Diabetes Prevention Interventions Research Articles

Fasting Glucose, Obesity, and Metabolic Syndrome as Predictors of Type 2 Diabetes

BackgroundTo determine risk for type 2 diabetes in subjects with fasting glucose levels in the ranges of normoglycemia, mild hyperglycemia, and intermediate hyperglycemia and to assess the effect of obesity...

Guidance for modellers for developing public health economic models

BackgroundHealth economic evaluation attempts to provide a rational and coherent framework to help policy makers to decide which health interventions to fund by comparing the differences in costs and outcomes between alternative options. Mathematical models are used to simplify complex realities; as such, there are always uncertainties associated with the model structure and inputs, and hence with the model results. It is thus important to be able to describe and justify the model structure and inputs used. The structural development of public health economic models is currently based on ad hoc non-transparent methods that are highly dependent on the modeller. We present a conceptual modelling framework to guide modellers when developing the structure of these models. MethodsTwo scientific literature reviews and qualitative research informed the framework. The reviews explored key challenges in public health economic modelling and conceptual modelling frameworks within the broader literature. They were undertaken with a systematic, iterative search method in accordance with UK National Institute for Health and Clinical Excellence technical support document guidance, including citation, reference, and key author searching within Medline, Scopus, and Web of Science. The qualitative research aimed to understand modellers' experiences with developing model structures and their views about the benefits and barriers of the use of a conceptual modelling framework. This involved a three-phase approach: tracking of the development of a Public Health economic model by in-depth interviews with the two modellers involved, and attendance at meetings between the project team and stakeholders, during which notes were made on the model development process; systematic analysis of our own notes from a previous public health economic project; and arrangement of a focus group with public health modellers from five different centres within the UK, identified purposively through relevant publications. Topic guides were developed for the interviews and focus group, using learning from the literature reviews for the former, and analysis of the interview data for the latter, including asking participants whether they agreed or disagreed with some of the interviewee responses. Each sentence from the transcripts and notes was copied into emergent categories in Excel. The analysis began after the first set of interviews. After coding of the first three interviews was complete, similar categories were grouped into themes, which were used for subsequent analysis. Similar and conflicting views between modellers were captured by the framework. A draft version of the framework was piloted with a case study of the cost-effectiveness of interventions for diabetes prevention to further develop it. FindingsWe identified three key principles for the conceptual modelling framework: a systems approach to public health economic modelling is most appropriate (ie, the system should be understood as a whole taking into account feedback loops and unintended consequences); a thorough documented understanding of the problem is valuable before development of the model structure to be able to communicate with stakeholders and justify the structure that is developed; and communication with stakeholders and members of the team throughout model development is important. The framework has four stages. First, identification of relevant stakeholders. Second, alignment of the framework with the decision making process. Third, understanding of the problem, which involves the development of a causal diagram of the problem and establishing current resource pathways. Fourth, development and justification of the model structure, which includes selection of the model interventions, setting of the model boundary and the level of detail, identification of the model type, and provision of a qualitative description of the quantitative model. InterpretationNon-prescriptive suggestions around how modellers might undertake each of the stages above are provided within the framework. This framework aims to improve the scope, quality, and communication of public health economic models to help decision makers to make appropriate policy decisions. FundingThis work is produced by HS under the terms of a doctoral research training fellowship issued by the NIHR.

A Community-Based Participatory Diabetes Prevention and Management Intervention in Rural India Using Community Health Workers

The purpose of this study was to test the effectiveness of a 6-month community-based diabetes prevention and management program in rural Gujarat, India. A community-based participatory research method was used to plan and tailor the intervention by engaging trained community health workers as change agents to provide lifestyle education, serve as community advocates, and collect data from 1638 rural Indians (81.9% response rate). Ten culturally and linguistically appropriate health education messages were provided in face-to-face individual and group sessions (demonstrations of model meals and cooking techniques). Mean age was 41.9 ± 15.9 years. Overall point prevalence of diabetes, prediabetes, obesity, and hypertension were 7.2%, 19.3%, 16.7%, and 28%, respectively, with significant differences between the low socioeconomic status (SES) participants (agricultural workers) and the high SES participants (business community) due to differing diet and activity levels. The intervention significantly reduced blood glucose levels by 5.7 and 14.9 mg/dL for individuals with prediabetes and diabetes, respectively, and systolic and diastolic blood pressure by 8 mm Hg and 4 mm Hg, respectively, in the overall population. Knowledge of diabetes and cardiovascular disease improved by 50% in the high SES group and doubled in the low SES group; general and abdominal obesity also decreased by ≤ 1%. High rates of undiagnosed hypertension (26.1%) were surprising. Among individuals with diabetes, metabolic complications such as diabetic nephropathy and chronic kidney disease were noted. Through collective engagement of the community, participatory programs can serve as a prototype for future prevention and management efforts, which are rare and underutilized in India.

Families United/Familias Unidas

The purpose of this study is to describe the development and implementation of a new diabetes prevention intervention that combines the benefits of family support with the group office model. Intensive lifestyle modification can effectively delay the onset of type 2 diabetes, yet health providers are challenged in translating these results to their patients. The group outpatient visit model can provide a means to address prevention issues in a financially sustainable manner. Materials from the Diabetes Prevention Program and a previously developed group office visit program were combined to create the Families United/Familias Unidas curriculum. The session content utilized a multiculturally tailored approach designed to help participants decrease portion size, decrease carbohydrate intake, increase physical activity, and increase resiliency. Adults aged 18 to 70 were recruited who had any diabetes risk factors but did not have diabetes. Eligible participants enlisted a support person, aged 14 to 70, to join them in the 6-month group office visit intervention. Twenty-nine pairs (n = 58) of primary participants plus support persons were recruited. Participants' average age was 45; 74% were female; 56.9% identified themselves as white and 37.9% as Hispanic/Latino. Over one-third had 4 or more diabetes risk factors. Twelve family group office visits were delivered over 6 months. The attendance rate for those who attended at least one session was 72%. Group office visits can provide a new sustainable model for diabetes prevention and are a natural fit for primary care physicians in collaboration with other health care professionals, such as dieticians or diabetes educators.

Preventing diabetes: will NICE guidance do what it says on the tin?

The goal of the programme was to achieve a 7% reduc-tion in body weight and physical activity of moderateintensity for at least 150 minutes per week. The cumula-tive incidence of diabetes was 4.8, 7.8 and 11.0 cases per100 person-years in the lifestyle, metformin and controlgroups, respectively. This reduction in incidence equatedto one case of diabetes prevented for every seven peoplewith IGT treated for three years in the lifestyle interven-tion group, compared with 14 for the metformin group. In addition, a review has also indicated that the numbersneeded to treat (NNT) to prevent one case of type 2 dia-betes with lifestyle intervention in people at risk of diabetesis dramatically low at 6.4 (over 1.8 to 4.6 years).

Training Peers to Deliver a Church-Based Diabetes Prevention Program

The purpose of this study was to examine the feasibility and acceptability of training peers to function as lifestyle coaches and to deliver a church-based lifestyle modification program. We recruited 6 African-American adults to participate in an 8-hour peer lifestyle coach (PLC) training program followed by a subsequent 2-hour booster session. The PLC training program addressed several key areas, including: (1) developing empowerment-based facilitation, active listening, and behavior change skills; (2) learning self-management strategies (eg, reading food labels, counting calories); (3) practicing session delivery; and (4) interpreting clinical lab results. Training evaluation was conducted retrospectively (immediately following the delivery of the diabetes prevention intervention rather than after the 8-hour training session) and measured program satisfaction and efficacy from the perspective of participants. Peer lifestyle coaches' confidence levels for performing core skills (eg, asking open-ended questions, 5-step behavioral goal-setting process) and advanced skills (eg, addressing resistance, discussing sensitive topics) were uniformly high. Similarly, PLCs were very satisfied with the length of training, balance between content and skills development, and preparation for leading group- and individual-based support activities. Findings suggest that it is feasible to customize a PLC training program that is acceptable to participants and that equips participants with the knowledge and skills to facilitate a church-based diabetes prevention intervention.

The 10-Year Cost-Effectiveness of Lifestyle Intervention or Metformin for Diabetes Prevention

OBJECTIVEThe Diabetes Prevention Program (DPP) and its Outcomes Study (DPPOS) demonstrated that either intensive lifestyle intervention or metformin could prevent type 2 diabetes in high-risk adults for at least 10 years after randomization. We report the 10-year within-trial cost-effectiveness of the interventions.RESEARCH DESIGN AND METHODSData on resource utilization, cost, and quality of life were collected prospectively. Economic analyses were performed from health system and societal perspectives.RESULTSOver 10 years, the cumulative, undiscounted per capita direct medical costs of the interventions, as implemented during the DPP, were greater for lifestyle ($4,601) than metformin ($2,300) or placebo ($769). The cumulative direct medical costs of care outside the DPP/DPPOS were least for lifestyle ($24,563 lifestyle vs. $25,616 metformin vs. $27,468 placebo). The cumulative, combined total direct medical costs were greatest for lifestyle and least for metformin ($29,164 lifestyle vs. $27,915 metformin vs. $28,236 placebo). The cumulative quality-adjusted life-years (QALYs) accrued over 10 years were greater for lifestyle (6.81) than metformin (6.69) or placebo (6.67). When costs and outcomes were discounted at 3%, lifestyle cost $10,037 per QALY, and metformin had slightly lower costs and nearly the same QALYs as placebo.CONCLUSIONSOver 10 years, from a payer perspective, lifestyle was cost-effective and metformin was marginally cost-saving compared with placebo. Investment in lifestyle and metformin interventions for diabetes prevention in high-risk adults provides good value for the money spent.

Translating the SLIM diabetes prevention intervention into SLIMMER: implications for the Dutch primary health care

All over the world, prevalence and incidence rates of type 2 diabetes mellitus are rising rapidly. Several trials have demonstrated that prevention by lifestyle intervention is (cost-) effective. This calls for translation of these trials to primary health care. This article gives an overview of the translation of the SLIM diabetes prevention intervention to a Dutch real-life setting and discusses the role of primary health care in implementing lifestyle intervention programmes. Currently, a 1-year pilot study, consisting of a dietary and physical activity part, performed by three GPs, three practice nurses, three dieticians and four physiotherapists is being conducted. The process of translating the SLIM lifestyle intervention to regular primary health care is measured by means of the process indicators: reach, acceptability, implementation integrity, applicability and key factors for success and failure of the intervention. Data will be derived from programme records, observations, focus groups and interviews. Based on these results, our programme will be adjusted to fit the role conception of the professionals and the organization structure in which they work.

An Outpatient-Based Clinical Program For Diabetes Prevention: an Update

To update outcomes of the Diet-Exercise-Activity-Lifestyle (DEAL) program, a clinic-based diabetes prevention intervention. Changes in weight, fasting blood glucose, and 2-hour glucose after a 75-g oral glucose tolerance test were evaluated in patients who enrolled in the DEAL program between January 2007 and August 2009. The 221 qualified participants had a mean age of 62 years, weight of 87.4 kg, body mass index of 31.2 kg/m², fasting glucose level of 109 mg/dL, and 2-hour glucose value of 138 mg/dL. Among the program participants, 67% were women and 88% were white; 56% had isolated impaired fasting glucose, 5% had impaired glucose tolerance only, and 39% had both. The 6-month follow-up medical appointment was kept by 72% of program participants, but only 56% attended the 12-month visit. By 6 months after baseline, 59% had significantly lower fasting glucose concentrations, 59% had improvement in 2-hour glucose levels, and 61% had weight loss. Nearly 40%, however, were nonresponders and had increased fasting glucose, 2-hour glucose, and weight by 6 months. By the 12-month visit, significant declines in fasting glucose (P<.001), 2-hour glucose (P<.001), and weight (P = .008) occurred in comparison with baseline values; however, no significant changes occurred in these measures between the 6- and 12-month visits (P>.30 for all). Most DEAL participants showed improvement in glucose levels and weight, but some patients exhibited worsening glucose intolerance. Factors underlying nonresponse need to be identified. Ongoing experience and analysis should help revise the DEAL program so that outcomes for all participating patients will improve.

Effect of Nutrition Changes on Foods Selected by Students in a Middle School‐Based Diabetes Prevention Intervention Program: The HEALTHY Experience

The HEALTHY primary prevention trial developed an integrated multicomponent intervention program to moderate risk factors for type 2 diabetes in middle schools. The nutrition component aimed to improve the quality of foods and beverages served to students. Changes in the School Breakfast Program (SBP), National School Lunch Program (NSLP), and à la carte venues are compared to the experience of control schools. The intervention was implemented in 21 middle schools from winter 2007 through spring 2009 (following a cohort of students from sixth through eighth grades); 21 schools acted as observed controls. The nutrition component targeted school food service environmental change. Data identifying foods and nutrients served (selected by students for consumption) were collected over a 20-day period at baseline and end of study. Analysis compared end of study values for intervention versus control schools. Intervention schools more successfully limited dessert and snack food portion size in NSLP and à la carte and lowered fat content of foods served. Servings of high-fiber grain-based foods and/or legumes were improved in SBP but not NSLP. Intervention and control schools eliminated >1% fat milk and added-sugar beverages in SBP, but intervention schools were more successful in NSLP and à la carte. The HEALTHY program demonstrated significant changes in the nutritional quality of foods and beverages served in the SBP, NSLP, and à la carte venues, as part of an effort to decrease childhood obesity and support beneficial effects in some secondary HEALTHY study outcomes.

Randomized Controlled Trial of the Effectiveness of Genetic Counseling and a Distance, Computer-Based, Lifestyle Intervention Program for Adult Offspring of Patients with Type 2 Diabetes: Background, Study Protocol, and Baseline Patient Characteristics

Relatives of type 2 diabetic patients are at a high risk of developing type 2 diabetes and should be regarded as target of intervention for diabetes prevention. However, it is usually hard to motivate them to implement preventive lifestyle changes, because of lack of opportunity to take advises from medical professionals, inadequate risk perception, and low priority for preventive behavior. Prevention strategy for them therefore should be highly acceptable and suited for them. The parallel, three-group trial is now being conducted to investigate the effects of genetic counseling and/or a computerized behavioral program on the prevention of type 2 diabetes in that population. The preventive strategies used in this study could provide a novel solution to the numbers of genetically high-risk individuals, if found to be effective. The objective of this paper is to describe the background, protocol, and baseline patient characteristics of the trial.

Effect of Nutrition Changes on Foods Selected by Students in a Middle School-Based Diabetes Prevention Intervention Program: The HEALTHY Experience

Effect of Nutrition Changes on Foods Selected by Students in a Middle School-Based Diabetes Prevention Intervention Program: The HEALTHY Experience

Challenges in real-life diabetes translation research: Early lessons from BRIDGES projects

AimsEfficacious interventions for prevention of diabetes and its complications exist; however, their implementation is woefully inadequate. The purpose of this project is to qualitatively assess the early lessons learnt from implementing translational research from eleven projects supported by BRIDGES, an International Diabetes Federation program. MethodsSemi-structured in-depth interviews conducted with 10 researchers, seeking their views on factors relating to success and barriers to implementation. Data were collected from June to September 2010 by a trained interviewer; information was recorded, transcribed and further analyzed with MAXQDA. ResultsPatient recruitment and retention were reported as challenges. Lack of availability of local multidisciplinary teams was highlighted as having a negative effect on the project. Grassroots and community participation were emphasized to have beneficial effects. Flexibility was recognized as a key for successful execution of the projects. Recommendations include: feedback from previous grantees, in the form of pre-submission workshops, and mentoring from experienced investigators with emphasis on the differences between traditional and translational researches. ConclusionsThis evaluation underscores the main contingencies to be considered for successful implementation of translational research. It emphasizes the importance of having the three stakeholders: patients, providers, and health systems, acting together in a flexible environment within real life settings.

Human information behaviour and physiological measurements as a basis to tailor health information. An explorative study in a physical activity intervention among prediabetic individuals in Northern Finland

To explore through an interdisciplinary approach the potential to tailor health information on the basis of human information behaviour (HIB) on par with the results of basic physiological measurements of individuals' health. The data were collected at the baseline of a physical activity and diabetes prevention intervention with 72 prediabetic participants, conducted in Oulu, Finland, by the University of Oulu and Oulu Deaconess Institute in 2010. Body mass index (BMI), fitness classifications and glucose values were obtained from all prediabetic participants. The interest in, the search for and the use of information on nutrition, physical activity and diabetes were examined through a self-report questionnaire with a response rate of 95.8%. The data were analysed with the SPSS statistics 18 software. The study shows that information behaviour of prediabetic individuals differs according to their BMI and fitness level. Poor physical fitness classifications and high BMI values were associated with an increased desire to receive tailored information on nutrition and physical activity frequently. These results add knowledge on the types and preferred frequencies of tailored information. Because of the small sample size, the results should be validated further.

Menopause and risk of diabetes in the Diabetes Prevention Program

The study objectives were to examine the association between menopause status and diabetes risk among women with glucose intolerance and to determine if menopause status modifies response to diabetes prevention interventions. The study population included women in premenopause (n = 708), women in natural postmenopause (n = 328), and women with bilateral oophorectomy (n = 201) in the Diabetes Prevention Program, a randomized placebo-controlled trial of lifestyle intervention and metformin among glucose-intolerant adults. Associations between menopause and diabetes risk were evaluated using Cox proportional hazard models that adjusted for demographic variables (age, race/ethnicity, family history of diabetes, history of gestational diabetes mellitus), waist circumference, insulin resistance, and corrected insulin response. Similar models were constructed after stratification by menopause type and hormone therapy use. After adjustment for age, there was no association between natural menopause or bilateral oophorectomy and diabetes risk. Differences by study arm were observed in women who reported bilateral oophorectomy. In the lifestyle arm, women with bilateral oophorectomy had a lower adjusted hazard for diabetes (hazard ratio [HR], 0.19; 95% CI, 0.04-0.94), although observations were too few to determine if this was independent of hormone therapy use. No significant differences were seen in the metformin (HR, 1.29; 95% CI, 0.63-2.64) or placebo arms (HR, 1.37; 95% CI, 0.74-2.55). Among women at high risk for diabetes, natural menopause was not associated with diabetes risk and did not affect response to diabetes prevention interventions. In the lifestyle intervention, bilateral oophorectomy was associated with a decreased diabetes risk.

Dietary Intakes of Urban, High Body Mass Index, African American Children: Family and Child Dietary Attributes Predict Child Intakes

Objective To identify family and child nutrition and dietary attributes related to children's dietary intakes. Design African American children (ages 8-11 years, n = 156), body mass index > 85th percentile, from urban, low-income neighborhoods. Baseline, cross-sectional data collected as part of an ongoing diabetes prevention intervention. Dietary intakes were collected by 3-day food diary to assess total energy, percent fat, discretionary fat, added sugar, whole grains, vegetables, fruit, meat, and dairy. Questionnaires on nutrition and dietary attributes administered to children and parents were used to develop 5 diet-related indices: child knowledge, child preferences, child snack habits, child beverage habits, and family food habits. Results A higher child nutrition knowledge score was significantly related to a lower starchy vegetable intake. Higher scores on the child snack habits index were significantly related to higher intakes of fruit, total fruits and vegetables, total fruits and nonstarchy vegetables, and to lower intakes of added sugars. A higher score on the family food habits index was significantly related to lower intakes of total energy and discretionary fat. Conclusions and Implications Targeting both child and family food and nutrition attributes may be used to promote more healthful eating among urban, low-income, overweight African American children.

The interplay of lifestyle and genetic susceptibility in Type 2 diabetes risk

SUMMARY Type 2 diabetes results from the complex interplay of adverse lifestyle exposures and genetic predisposition. Accordingly, genetic information might one day facilitate personalized medical interventions for diabetes prevention, thus minimizing treatment costs, reducing patient exposure to ineffective therapies and improving patient adherence to treatment recommendations and their prognosis. Here, we briefly overview the roles that obesity, physical activity and dietary factors play in Type 2 diabetes; define common approaches used to discover genetic risk factors and gene–lifestyle interactions; provide relevant examples of gene–lifestyle interactions; and speculate on the application of genetics to the prediction, prevention and treatment of diabetes.

Relationship between self‐efficacy, unhealthy food purchasing, and depressive symptoms among adult African American churchgoers in Baltimore

We investigated the relationship between self‐efficacy for making healthy food choices, food purchasing behavior, and depressive symptoms among non‐diabetic African American churchgoers. Participants included 130 adult respondents, 31.5% males and 68.5% females from 6 African American churches in Baltimore. This is baseline cross‐sectional data from the Healthy Bodies Healthy Souls project, a multi‐site church‐based environmental diabetes prevention intervention. Information about unhealthy (defined as high fat and/or high sugar) food purchasing was measured according to frequency of purchasing 52 items. Food and activity‐related self‐efficacy was measured using a 13 question scale. Depressive symptoms were assessed by the 10‐item Center for Epidemiologic Studies Depression Scale (CES‐D). We found a significant association between low self‐efficacy and more frequent unhealthy food purchasing, controlling for income (β= −0.69, R2 =0.10, p =0.009) but not between self‐efficacy and healthy food purchasing. Depressive symptoms were associated with self‐efficacy (r = 0.357, p &lt; 0.001); due to the collinearity between depressive symptoms and self‐efficacy, depressive symptoms were excluded from the final model. Findings suggest that African American churchgoers with low self‐efficacy make more unhealthy food purchasing decisions.Grant Funding Source: American Diabetes Association

The Economics of Diabetes Prevention

In the United States, the costs associated with diabetes mellitus are increasing. Although people with diabetes comprise less than 6% of the US population, approximately 1 in 5 health care dollars is spent caring for people with diabetes. Healthy lifestyle interventions for the general population and intensive lifestyle and medication interventions for high-risk individuals present opportunities for diabetes prevention. This article describes the costs associated with glucose intolerance and diabetes, the effect of glucose intolerance and diabetes on the quality of life, and the cost-effectiveness of screening and primary prevention interventions for diabetes prevention.

Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling

BackgroundType 2 diabetes mellitus (T2D) poses a large worldwide burden for health care systems. One possible tool to decrease this burden is primary prevention. As it is unethical to wait until perfect data are available to conclude whether T2D primary prevention intervention programmes are cost-effective, we need a model that simulates the effect of prevention initiatives. Thus, the aim of this study is to investigate the long-term cost-effectiveness of lifestyle intervention programmes for the prevention of T2D using a Markov model. As decision makers often face difficulties in applying health economic results, we visualise our results with health economic tools.MethodsWe use four-state Markov modelling with a probabilistic cohort analysis to calculate the cost per quality-adjusted life year (QALY) gained. A one-year cycle length and a lifetime time horizon are applied. Best available evidence supplies the model with data on transition probabilities between glycaemic states, mortality risks, utility weights, and disease costs. The costs are calculated from a societal perspective. A 3% discount rate is used for costs and QALYs. Cost-effectiveness acceptability curves are presented to assist decision makers.ResultsThe model indicates that diabetes prevention interventions have the potential to be cost-effective, but the outcome reveals a high level of uncertainty. Incremental cost-effectiveness ratios (ICERs) were negative for the intervention, ie, the intervention leads to a cost reduction for men and women aged 30 or 50 years at initiation of the intervention. For men and women aged 70 at initiation of the intervention, the ICER was EUR27,546/QALY gained and EUR19,433/QALY gained, respectively. In all cases, the QALYs gained were low. Cost-effectiveness acceptability curves show that the higher the willingness-to-pay threshold value, the higher the probability that the intervention is cost-effective. Nonetheless, all curves are flat. The threshold value of EUR50,000/QALY gained has a 30-55% probability that the intervention is cost-effective.ConclusionsLifestyle interventions for primary prevention of type 2 diabetes are cost-saving for men and women aged 30 or 50 years at the start of the intervention, and cost-effective for men and women aged 70 years. However, there is a high degree of uncertainty around the ICERs. With the conservative approach adopted for this model, the long-term effectiveness of the intervention could be underestimated.