and verified for accuracy. Data was analyzed using content analysis and managed using ATLAS.ti 8.

Results

In total, we conducted 21 semi-structured interviews (6 at 6-months; 15 at 24-months) with 11 participants. Participants included 3 care coordinators and 8 local healthcare providers, including registered nurses, licensed practical nurses, and registered dietitians. We found that adoption of RADAR was influenced by leadership as well as appropriateness, acceptability, and perceived value of the model. In addition, we found that implementation of RADAR was variable across communities regardless of implementation supports and appropriate community-specific adaptations.

Conclusions

The variable adoption and implementation of RADAR has implications for how likely it will achieve its anticipated outcomes. RADAR is well positioned for spread through continued appropriate community-based adaptations and by expanding the existing implementation supports, including dedicated human resources to support the delivery of RADAR and the provision of levels of RADAR based on existing or developed capacity among local HCPs.

Trial registration

Not applicable to this qualitative assessment. ISRCTN14359671.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06424-1.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India

IMPORTANCE

A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective.

OBJECTIVE

To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India.

INTERVENTIONS

The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice.

MAIN OUTCOMES AND MEASURES

Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $).

RESULTS

The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

A Mixed Methods Evaluation of a Randomized Control Trial to Evaluate the Effectiveness of the Pure Prairie Living Program in Type 2 Diabetes Participants

The primary objective of this randomized control trial was to evaluate the effectiveness of the Pure Prairie Living Program (PPLP) in a primary care setting. Adults with type 2 diabetes were randomized into intervention (PPLP, n = 25) and wait-listed controls (CON, n = 24). The PPLP group participated in education sessions. The intervention yielded no significant within-group changes in HbA1c at three-month (−0.04 (−0.27 to 0.17) and −0.15 (−0.38 to 0.08)) or six-month (−0.09 (−0.41 to 0.22) and 0.06 (−0.26 to 0.38)) follow ups in either CON or PPLP groups, respectively. Dietary adherence scores improved in the PPLP group (p < 0.05) at three and six months but were not different in the between-group comparison. No changes in diabetes self-efficacy scores were detected. In the qualitative analysis, participants described the program as clear and easy to understand. Knowledge acquired influenced their everyday decision making but participants faced barriers that prevented them from fully applying what they learned. Healthcare professionals enjoyed delivering the program but described the “back-stage” workload as detrimental. In conclusion, while some positive effects of the PPLP intervention were observed, they were not comparable to those previously attained by our group in an academic setting or to what the guidelines recommend, which reflects the challenge of translating lifestyle intervention to real-world settings.

Solution-based science to prevent and control diabetes in underserved communities around the world (commentary, for Diabetes special section)

Despite the numerous successful behavioral interventions that have been published in the behavioral medicine field over a number of decades, surprisingly few have been translated and adapted for real-world settings using participatory research methods. The purpose of this commentary is to highlight the advances in participatory behavioral medicine reflected in the articles contained in the Diabetes special section. The articles contained in the Diabetes special section were reviewed, with a focus on the advances made with this type of research and the challenges that came to light. Numerous strengths of the large-scale translational studies were identified. The studies also highlighted important areas meriting further attention, including exploration of additional dissemination pathways, and further piloting and refinement of program components for different population segments. The articles in this special section represent major advances in implementing successful, impactful programs for diabetes prevention and control in low- and middle-income countries.

What predicts regression from pre-diabetes to normal glucose regulation following a primary care nurse-delivered dietary intervention? A study protocol for a prospective cohort study

INTRODUCTION

Pre-diabetes is a high-risk state for the development of type 2 diabetes mellitus (T2DM) and cardiovascular disease. Regression to normoglycaemia, even if transient, significantly reduces the risk of developing T2DM. The primary aim of this mixed-methods study is to determine if there are clinically relevant differences among those with pre-diabetes and excess weight who regress to normoglycaemia, those who have persistent pre-diabetes and those who progress to T2DM following participation in a 6-month primary care nurse-delivered pre-diabetes dietary intervention. Incidence of T2DM at 2 years will be examined.

METHODS AND ANALYSIS

Four hundred participants with pre-diabetes (New Zealand definition glycated haemoglobin 41-49 mmol/mol) and a body mass index >25 kg/m² will be recruited through eight primary care practices in Hawke's Bay, New Zealand. Trained primary care nurses will deliver a 6-month structured dietary intervention, followed by quarterly reviews for 18 months post-intervention. Clinical data, data on lifestyle factors and health-related quality of life (HR-QoL) and blood samples will be collected at baseline, 6 months, 12 months and 24 months. Sixty participants purposefully selected will complete a semi-structured interview following the 6-month intervention. Poisson regression with robust standard errors and clustered by practice will be used to identify predictors of regression or progression at 6 months, and risk factors for developing T2DM at 2 years. Qualitative data will be analysed thematically. Changes in HR-QoL will be described and potential cost savings will be estimated from a funder's perspective at 2 years.

ETHICS AND DISSEMINATION

This study was approved by the Northern A Health and Disability Ethics Committee, New Zealand (Ethics Reference: 17/NTA/24). Study results will be presented to participants, published in peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000591358; Pre-results.

Effectiveness of the Diabetes Prevention Program for Obesity Treatment in Real World Clinical Practice in a Middle-Income Country in Latin America

The Diabetes Prevention Program (DPP) is effective for the prevention of type 2 diabetes by weight loss with diet and physical activity. However, there is little evidence as to whether this program could be translated into real-world clinical practice in Latin American countries. The objective of this work was to evaluate the effectiveness of the DPP for the management of overweightness and obesity at 6 and 12 months in clinical practice in Mexico. This was a non-controlled intervention study implemented in five public clinics in northern Mexico. Two hundred and thirty-seven adults aged 45.7 ± 9.9 years with a Body Mass Index (BMI) of 34.4 ± 5.4 kg/m² received group sessions with an adaptation of the DPP, in addition to nutrition counseling. One hundred and thirty-three (56%) participants concluded the 6 month phase. They showed a significant weight loss, ranging from 2.76 ± 4.76 to 7.92 ± 6.85 kg (p ≤ 0.01) in the clinics. The intention-to-treat analysis showed a more conservative weight loss. Participant retention at the end of 12 months was low (40%). The implementation of the DPP in different public clinics in Mexico was effective in the management of obesity in the short term, but better strategies are required to improve participant retention in the long term.

Effect on Health Care Expenditures During Nationwide Implementation of the Diabetes Prevention Program as a Health Insurance Benefit

OBJECTIVE

Lifestyle interventions slow development of type 2 diabetes by half, but the impact of health payer reimbursement for delivery of intervention programs is not well known. We evaluated net commercial health payer expenditures when offering reimbursement for access to YMCA's Diabetes Prevention Program (YDPP) in 42 states.

RESEARCH DESIGN AND METHODS

We used a nonequivalent comparison group design to evaluate net health care expenditures for adults with prediabetes who attended one or more YDPP visit between 1 July 2009 and 31 May 2013 ("YDPP users"). Rolling, 1:1 nearest neighbor propensity score (PS) matching was used to identify a comparison group of nonusers. Administrative data provided measures of YDPP attendance, body weight at YDPP visits, and health care expenditures. Random effects, difference-in-difference regression was used to estimate quarterly health care expenditures before and after participants' first visit to YDPP.

RESULTS

Worksite screening identified 9.7% of the target population; 39.1% of those identified (19,933 participants through June 2015) became YDPP users. Mean weight loss for YDPP users enrolled before June 2013 (n = 1,725) was 7.5 lb (3.4%); 29% achieved ≥5% weight loss. Inclusive of added costs to offer YDPP, there were no statistically significant differences in mean per-person net health care expenditures between YDPP users and PS-matched nonusers over 2 years ($0.2 lower [95% CI $56 lower to $56 higher]). Mean reimbursement to the YMCA was $212 per YDPP user, with 92.8% of all expenditures made for those who attended at a high rate (≥9 completed YDPP visits).

CONCLUSIONS

Worksite screening was inefficient for identifying the population with prediabetes, but those identified achieved modest YDPP attendance and clinically meaningful weight loss. Over 2 years, added costs to offer the intervention were modest, with neutral effects on net health care costs.

Lifestyle intervention for obesity: a call to transform the clinical care delivery system in Mexico

Obesity and its comorbidities have become the most important public health problems for Latin America. In Mexico obesity has increased dramatically to the point where the government has declared it an epidemiological emergency. The most recent national data showed overweight and obesity affects 72.5% of adults, or around 56 million Mexicans. Most Mexican adults with obesity are undiagnosed. According to data derived from a national representative survey, only 20% of adults with BMI >30 kg/m² were diagnosed with obesity by a health provider. Likewise, only 8% of individuals with obesity had received treatment for obesity. Interventions offered in the Mexican health care delivery system generally consist of traditional consultations with recommendations on diet and exercise, visits are monthly to quarterly, and validated behavior change protocols are not used. Evidence from clinical trials has shown that weight loss with this type of treatment is generally less than 1 kg per year. In contrast, intensive lifestyle interventions - protocols focusing on achieving changes in diet, physical activity, and moderate weight loss using behavioral strategies with weekly or bi-weekly sessions for the first 3 to 6 months, and a maintenance phase with trained interventionists - as implemented in the Diabetes Prevention Program and the Look AHEAD studies achieved weight loss of 7-9% at one year. Additionally, translation studies of these interventions to the community and to real-world clinical practice have achieved weight loss of around 4%. Adaptations of intensive lifestyle interventions have been implemented in the United States, both in clinical practice and in the community, and this type of intervention represents a potential model to combat obesity in Mexico and other Latin American countries. It is essential that primary care providers in Mexico implement clinical practice guidelines based on the best evidence available as discussed here to effectively treat obesity. The authors make recommendations to improve the treatment of obesity in the clinical care delivery system in Mexico using intensive lifestyle interventions.

An Evaluation of a Diabetes Self-Management Education (DSME) Intervention Delivered Using Avatar-Based Technology: Certified Diabetes Educators' Ratings and Perceptions

Purpose The purpose of this study was to evaluate the perceptions that certified diabetes educators (CDEs), of diverse health professions, have of a culturally appropriate e-health intervention that used avatar-based technology. Methods Cross-sectional, survey-based design using quantitative and qualitative paradigms. A logic model framed the study, which centered on the broad and general concepts leading to study outcomes. In total, 198 CDEs participated in the evaluation. Participants were mostly female and represented an age range of 26 to 76 years. The profession representative of the sample was registered nurses. Study setting and data collection occurred at https://www.surveymonkey.com/r/AvatarVideoSurvey-for-Certified_Diabetes_Educators . Study instruments used were the Basic Demographics Survey (BD-13), Educational Material Use and Rating of Quality Scale (EMU-ROQ-9), Marlowe-Crowne Social Desirability Survey (MS-SOC-DES-CDE-13), Quality of Avatar Video Rating Scale (QAVRS-7), Recommend Avatar to Patients Scale (RAVTPS-3), Recommend Avatar Video to Health Professionals Scale (RAVTHP-3), and Avatar Video Applications Scale (AVAPP-1). Statistical analysis used included t tests, Pearson product moment correlations, backward stepwise regression, and content/thematic analysis. Results Age, ethnicity, Arab/Middle Eastern, Asian, and white/European descents were significant predictors of a high-quality rating of the video. Thematic and content analysis of the data revealed an overall positive perception of the video. Conclusions An e-health intervention grounded in evidence-based health behavior theories has potential to increase access to diabetes self-management education as evidenced in the ratings and perceptions of the video by CDEs.

Sustaining diabetes prevention and care interventions: A multiple case study of translational research projects

BACKGROUND

This study identifies the barriers and enablers for sustainability of interventions in primary and secondary prevention of diabetes. In the context of translational research, sustainability is defined as the continued use of program components and activities for the continued achievement of desirable program and population outcomes.

METHODS

In this study, eleven translational research projects, supported by the BRIDGES program of the International Diabetes Federation, were investigated. By theoretically-informed semi-structured interviews and analyses of project reports, qualitative data was collected on the sustainability outcomes and the barriers and enablers.

RESULTS

The sustainability outcomes can be grouped in three main areas: (1) sustainability at the intervention site(s); (2) diffusion to the wider community; and (3) replication of the intervention at other site(s). Each of the outcomes has their own set of enablers and barriers, and thus requires consideration for a different sustainability strategy.

CONCLUSIONS

This study is the first international study that relates the sustainability outcomes of translational research project to specific barriers and enablers, and develops an evidence-based framework which provides practical advice on how to ensure the sustainability of health interventions.

A Feasibility Study of Supply and Demand for Diabetes Prevention Programs in North Carolina

Introduction

Diabetes Prevention Programs (DPPs) have shown that healthy eating and moderate physical activity are effective ways of delaying and preventing type 2 diabetes in people with impaired glucose tolerance. We assessed willingness to pay for DPPs from the perspective of potential recipients and the cost of providing these programs from the perspective of community health centers and local health departments in North Carolina.

Methods

We used contingent valuation to determine how much potential recipients would be willing to pay to participate in DPPs under 3 different models: delivered by registered professionals (traditional model), by community health workers, or online. By using information on the minimum reimbursement rate at which public health agencies would be prepared to provide the 3 models, we estimated the marginal costs per person of supplying the programs. Matching supply and demand, we estimated the degree of cost sharing between recipients and providers.

Results

Potential program recipients (n = 99) were willing to pay more for programs led by registered professionals than by community health workers, and they preferred face-to-face contact to an online format. Socioeconomic status (measured by education and employment) and age played the biggest roles in determining willingness to pay. Leaders of public health agencies (n = 27) reported up to a 40% difference in the cost of providing the DPP, depending on the delivery model.

Conclusion

By using willingness to pay to understand demand for DPPs and computing the provider’s marginal cost of providing these services, we can estimate cost sharing and market coverage of these services and thus compare the viability of alternate approaches to scaling up and sustaining DPPs with available resources.

The healthy living partnerships to prevent diabetes and the diabetes prevention program: a comparison of year 1 and 2 intervention results

A number of research studies have attempted to translate the behavioral lifestyle intervention delivered in the Diabetes Prevention Program (DPP). To compare the active interventions of two trials, Diabetes Prevention Program DPP and Healthy Living Partnerships to Prevent Diabetes (HELP PD), after 1 and 2 years of intervention. DPP included 3234 adults with prediabetes randomized to intensive lifestyle intervention, metformin, troglitazone, or placebo. The lifestyle intervention, professionally delivered to individuals in a clinical setting, focused on diet and increased physical activity. HELP PD, a community-based translation of DPP, included 301 adults randomized to receive intensive lifestyle intervention or enhanced usual care. Mean weight-losses at 1 year (6.9 kg in DPP, 6.4 kg in HELP PD) and 2 years (5.5 kg in DPP, 4.4 kg in HELP PD) were similar across studies. Reductions in glucose were also similar across studies at both time points (5.2 mg/dL in DPP and 4.1 mg/dL in HELP PD at 1 year; 1.8 mg/dL and 1.6 mg/dL at 2 years). HELP PD participants achieved larger reductions in triglycerides at 1 and 2 years (38.4 mg/dL and 34.9 mg/dL, respectively) than DPP participants (24.8 mg/dL and 22.4 mg/dL). High-density lipoprotein decreased in HELP PD participants at year 1 (-0.6 mg/dL) and increased in DPP (1.2 mg/dL) but there were no significant differences in year 2. HELP PD, a community model for diabetes prevention, was similar to DPP in reducing body weight and lowering blood glucose, both important risk factors that should be controlled to reduce risk for developing type 2 diabetes.

Effect and maintenance of the SLIMMER diabetes prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled trial

BACKGROUND/OBJECTIVES

To assess the effectiveness of the SLIMMER combined dietary and physical activity lifestyle intervention on clinical and metabolic risk factors, dietary intake, physical activity, and quality of life after 12 months, and to investigate whether effects sustained six months after the active intervention period ended.

SUBJECTS/METHODS

SLIMMER was a randomised controlled intervention, implemented in Dutch primary healthcare. In total, 316 subjects aged 40-70 years with increased risk of type 2 diabetes were randomly allocated to the intervention group (10-month dietary and physical activity programme) or the control group (usual healthcare). All subjects underwent an oral glucose tolerance test and physical examination, and filled in questionnaires. Identical examinations were performed at baseline and after 12 and 18 months. Primary outcome was fasting insulin.

RESULTS

The intervention group showed significantly greater improvements in anthropometry and glucose metabolism. After 12 and 18 months, differences between intervention and control group were -2.7 kg (95% confidence interval (CI): -3.7; -1.7) and -2.5 kg (95% CI: -3.6; -1.4) for weight, and -12.1 pmol l-1 (95% CI: -19.6; -4.6) and -8.0 pmol l-1 (95% CI: -14.7; -0.53) for fasting insulin. Furthermore, dietary intake, physical activity, and quality of life improved significantly more in the intervention group than in the control group.

CONCLUSIONS

The Dutch SLIMMER lifestyle intervention is effective in the short and long term in improving clinical and metabolic risk factors, dietary intake, physical activity, and quality of life in subjects at high risk of diabetes.

Assessment of Knowledge of Diabetes Mellitus in the Urban Areas of Klang District, Malaysia

Diabetes is the most common cause of non-traumatic lower limb amputations and cardiovascular diseases. However, only a negligible percentage of the patients and subjects knew that the feet are affected in diabetes and diabetes affects the heart. Hence, a cross-sectional study was carried out to evaluate the knowledge of diabetes mellitus among the public of different age group, gender, ethnicity, and education level. A sample of 400 participants was randomly selected and data was collected using a structured questionnaire under non-contrived setting. The results showed that there is a statistically significant difference in knowledge on diabetes mellitus among different age groups and different ethnic origin but there is no significant difference in the knowledge among different gender and education level. Out of 400 respondents, 284 respondents (71%) knew that diabetes mellitus is actually a condition characterized by raised blood sugar. Age and education level of respondents were found to be the predominant predictive factors on diabetes knowledge, whereas the gender of respondents did not affect the findings of this study. An improved and well-structured educational programme that tackles the areas of weaknesses should be recommended to increase the level of knowledge on diabetes among Malaysians.

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.

Translational Research Principles of an Effectiveness Trial for Diabetes Care in an Urban African American Population

Purpose

Large-scale effectiveness trials designed to translate evidence-based diabetes care to community settings are few. Studies describing these methods among high-risk minority populations are particularly limited.

Methods

The authors describe Project Sugar, a randomized controlled trial conducted in 2 phases: Project Sugar 1 (1994-1999), which piloted a 4-arm clinic and homebased intervention using nurse case management and community health workers in 186 urban African Americans with type 2 diabetes, and Project Sugar 2 (2000-2005), which examined effectiveness of this intervention among 542 diabetic, urban African Americans.

Results and Conclusions

Project Sugar had success with regard to recruitment and retention, both in phase 1 (80% rate at 24 months) and phase 2 (>90% at 24 months). Using the RE-AIM framework, planning and research design for Project Sugar 2 is described in detail for elements that contributed to the reach, effectiveness, adoption, implementation, and maintenance of this study within a minority community setting. In addition to successful strategies, challenges to conducting effectiveness trials in an inner-city African American community are identified.

Implementation of Lifestyle Modification Program Focusing on Physical Activity and Dietary Habits in a Large Group, Community-Based Setting

BACKGROUND

Lifestyle modification programs improve several health-related behaviors, including physical activity (PA) and nutrition. However, few of these programs have been expanded to impact a large number of individuals in one setting at one time. Therefore, the purpose of this study was to determine whether a PA- and nutrition-based lifestyle modification program could be effectively conducted using a large group format in a community-based setting.

METHOD

One hundred twenty-one participants enrolled in a 16-week, community-based lifestyle modification program and separated in small teams of 13 to 17 individuals. Height, weight, fruit and vegetable (FAV) consumption, physical fitness, and several psychosocial measures were assessed before and after the program.

RESULTS

Significant improvements in 6-minute walk distance (+68.3 m; p < .001), chair stands (+6.7 repetitions; p < .001), FAV servings (+1.8 servings/day; p < .001), body weight (-3.2 lbs; p < .001), as well as PA social support and eating habits self-efficacy were observed. Our lifestyle modification program was also successful in shifting participants to higher levels of stages of change for nutrition and PA, increasing overall levels of self-efficacy for healthy eating, and improving levels of social support for becoming more active.

CONCLUSIONS

A lifestyle modification program can be successfully implemented in a community setting using a large group format to improve PA and FAV attitudes and behaviors.

Assessing Barriers and Enhancers to Increasing Physical Activity during the School Day in Children on an American Indian Reservation: A Qualitative Research Study

Objective

We attempted to determine factors that enhance or limit physical activity (PA) in children living on an American Indian (AI) reservation.

Methods

Six audio-recorded focus groups (FGs) were conducted. Each group included 6 - 8 participants (N = 42) with 3 grade specific FGs (4^th - 6^th grade students) and 3 adult FGs.

Results

FG analysis identified 4 main barriers to PA: school environment; community and school resources; electronic devices; and the role of parents and family. Analysis revealed 3 main strategies to increase PA: structured/non-competitive activities; structured/competitive activities; and increasing school and community-wide capacity.

Conclusion

The results from this study provide a school health perspective on the 4-day school week.

The Public Health Leadership and Implementation Academy (PH-LEADER) for Non-Communicable Diseases

Low- and middle-income countries (LMICs) are experiencing a growing burden of non-communicable diseases (NCDs) and confront challenges of leadership, lack of local data and evidence, and gaps in implementation of successful interventions. To address these challenges, we designed an interdisciplinary training program, the Public Health Leadership and Implementation Academy (PH-LEADER) for NCDs. The year-long program has three components; a two-month preparation period; a three-week, in-person summer short course; and an in-country mentored project phase. The training was directed at mid-career, high-potential public health professionals from LMICs who are involved in NCDs prevention and control. We collected demographic data and information about achievements and products attained from participation in the program among trainees. Over four and a half years (2012-2016), 67 NCDs professionals (mean age 38.7 years; 58% male) from 11 countries have been trained. The training program has promoted the design and implementation of 49 projects focused on implementation of programs and policies addressing NCDs; 20 manuscripts submitted for publication; and four abstracts submitted for conference presentations. The PH-LEADER program promotes the design and implementation of evidence-based strategies to address NCDs in LMICs. Impact on trainee implementation research capacity and leadership skills and ultimately on NDCs prevention and control is yet to be assessed.

Text Message Support for Weight Loss in Patients With Prediabetes: A Randomized Clinical Trial

OBJECTIVE

Although the benefits of in-person Diabetes Prevention Program (DPP) classes for diabetes prevention have been demonstrated in trials, effectiveness in clinical practice is limited by low participation rates. This study explores whether text message support enhances weight loss in patients offered DPP classes.

RESEARCH DESIGN AND METHODS

English- and Spanish-speaking patients with prediabetes (n = 163) were randomized to the control group, which only received an invitation to DPP classes as defined by the Centers for Disease Control and Prevention, or to the text message-augmented intervention group, which also received text messages adapted from the DPP curriculum for 12 months.

RESULTS

Mean weight decreased 0.6 pounds (95% CI -2.7 to 1.6) in the control group and 2.6 pounds (95% CI -5.5 to 0.2) in the intervention group (P value 0.05). Three percent weight loss was achieved by 21.5% of participants in the control group (95% CI 12.5-30.6), compared with 38.5% in the intervention group (95% CI 27.7-49.3) (absolute difference 17.0%; P value 0.02). Mean glycated hemoglobin (HbA1c) increased by 0.19% or 2.1 mmol/mol (95% CI -0.1 to 0.5%) and decreased by 0.09% or 1.0 mmol/mol (95% CI -0.2 to 0.0%) in the control group and intervention participants, respectively (absolute difference 0.28%; P value 0.07). Stratification by language demonstrated a significant treatment effect in Spanish speakers but not in English speakers.

CONCLUSIONS

Text message support can lead to clinically significant weight loss in patients with prediabetes. Further study assessing effect by primary language and in an operational setting is warranted.

A qualitative study examining healthcare managers and providers' perspectives on participating in primary care implementation research

BACKGROUND

Primary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research.

METHODS

Guided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts.

RESULTS

Two major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues.

CONCLUSIONS

Healthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.

Process evaluation of a randomised controlled trial of a diabetes prevention intervention in Dutch primary health care: the SLIMMER study

OBJECTIVE

To investigate (i) how the SLIMMER intervention was delivered and received in Dutch primary health care and (ii) how this could explain intervention effectiveness.

DESIGN

A randomised controlled trial was conducted and subjects were randomly allocated to the intervention (10-month combined dietary and physical activity intervention) or the control group. A process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity and applicability) were collected via semi-structured interviews with health-care professionals (n 45) and intervention participant questionnaires (n 155).

SETTING

SLIMMER was implemented in Dutch primary health care in twenty-five general practices, eleven dietitians, nine physiotherapist practices and fifteen sports clubs.

SUBJECTS

Subjects at increased risk of developing type 2 diabetes were included.

RESULTS

It was possible to recruit the intended high-risk population (response rate 54 %) and the SLIMMER intervention was very well received by both participants and health-care professionals (mean acceptability rating of 82 and 80, respectively). The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour.

CONCLUSIONS

The present study showed that it is feasible to implement a diabetes prevention intervention in Dutch primary health care. Higher dose received and participant acceptability were associated with improved health outcomes and dietary behaviour. Using an extensive process evaluation plan to gain insight into how an intervention is delivered and received is a valuable way of identifying intervention components that contribute to implementation integrity and effective prevention of type 2 diabetes in primary health care.

Type 2 Diabetes: Why We Are Winning the Battle but Losing the War? 2015 Kelly West Award Lecture

Diabetes is among the biggest of the 21st-century global health challenges. In the U.S. and other high-income countries, thanks to investments in science, dedication to implementing these findings, and measurement of quality of care, there have been improvements in diabetes management and declines in rate of diabetes complications and mortality. This good news, however, is overshadowed by the ever-increasing absolute numbers of people with diabetes and its complications and the unprecedented growth of diabetes in low- and middle-income countries of the world. To comprehensively win the war against diabetes requires 1) concerted attention to prevention and 2) expansion of global research to better inform population-level policies to curb diabetes but also to better understand individual- and population-level variations in pathophysiology and phenotypes globally so that prevention and treatment can be tailored. For example, preliminary data show that thin people in low- and middle-income countries such as India commonly experience type 2 diabetes. Global studies comparing these thin Asian Indians with other high-risk groups such as Pima Indians, a population with a high mean BMI, suggest that type 2 diabetes may not be a single pathophysiological entity. Pima Indians may represent the well-studied phenotype of poor insulin action (type 2A), whereas Asian Indians represent the grossly understudied phenotype of poor insulin secretion (type 2B). This has major implications for diagnosis, prevention, and treatment and highlights the mismatch between where diabetes burdens occur (i.e., low- and middle-income countries) and where research happens (i.e., high-income countries). Correcting this imbalance will advance our knowledge and arsenal to win the global war against diabetes.

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.

Diabetes Knowledge Translation Status in Developing Countries: A Mixed Method Study Among Diabetes Researchers in Case of Iran

BACKGROUND

Despite considerable investment in research, the existing research evidence is frequently not implemented and/or leads to useless or detrimental care in healthcare. The knowledge-practice gap proposed as one of the main causes of not achieving the treatment goals in diabetes. Iran also is facing a difference between the production and utilization of the knowledge of diabetes. The aim of this study was to assess the status of diabetes knowledge translation (KT) in Iran.

METHODS

This was a survey that executed in 2015 by concurrent mixed methods approach in a descriptive, cross-sectional method. The research population was 65 diabetes researchers from 14 diabetes research centers throughout Iran. The research was carried out via the self-assessment tool for research institutes (SATORI), a valid and reliable tool. Focus group discussions were used to complete this tool. The data were analyzed using quantitative (descriptive method by Excel software) and qualitative approaches (thematic analysis) based on SATORI-extracted seven themes.

RESULTS

The mean of scores "the question of research," "knowledge production," "knowledge transfer," "promoting the use of evidence," and all aspects altogether were 2.48, 2.80, 2.18, 2.06, and 2.39, respectively. The themes "research quality and timeliness" and "promoting and evaluating the use of evidence" received the lowest (1.91) and highest mean scores (2.94), respectively. Except for the theme "interaction with research users" with a relatively mediocre scores (2.63), the other areas had scores below the mean.

CONCLUSIONS

The overall status of diabetes KT in Iran was lower than the ideal situation. There are many challenges that require great interventions at the organizational or macro level. To reinforce diabetes KT in Iran, it should hold a more leading and centralized function in the strategies of the country's diabetes research system.

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.

Translation of lifestyle modification programs focused on physical activity and dietary habits delivered in community settings

BACKGROUND

Lifestyle modification programs (LMPs) can provide individuals with behavioral skills to sustain long-term changes to their physical activity (PA) levels and dietary habits. Yet, there is much work to be done in the translation of these programs to community settings.

PURPOSE

This review identified LMPs that focused on changing both PA and dietary behaviors and examined common features and barriers faced in their translation to community settings.

METHODS

A search of multiple online databases was conducted to identify LMPs that included participants over the age of 18 who enrolled in LMPs, offered in community settings, and had the goal of improving both PA and dietary behaviors. Data were extracted on participant demographics, study design characteristics, and study outcome variables including changes in PA, dietary habits, body weight, and clinical outcomes.

RESULTS

We identified 27 studies that met inclusion criteria. Despite high levels of retention and adherence to the interventions, varying levels of success were observed in increasing PA levels, improving dietary habits, reducing body weight, and improving clinic outcomes.

CONCLUSION

LMPs addressing issues of PA and dietary habits can be successfully implemented in a community setting. However, inconsistent reporting of key components in the translation of these studies (participant recruitment, utilization of behavioral strategies) may limit their replication and advancement of future programs. Future efforts should better address issues such as identifying barriers to participation and program implementation, utilization of community resources, and evaluating changes across multiple health behaviors.

Design and participant characteristics for a randomized effectiveness trial of an intensive lifestyle intervention to reduce cardiovascular risk in adults with type 2 diabetes: The I-D-HEALTH study

Intervening in Diabetes with Healthy Eating, Activity and Linkages To Healthcare (I-D-HEALTH) is a community-based randomized trial evaluating the effectiveness of a group-based adaption of the Look AHEAD intensive lifestyle intervention. Most potentially eligible patients were identified through electronic medical record queries or referral to a diabetes resource hub. Trial enrollees had a usual source of primary care, elevated body mass index (BMI) and type 2 diabetes. I-D-HEALTH participants were randomized to either standard care alone or standard care plus free-of-charge access to a group-based lifestyle intervention (GLI) offered by the YMCA. GLI participation was encouraged, but not required, for the latter group. The primary outcome is percent weight change over 6, 12 and 24months. Secondary outcomes include direct intervention costs and direct medical and non-medical expenditures, as well as changes in systolic blood pressure, hemoglobin A1c and cholesterol. Among 331 I-D-HEALTH participants, 167 were randomized to standard care and 164 to GLI. The mean age (±standard deviation) in each group was 57.1years (±12.2) and 57.6years (±10.5), respectively. Mean BMI was 34.9kg/m(2) (±7.3) among standard care participants and 36.2kg/m(2) (±7.8) among GLI participants. In both groups, approximately one third of participants were non-Hispanic Whites. We detected no significant differences between groups in mean systolic blood pressure, hemoglobin A1c or total cholesterol (P >0.05 for all characteristics above). The I-D-HEALTH study enrolled a diverse sample of adults with diabetes and offers a unique opportunity to evaluate the effectiveness of offering a community-based intensive lifestyle intervention.

The rationale, design, and baseline characteristics of PREVENT-DM: A community-based comparative effectiveness trial of lifestyle intervention and metformin among Latinas with prediabetes

Promotora Effectiveness Versus Metformin Trial (PREVENT-DM) is a randomized comparative effectiveness trial of a lifestyle intervention based on the Diabetes Prevention Program delivered by community health workers (or promotoras), metformin, and standard care. Eligibility criteria are Hispanic ethnicity, female sex, age ≥ 20 years, fluent Spanish-speaking status, BMI ≥ 23 kg/m(2), and prediabetes. We enrolled 92 participants and randomized them to one of the following three groups: standard care, DPP-based lifestyle intervention, or metformin. The primary outcome of the trial is the 12-month difference in weight between groups. Secondary outcomes include the following cardiometabolic markers: BMI, waist circumference, blood pressure, and fasting plasma glucose, hemoglobin A1C (HbA1c), total cholesterol, triglycerides, LDL cholesterol, HDL cholesterol, and insulin. PREVENT-DM participants are socioeconomically disadvantaged Latinas with a mean annual household income of $15,527 ± 9922 and educational attainment of 9.7 ± 3.6 years. Eighty-six percent of participants are foreign born, 20% have a prior history of gestational diabetes, and 71% have a first-degree relative with diagnosed diabetes. At baseline, PREVENT-DM participants had a mean age of 45.1 ± 12.5 years, weight of 178.8 ± 39.3 lbs, BMI of 33.3 ± 6.5 kg/m(2), HbA1c of 5.9 ± 0.2%, and waist circumference of 97.4 ± 11.1cm. Mean baseline levels of other cardiometabolic markers were normal. The PREVENT-DM study successfully recruited and randomized an understudied population of Latinas with prediabetes. This trial will be the first U.S. study to test the comparative effectiveness of metformin and lifestyle intervention versus standard care among prediabetic adults in a "real-world" setting.

Implementing Specialized Diabetes Teams in Primary Care in Southern Ontario

OBJECTIVES

This study explores the implementation processes of integrating specialized diabetes teams into primary care in southern Ontario, Canada.

METHODS

In-depth qualitative interviews were conducted with 23 patients, 20 diabetes educators and 16 primary care physicians. In addition, group debriefing sessions were conducted and field notes were collected from diabetes educators and diabetes education program managers to further explore the day-to-day issues of implementation. Data were analyzed using an inductive content analysis approach.

RESULTS

Analysis revealed 3 main themes: Right Place, Right Time, Right Service: the convenience and comfort of local care, timely, preventive management and delivering person-centred care; Creating Partnerships: generating intervention buy-in, formal discussion, service agreements, site orientation and team development; Operational Complexities and Strategies: access to electronic medical records and documentation, referral and scheduling procedures, and costs and resources.

CONCLUSIONS

Because situating diabetes teams in primary care currently involves using existing healthcare structures and human resources, pragmatic methods of fostering successful implementation of this model of practice are required. The utility of this model was perceived as being viable, and benefits were visible to all study participants. Strategies to facilitate implementation include outlining roles and expectations by educators and the primary care providers' team in the beginning, investment in the intervention by all stakeholders, and clear channels of communication that allow educators to perform their roles and leverage opportunities for team collaboration in patient care. Further evaluation of implementation processes can serve to expand this model of practice, which has proven so far to be favourable to the players involved.

A Randomized Comparative Effectiveness Trial for Preventing Type 2 Diabetes

OBJECTIVES

We evaluated the weight loss effectiveness of a YMCA model for the Diabetes Prevention Program (DPP) lifestyle intervention.

METHODS

Between July 2008 and November 2010, we individually randomized 509 overweight or obese, low-income, nondiabetic adults with elevated blood glucose in Indianapolis, Indiana, to receive standard care plus brief lifestyle counseling or be offered a group-based YMCA adaptation of the DPP (YDPP). Primary outcome was mean weight loss difference at 12 months. In our intention-to-treat analyses, we used longitudinal linear or logistic regression, multiply imputing missing observations. We used instrumental variables regression to estimate weight loss effectiveness among participants completing 9 or more intervention lessons.

RESULTS

In the YDPP arm, 161 (62.6%) participants attended ≥ 1 lesson and 103 (40.0%) completed 9 or more lessons. In intention-to-treat analysis, mean 12-month weight loss was 2.3 kilograms (95% confidence interval [CI] = 1.1, 3.4 kg) more for the YDPP arm than for standard care participants. In instrumental variable analyses, persons attending 9 or more lessons had a 5.3-kilogram (95% CI = 2.8, 7.9 kg) greater weight loss than did those with standard care alone.

CONCLUSIONS

The YMCA model for DPP delivery achieves meaningful weight loss at 12 months among low-income adults.

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.

Contextualizing the Proven Effectiveness of a Lifestyle Intervention for Type 2 Diabetes in Primary Care: A Qualitative Assessment Based on the RE-AIM Framework

OBJECTIVE

The Healthy Eating and Active Living for Diabetes in Primary Care Networks (HEALD) intervention proved effective in increasing daily physical activity among people with type 2 diabetes in 4 community-based primary care networks (PCNs) in Alberta. Here, we contextualize its effectiveness by describing implementation fidelity and PCN staff's perceptions of its success in improving diabetes management.

METHODS

We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate the HEALD intervention. Qualitative methods used to collect data related to the RE-AIM dimensions of implementation and effectiveness included interviews with PCN staff (n=24), research team reflections (n=4) and systematic documentation. We used content analysis, and data were imported into and managed using Nvivo 10.

RESULTS

HEALD was implemented as intended with adequate fidelity across all 4 PCNs. Identified implementation facilitators included appropriate human resources, the training provided, ongoing support, the provision of space and the simplicity of the intervention. However, PCN staff reported varying opinions regarding its potential for improving diabetes management among patients. Rationales for their views included intervention "dose" inadequacy; that the quality of usual care for people with diabetes was already good; patients were already managing their diabetes well; and the potential for cointervention. Recommended improvements to HEALD included increasing the dose of the intervention, expanding it to other modes of exercise and incorporating a medical clearance process.

CONCLUSIONS

Based on the high degree of fidelity, the demonstrated effectiveness of HEALD in improving physical activity among patients was a result of sound implementation of an efficacious intervention. Increasing the dose of HEALD could result in additional improvements for patients.

A review of the mental health issues of diabetes conference

Individuals with type 1 diabetes are at increased risk for depression, anxiety disorder, and eating disorder diagnoses. People with type 1 diabetes are also at risk for subclinical levels of diabetes distress and anxiety. These mental/behavioral health comorbidities of diabetes are associated with poor adherence to treatment and poor glycemic control, thus increasing the risk for serious short- and long-term physical complications, which can result in blindness, amputations, stroke, cognitive decline, decreased quality of life, as well as premature death. When mental health comorbidities of diabetes are not diagnosed and treated, the financial cost to society and health care systems is catastrophic, and the human suffering that results is profound. This review summarizes state-of-the-art presentations and working group scholarly reports from the Mental Health Issues of Diabetes Conference (7-8 October 2013, Philadelphia, PA), which included stakeholders from the National Institutes of Health, people living with type 1 diabetes and their families, diabetes consumer advocacy groups, the insurance industry, as well as psychologists, psychiatrists, endocrinologists, and nurse practitioners who are all nationally and internationally recognized experts in type 1 diabetes research and care. At this landmark conference current evidence for the incidence and the consequences of mental health problems in type 1 diabetes was presented, supporting the integration of mental health screening and mental health care into routine diabetes medical care. Future research directions were recommended to establish the efficacy and cost-effectiveness of paradigms of diabetes care in which physical and mental health care are both priorities.

Preventing diabetes in primary care: a feasibility cluster randomized trial

OBJECTIVE

To determine the feasibility of implementing a large-scale primary care-based diabetes prevention trial.

METHODS

A feasibility cluster randomized controlled trial was conducted in British Columbia, Canada, amongst adults with prediabetes using the Facilitated Lifestyle Intervention Prescription (FLIP) vs. usual care. FLIP included lifestyle advice, a pedometer, and telephone support from a lifestyle facilitator for 6 months. Indicators of feasibility included recruitment rates of family practices, participants and facilitators, as well as feasibility and retention rates in the FLIP program and study protocols.

RESULTS

Six family practices participated; 59 patients were enrolled between October 2012 and March 2013. The trial protocol was acceptable to practices and participants and had a 95% participant retention rate over the 6 months (56/59). Adherence to the intervention was high (97%), with 34 of 35 patients continuing to receive telephone calls from the facilitator for 6 months. The mean cost of the intervention was C$144 per person. Compared with control, intervention participants significantly reduced weight by 3.2 kg (95% CI, 1.7 to 4.6); body mass index by 1.2 (95% CI, 0.7 to 1.7) and waist circumference by 3 cm (95% CI, 0.3 to 5.7).

CONCLUSIONS

It is feasible to implement FLIP and to conduct a trial to assess effectiveness. A larger trial with longer follow up to assess progression to diabetes is warranted.

Effect of self-efficacy on weight loss: a psychosocial analysis of a community-based adaptation of the diabetes prevention program lifestyle intervention

Objective. Weight loss is the most effective approach to reducing diabetes risk. It is a research priority to identify factors that may enhance weight loss success, particularly among those at risk for diabetes. This analysis explored the relationships between self-efficacy, weight loss, and dietary fat intake among adults at risk for developing type 2 diabetes. Methods. This pilot, site-randomized trial was designed to compare group-based Diabetes Prevention Program lifestyle intervention delivery by YMCA staff to brief counseling alone (control) in 92 adults at risk for diabetes (BMI ≥ 24 kg/m(2), ≥ 2 diabetes risk factors, and a random capillary blood glucose of 110-199 mg/dl). Self-efficacy was measured using the Weight Efficacy Lifestyle questionnaire. Data were collected at baseline, 6 months, and 12 months. A paired t test was used to determine within-group changes in self-efficacy and weight at 6 and 12 months. Using a fitted model, we estimated how much of an increase in self-efficacy was related to a 5% weight reduction at 6 and 12 months. Results. Self-efficacy was associated with a 5% reduction in baseline weight at 6 and 12 months but was not related to fat intake. Conclusion. These findings suggest that it is important to assess the level of self-efficacy when counseling adults at high risk for diabetes about weight loss. Certain aspects of self-efficacy seem to play a greater role, depending on the stage of weight loss.

[Translational research in gestational diabetes mellitus and mild gestational hyperglycemia: current knowledge and our experience]

Maternal diabetes constitutes an unfavorable environment for fetal-placental and embryonic development. It is has important repercussion in modern obstetrics, since it is associated to an increased risk of neonatal and maternal morbidity, and it still is a significant medical challenge. The increased occurrence of diabetes worldwide, the increase in diabetes type 2 in women at reproductive age and the crossed generation of intrauterine programming for diabetes type 2 are the bases for the growing interest in utilization of diabetic experimental samples, with the aim to acquire knowledge about the mechanisms that induce development alterations in gestational diabetes. Several studies have shown the benefits of diabetes prevention, with interventions in lifestyle, metabolic improvement and control of cardiovascular risk factors to substantially prevent the complications of this devastating disease. Despite these findings, the recent revolution in the scientific knowledge, and the infinite number of new therapies for diabetes, there is still a large gap between what was learned through research and what is really done in public, clinical and community health. The negative economic impact of this complacency in people, families, and national economies is alarming. It is expected that translational research in the binomial diabetes and pregnancy are implemented in centers of excellence, in both basic and applied research, and complemented by multicenter clinical studies, conducted in a pragmatic way to increase the level of scientific evidence with more reliable diagnostic and propaedeutic resources.

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.

Awareness regarding risk factors of type 2 diabetes among individuals attending a tertiary-care hospital in Bangladesh: a cross-sectional study

Background

Awareness regarding risk factors is a prerequisite for the prevention of diabetes in general population. However, there are great variations in the level of this awareness from population to population and this needs to be explored in different ethnic and social groups for designing appropriate preventive strategies. The purpose of the study was to assess the level of awareness regarding the risk factors responsible for the development of type 2 diabetes and its determinants among individuals who attended a tertiary care hospital.

Methods

Under an analytical cross-sectional design, 400 non-diabetic respondents, aged >30 years, were conveniently selected from the Out-Patient Department of BIRDEM, the tertiary care hospital of the Diabetic Association of Bangladesh. A pretested, semi-structured questionnaire was developed to assess knowledge and attitude of the respondents. Respondents’ level of knowledge and attitude were categorized as good, average and poor (GAP). Multivariate along with bivariate statistics was used to measure knowledge and attitude of type 2 diabetes.

Results

Among the respondents the levels of knowledge and attitude were 13%, 10% good; 68%, 75% average and 19%, 14% poor respectively. In multivariate analysis, high literacy (p = 0.0001), respondents who are in service (p = 0.02) and family history of diabetes (p = 0.02) were found significantly associated with the knowledge score after adjustment. Respondents who had passed secondary and higher secondary education had a significant association (p = 0.03) with the attitude score. Housewives had a significantly lower attitude score than others (p = 0.04). Family history of diabetes and knowledge on the risk factors of diabetes showed significant positive association with the attitude score (p = 0.013 and p = 0.0001 respectively).

Conclusions

Overall, respondents participating in this study have average awareness regarding risk factors of diabetes. From a public health perspective, there is a decisive need of innovative prevention programs for targeting people including high-risk individuals.

SLIMMER: a randomised controlled trial of diabetes prevention in Dutch primary health care: design and methods for process, effect, and economic evaluation

BACKGROUND

Implementation of interventions in real-life settings requires a comprehensive evaluation approach. The aim of this article is to describe the evaluation design of the SLIMMER diabetes prevention intervention in a Dutch real-life setting.

METHODS/DESIGN

The SLIMMER study is a randomised, controlled intervention study including subjects aged 40 through 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involves a dietary and physical activity intervention, including case management and a maintenance programme. The control group receives usual health care and written information about a healthy lifestyle. A logic model of change is composed to link intervention activities with intervention outcomes in a logical order. Primary outcome is fasting insulin. Measurements are performed at baseline and after 12 and 18 months and cover quality of life, cardio-metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), eating and physical activity behaviour, and behavioural determinants. A process evaluation gives insight in how the intervention was delivered and received by participants and health care professionals. The economic evaluation consists of a cost-effectiveness analysis and a cost-utility analysis. Costs are assessed from both a societal and health care perspective.

DISCUSSION

This study is expected to provide insight in the effectiveness, including its cost-effectiveness, and delivery of the SLIMMER diabetes prevention intervention conducted in Dutch primary health care. Results of this study provide valuable information for primary health care professionals, researchers, and policy makers.

TRIAL REGISTRATION

The SLIMMER study is registered with ClinicalTrials.gov (NCT02094911) since March 19, 2014.

A community based prevention of weight gain intervention (Mothers In Motion) among young low-income overweight and obese mothers: design and rationale

BACKGROUND

Over 45% of American women 20-39 years old are at risk for type 2 diabetes, cardiovascular disease, and other health conditions because they are overweight or obese. The prevalence of overweight and obesity is disproportionately high among low-income women. This paper describes the study design and rationale of a community based intervention (Mothers In Motion, MIM) aimed to prevent weight gain among low-income overweight and obese mothers 18-39 years old by promoting stress management, healthy eating, and physical activity.

METHODS/DESIGN

Peer recruiters approach participants from 5 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Michigan. The MIM delivers theory-based, culturally-sensitive intervention messages via a combination of DVDs and peer support group teleconferences (PSGTs). The DVD features African American and white overweight and obese WIC mothers who participated in a healthy lifestyle intervention patterned after MIM. The PSGTs are led by paraprofessionals from Michigan State University Extension and WIC providers in Michigan who are trained in motivational interviewing and group facilitation skills. Participants are randomly assigned to an intervention (n=350) or comparison group (n=175). The intervention group receives a 16-week intervention on a weekly or bi-weekly basis. Participants are asked to watch 10 MIM DVD chapters at home and join 10 PSGT sessions by phone. The comparison group receives printed educational materials. The primary outcome is body weight. Secondary outcomes include dietary fat, fruit, and vegetable intake; physical activity; stress, and affect. Mediators are self-efficacy, emotional coping response, social support, and autonomous motivation. Telephone interviews and in-person data collection at WIC offices occur at 3 time points: baseline, immediately, and 3 months after the 16-week intervention.

DISCUSSION

If MIM shows effectiveness, it could have a favorable impact on public health and community programs. The DVDs and PSGTs will be disseminated in WIC, Extension, clinical practice that promote healthy lifestyles for similar target audiences to make a broad contribution to the prevention of weight gain in low-income mothers. Also, our methodology can be adapted by researchers and community stakeholders to help other low-income populations prevent weight gain.

TRIAL REGISTRATION

Clinical Trials Number: NCT01839708.

Features of online health communities for adolescents with type 1 diabetes

The aim of this exploratory study was to examine diabetes online health communities (OHCs) available to adolescents with type 1 diabetes (T1D). We sought to identify and classify site features and relate them to evidence-based processes for improving self-management. We reviewed 18 OHCs and identified the following five feature categories: social learning and networking, information, guidance, engagement, and personal health data sharing. While features that have been associated with improved self-management were present, such as social learning, results suggest that more guidance or structure would be helpful to ensure that those processes were focused on promoting positive beliefs and behaviors. Enhancing guidance-related features and structure to existing OHCs could provide greater opportunity for effective diabetes self-management support. To support clinical recommendations, more research is needed to quantitatively relate features and participation in OHCs to patient outcomes.

Rationale, design, and baseline characteristics of a community-based comparative effectiveness trial to prevent type 2 diabetes in economically disadvantaged adults: the RAPID Study

Reaching Out and Preventing Increases in Diabetes (RAPID) is a community-based randomized trial evaluating the comparative costs and effectiveness of a group-based adaption of the DPP lifestyle intervention developed and implemented in partnership with the YMCA. RAPID enrolled adult primary care patients, with BMI 24 kg/m(2) or higher and abnormal glucose metabolism (HbA1c 5.7-6.9% or fasting plasma glucose 100-125 mg/dL). 509 participants were enrolled and randomized to one of two groups: standard clinical advice plus free-of-charge access to a group-based adaption of the DPP offered by the Y, versus standard clinical advice alone. Key outcomes for future analysis will include differences in body weight and other cardiovascular risk factors over a 24-month intervention period. At baseline, RAPID participants had a mean (SD) age of 51 ± 12.1 years, weight of 225.1 ± 56.2 lbs, and BMI of 36.9 ± 8.6 kg/m(2). 70.7% were women, 57.2% were African American, 35.4% were non-Hispanic White, and 3.2% were Hispanic. Mean HbA1c was 6.05 ± 0.34%. Additionally, 55.4% of participants had a baseline systolic blood pressure of ≥130 mmHg, 33.1% had a total blood cholesterol exceeding 200mg/dL, and 74% reported a household income of <$25,000. The RAPID Study successfully randomized a large cohort of participants with a wide distribution of age, body weight, and race who are at high risk for developing type 2 diabetes.

Type 2 translational research for CKD

Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a "bench-to-bedside" paradigm (conventional type 1 translation) to research that encompasses "clinic and community" is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of high-quality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge.

Translating the Diabetes Prevention Program into American Indian and Alaska Native communities: results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project

OBJECTIVE

The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities.

RESEARCH DESIGN AND METHODS

The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated.

RESULTS

The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure.

CONCLUSIONS

Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.

Designing a natural experiment to evaluate a national health care-community partnership to prevent type 2 diabetes

To address the growing incidence of type 2 diabetes in the United States, UnitedHealth Group, the YMCA of the USA, and the Centers for Disease Control and Prevention have partnered to bring a group-based adaptation of the Diabetes Prevention Program lifestyle intervention to a national scale. Researchers at Northwestern and Indiana universities are collaborating with these partners to design a robust evaluation of the reach, effectiveness, and costs of this natural experiment. We will employ a quasi-experimental, cluster-randomized study design and combine administrative, clinical, and programmatic data from existing sources to derive reliable, timely, and policy-relevant estimates of the program’s impact and potential for sustainability. In this context, evaluation results will provide information about the unique role of a health care–community partnership to prevent type 2 diabetes.