Prevention in Prison: The Diabetes Prevention Program in a Correctional Setting

Linking biomarkers with healthy lifestyle outcomes after stroke: Supplementary results of a 12-month randomized controlled trial

BACKGROUND AND AIMS

Participation in a healthy lifestyle intervention such as the Diabetes Prevention Program Group Lifestyle Balance-adapted for stroke (GLB-CVA) may reduce stroke burden. Identifying biomarkers associated with lifestyle changes may enhance an individualized approach to stroke recovery. We investigated metabolic biomarkers related to cardiovascular and neurological function in individuals with stroke in the GLB-CVA study and healthy (non-stroke) individuals.

METHODS AND RESULTS

Participants with chronic (>12 months) stroke were recruited to this wait-list randomized controlled trial if they were overweight (BMI ≥25 kg/m2). Participants were randomized to (1) the GLB-CVA program to complete 22 educational sessions addressing behavioral principals of dietary and physical activity or (2) a 6 month wait-list control (WLC). Biomarkers [Plasma irisin, vascular endothelial growth factor, lipoprotein-associated phospholipase A2 (Lp-PLA2), insulin-like growth factor 1 and brain-derived neurotrophic factor (BDNF)] were collected at baseline, 3, and 6 months. Age-matched healthy individuals were recruited for biomarker assessment. Compared to healthy adults (n = 19), participants with stroke (GLB-CVA = 24; WLC = 24) at baseline had higher tHcy levels (p < 0.001) and lower PLA2 levels (p = 0.016). No statistically significant interactions were observed for any biomarkers between the GLB-CVA and WLC or between people who achieved 5% weight loss and those who did not.

CONCLUSION

Participation in a 6-month healthy lifestyle program did not result in statistically significant changes to select metabolic biomarker levels for our participants with chronic stroke. However, participants with stroke demonstrated a unique biomarker profile compared to age-matched healthy individuals.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review

BACKGROUND

High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison.

METHODS

Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text.

RESULTS

Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity.

CONCLUSIONS

It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

Results of a 12-Month Randomized Controlled Trial Testing the Efficacy of the Diabetes Prevention Program Group Lifestyle Balance (DPP-GLB) for People Post Stroke (GLB-CVA)

BACKGROUND

Experience of stroke is associated with an increased risk for diabetes and metabolic syndrome, yet few interventions exist that have been tailored to the population's unique needs.

PURPOSE

To examine adherence and efficacy of the Diabetes Prevention Program Group Lifestyle Balance program (DPP-GLB) modified for individuals post stroke (GLB-CVA) using a randomized controlled trial.

METHODS

Adults (18-85 years of age), >12 months post stroke, and body mass index ≥25 kg/m2 were included in this study. Sixty-five individuals were assigned to either the GLB-CVA intervention or a 6-month wait-list control. Participants completed the 12-month GLB-CVA intervention, with attendance and assessment of weight, anthropometric, biomarker, functional, and patient reported outcome data collected at baseline, 3, 6, and 12 months.

RESULTS

High attendance (90%) and dietary and activity tracking (71%) suggest high adherence to the 12-month GLB-CVA. Six-month randomized controlled trial data indicate significant weight loss (p = .005) in the GLB-CVA group (7.4 ± 13.6 lbs, 3.65%) compared with the wait-list control (0.1 ± 10.1 lbs, 0%), and improvements in arm circumference (p = .04), high-density lipoprotein (HDL) cholesterol (p = .028), 8-year diabetes risk (p = .011), and pain interference (p < .001). Combined 12-month data showed participants lost 10.1 ± 16.8 lbs (4.88%) and improved waist circumference (p = .001), HbA1c (3.6%), diastolic blood pressure (p < .001), pain (p = .001), social participation (p = .025), and eating practices (p = .01) and habits (p < .001).

CONCLUSIONS

Engagement in the GLB-CVA can result in weight loss and improved health for individuals who are overweight or obese following stroke. Future efforts should examine effectiveness in real-world settings and focus on knowledge translation efforts.

Efficacy of the Diabetes Prevention Program Group Lifestyle Balance Program Modified for Individuals with TBI (GLB-TBI): Results from a 12-month Randomized Controlled Trial

BACKGROUND

Obesity after traumatic brain injury (TBI) is a public health issue and no evidence-based weight loss interventions exist to meet the unique needs of individuals after TBI.

PURPOSE

To (a) examine the efficacy of the Diabetes Prevention Program Group Lifestyle Balance for TBI (GLB-TBI) weight-loss intervention compared to an attention control for primary (weight-loss) and secondary health outcomes; (b) determine participant compliance with the GLB-TBI; and (c) determine if compliance is associated with improved outcomes.

METHODS

Individuals with moderate to severe TBI, age 18-64 years, ≥6 months postinjury, and body mass index of ≥25 kg/m2 were randomized to a 12-month, 22-session GLB-TBI intervention or attention control condition. Weight-loss (lbs.), anthropometric, biomarkers, and patient-reported outcomes were collected at baseline, 3, 6, and 12 months.

RESULTS

The GLB-TBI group (n = 27) lost 17.8 ± 41.4lbs (7.9%) over the 12-month program and the attention control group (n = 27) lost 0 ± 55.4lbs (0%). The GLB-TBI group had significant improvements in diastolic blood pressure, triglycerides, and HDL cholesterol. GLB-TBI attendance was 89.6% and weekly self-monitoring of diet and activity was 68.8%. Relative to baseline, the GLB-TBI compliant group (≥80% attendance; ≥85% self-monitoring; n = 10) had a statistically significant decrease in weight at each assessment, the noncompliant group had a significant decrease between 6 and 12 months (n = 17), with no change in weight in the attention control group (n = 27).

CONCLUSIONS

Findings suggest for adults with TBI who are overweight or obese, participation in the GLB-TBI can significantly reduce weight and metabolic risk factors and increase self-reported habits for diet and exercise.

Evaluation of an adapted version of the Diabetes Prevention Program for low- and middle-income countries: A cluster randomized trial to evaluate "Lifestyle Africa" in South Africa

BACKGROUND

Low- and middle-income countries (LMICs) are experiencing major increases in diabetes and cardiovascular conditions linked to overweight and obesity. Lifestyle interventions such as the United States National Diabetes Prevention Program (DPP) developed in high-income countries require adaptation and cultural tailoring for LMICs. The objective of this study was to evaluate the efficacy of "Lifestyle Africa," an adapted version of the DPP tailored for an underresourced community in South Africa compared to usual care.

METHODS AND FINDINGS

Participants were residents of a predominantly Xhosa-speaking urban township of Cape Town, South Africa characterized by high rates of poverty. Participants with body mass index (BMI) ≥ 25 kg/m2 who were members of existing social support groups or "clubs" receiving health services from local nongovernmental organizations (NGOs) were enrolled in a cluster randomized controlled trial that compared Lifestyle Africa (the intervention condition) to usual care (the control condition). The Lifestyle Africa intervention consisted of 17 video-based group sessions delivered by trained community health workers (CHWs). Clusters were randomized using a numbered list of the CHWs and their assigned clubs based on a computer-based random allocation scheme. CHWs, participants, and research team members could not be blinded to condition. Percentage weight loss (primary outcome), hemoglobin A1c (HbA1c), blood pressure, triglycerides, and low-density lipoprotein (LDL) cholesterol were assessed 7 to 9 months after enrollment. An individual-level intention-to-treat analysis was conducted adjusting for clustering within clubs and baseline values. Trial registration is at ClinicalTrials.gov (NCT03342274). Between February 2018 and May 2019, 782 individuals were screened, and 494 were enrolled. Participants were predominantly retired (57% were receiving a pension) and female (89%) with a mean age of 68 years. Participants from 28 clusters were allocated to Lifestyle Africa (15, n = 240) or usual care (13, n = 254). Fidelity assessments indicated that the intervention was generally delivered as intended. The modal number of sessions held across all clubs was 17, and the mean attendance of participants across all sessions was 61%. Outcome assessment was completed by 215 (90%) intervention and 223 (88%) control participants. Intent-to-treat analyses utilizing multilevel modeling included all randomized participants. Mean weight change (primary outcome) was -0.61% (95% confidence interval (CI) = -1.22, -0.01) in Lifestyle Africa and -0.44% (95% CI = -1.06, 0.18) in control with no significant difference (group difference = -0.17%; 95% CI = -1.04, 0.71; p = 0.71). However, HbA1c was significantly lower at follow-up in Lifestyle Africa compared to the usual care group (mean difference = -0.24, 95% CI = -0.39, -0.09, p = 0.001). None of the other secondary outcomes differed at follow-up: systolic blood pressure (group difference = -1.36; 95% CI = -6.92, 4.21; p = 0.63), diastolic blood pressure (group difference = -0.39; 95% CI = -3.25, 2.30; p = 0.78), LDL (group difference = -0.07; 95% CI = -0.19, 0.05; p = 0.26), triglycerides (group difference = -0.02; 95% CI = -0.20, 0.16; p = 0.80). There were no unanticipated problems and serious adverse events were rare, unrelated to the intervention, and similar across groups (11 in Lifestyle Africa versus 13 in usual care). Limitations of the study include the lack of a rigorous dietary intake measure and the high representation of older women.

CONCLUSIONS

In this study, we found that Lifestyle Africa was feasible for CHWs to deliver and, although it had no effect on the primary outcome of weight loss or secondary outcomes of blood pressure or triglycerides, it had an apparent small significant effect on HbA1c. The study demonstrates the potential feasibility of CHWs to deliver a program without expert involvement by utilizing video-based sessions. The intervention may hold promise for addressing cardiovascular disease (CVD) and diabetes at scale in LMICs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03342274.

Estimating the burden of type 2 diabetes in the UK prison environment for the next decade

Although limited, global evidence suggests that the cardiometabolic health of those in prison is poorer than their community peers. Type 2 diabetes (T2DM) is a public health challenge and community rates are continuing to rise. Given that cardiometabolic risk factors are prevalent amongst younger individuals within the prison population, it is reasonable to assume that the prison environment will also experience an increase in new cases of T2DM. Therefore, the aim of this study was, to predict in a current prison population, how many potential new cases of T2DM could develop in the next 10 years. This study used health data collected from a prison sample (n = 299) aged 25-84 years in HMP Parc, UK, and the Diabetes UK Risk Score was used to predict T2DM risk. In terms of projecting new cases, it was estimated that in the next decade 6.4 individuals per 100 would develop T2DM, and this value increased to 16.4 individuals per 100 in those aged 50 years and older. The development of new cases across all age groups is a concern, and it appears that the prison community are a 'target population' for prevention opportunities.

Cognitive Training for Very High Risk Incarcerated Adolescent Males

OBJECTIVE

Persistent violent and antisocial behavior, as manifested in conduct disorder (CD) traits, are associated with a range of cognitive deficits. Individuals with more severe cognitive deficits are more likely to commit violent crimes. Currently, no treatments target improving cognition in high-risk CD youth. This pilot study tests the feasibility and efficacy of delivering intensive tablet-based cognitive training (CT) to adolescent males incarcerated in a youth maximum-security prison.

METHODS

Participants were fourteen adolescent males, diagnosed with CD. All participants completed up to 30 h of unsupervised, intensive, adaptive CT exercises that targeted multiple neurocognitive domains, as well as a battery of standardized neurocognitive measures and computerized assessments at baseline and post-training.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

At baseline, participants exhibited significant impairments on neurocognitive measures, relative to age-matched healthy controls. Twelve participants completed training and showed evidence of target engagement, as indexed by improvement in cognitive processing speed. Significant gains were observed in measures of global cognition, with additional gains in cognitive flexibility at trend level significance. Improvements in these measures were positively related to total training time. In summary, both assessments and intervention appear to be feasible, tolerable, and acceptable in incarcerated youth. Intensive CT shows preliminary efficacy in improving neurocognitive performance in key domains, with large effect sizes, and significant performance improvement associations with the time in training.