Rethinking the Goals of Diabetes Prevention Programs

Diabetes beliefs, perceived risk and health behaviours: an embedded mixed-methods analysis from the Richmond Stress and Sugar Study

INTRODUCTION

Efforts to increase engagement with diabetes prevention programmes largely focus on increasing diabetes awareness, with the logic that risk knowledge will motivate behaviour change. However, the salience of perceived risk as it relates to diabetes prevention is contested. The goal of this cross-sectional, embedded mixed-methods study was to examine the relationships between perceived risk, diabetes beliefs and prevention behaviours among adults at elevated risk of type 2 diabetes.

METHODS

Data come from the Richmond Stress and Sugar Study (n=125). Diabetes beliefs (ie, internal, chance, powerful others) were assessed using the Multidimensional Health Locus of Control. Preventive behaviours (eg, changing diet, exercise, tobacco, alcohol) were measured by self-report. Perceived risk of developing diabetes was measured using a probability scale (0%-100%). Logistic and Poisson regression models quantified the relationships between beliefs, behaviours and perceived risk. Qualitative themes regarding challenges and facilitators to preventive behaviours were abstracted from open-ended questions and summarised using content analysis.

RESULTS

Perceived risk of developing diabetes was low (median: 35% likelihood) and only 10% of participants had ever attended a prevention class. None of the diabetes belief domains were significantly associated with either engagement in preventive behaviours or perceived diabetes risk. Perceived diabetes risk was not associated with engagement in preventive behaviours; however, having a family history of diabetes was strongly related to perceived risk (OR: 3.35, 95% CI: 1.42 to 7.86). Qualitative facilitators and barriers of preventive behaviours reflected psychosocial factors (eg, determination, stress, preferences) and resources (eg, social support, time, overall health).

CONCLUSIONS

Perceptions of risk and health beliefs are not correlated with engagement in preventive behaviours among adults at clinically elevated risk of diabetes. Awareness campaigns may benefit from incorporating family health history information. Diabetes prevention programmes should address barriers beyond health beliefs to promote engagement in behaviour change.

Peer Facilitator Training for Diabetes Prevention in a Nigerian Drug Treatment Center

INTRODUCTION AND BACKGROUND

Individuals with substance use disorders (SUDs) are at an increased risk of developing comorbid medical conditions, including Type 2 diabetes. Although the diabetes prevention program (DPP) is efficacious and cost-effective, there is no published evidence to support its implementation in Nigeria or within SUD treatment settings. In this first known DPP within an SUD treatment program, we implemented a multiphased, nurse-led DPP at a small outpatient drug treatment center in Nigeria. The aim of this article was to describe only the processes utilized for the initial peer facilitator (PF) training (Phase 1).

METHODS

In Phase 1, a diabetes prevention master trainer delivered a virtual DPP training to the facility's lead nurse, who return-demonstrated the DPP workshop skills and competencies over four 4-hour sessions. The lead nurse then independently delivered four 8-hour training sessions to a small number of client volunteers (n = 4) who subsequently delivered the DPP lifestyle interventions to their peers in the outpatient treatment program.

RESULTS

The client volunteers attended all PF workshop sessions and were observed to be proficient in all aspects of implementation. They indicated that the training objectives were easily achieved and expressed enthusiasm for delivering DPP content to their peers. The need to better contextualize the DPP curriculum specific to Nigerian food preferences was identified.

CONCLUSION

The Phase 1 training process appears to be an appropriate and effective approach for preparing PFs to deliver health programs, like the DPP, in environments with limited resources for populations facing numerous challenges.

Implementation and Evaluation of a mHealth-Based Community Health Worker Feedback Loop for Hispanics with and at Risk for Diabetes

BACKGROUND

Gaps in accessibility and communication hinder diabetes care in poor communities. Combining mobile health (mHealth) and community health workers (CHWs) into models to bridge these gaps has great potential but needs evaluation.

OBJECTIVE

To evaluate a mHealth-based, Participant-CHW-Clinician feedback loop in a real-world setting.

DESIGN

Quasi-experimental feasibility study with intervention and usual care (UC) groups.

PARTICIPANTS

A total of 134 participants (n = 67/group) who were all low-income, uninsured Hispanics with or at-risk for type 2 diabetes.

INTERVENTION

A 15-month study with a weekly to semimonthly mHealth Participant-CHW-Clinician feedback loop to identify participant issues and provide participants monthly diabetes education via YouTube.

MAIN MEASURES

We used pre-defined feasibility measures to evaluate our intervention: (a) implementation, the execution of feedback loops to identify and resolve participant issues, and (b) efficacy, intended effects of the program on clinical outcomes (baseline to 15-month HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight changes) for each group and their subgroups (at-risk; with diabetes, including uncontrolled (HbA1c ≥ 7%)).

KEY RESULTS

CHWs identified 433 participant issues (mean = 6.5 ± 5.3) and resolved 91.9% of these. Most issues were related to supplies, 26.3% (n = 114); physical health, 23.1% (n = 100); and medication access, 20.8% (n = 90). Intervention participants significantly improved HbA1c (- 0.51%, p = 0.03); UC did not (- 0.10%, p = 0.76). UC DBP worsened (1.91 mmHg, p < 0.01). Subgroup analyses revealed HbA1c improvements for uncontrolled diabetes (intervention: - 1.59%, p < 0.01; controlled: - 0.72, p = 0.03). Several variables for UC at-risk participants worsened: HbA1c (0.25%, p < 0.01), SBP (4.05 mmHg, p < 0.01), DBP (3.21 mmHg, p = 0.01). There were no other significant changes for either group.

CONCLUSIONS

A novel mHealth-based, Participant-CHW-Clinician feedback loop was associated with improved HbA1c levels and identification and resolution of participant issues. UC individuals had several areas of clinical deterioration, particularly those at-risk for diabetes, which is concerning for progression to diabetes and disease-related complications.

CLINICAL TRIAL

NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Evaluation of feasibility and acceptability of a web-based diabetes prevention program (DPP) for diabetes risk reduction in Chinese Americans in New York City

Introduction

Intensive lifestyle intervention remains an effective modality to reduce diabetes incidence and delay the progression to type 2 diabetes. The primary aim of this study was to pilot-test the feasibility and acceptability of a culturally and linguistically tailored web-based DPP intervention among Chinese Americans with prediabetes living in New York City.

Methods

Thirteen Chinese American participants with prediabetes were recruited to complete a 1-year web-based Diabetes Prevention Program (DPP) lifestyle intervention. Quantitative and qualitative measures such as retention rate and data collected from web-based questionnaires and focus groups were collected and analyzed to assess study feasibility and acceptability.

Results and Discussion

Participants were receptive to the program through high engagement, retention and satisfaction. Retention rate was 85%. 92% of participants completed at least 16 sessions out of 22 sessions. Post-trial surveys indicated high satisfaction of 27.2/32 based on Client Satisfaction Questionnaire (CSQ-8) score. Participants expressed the program increased their knowledge and methods to prevent onset of type 2 diabetes such as incorporating healthy eating habits and increasing physical activities. Although not a primary outcome, there was a significant weight reduction of 2.3% at the end of month 8 of the program (p < 0.05). The culturally and linguistically adapted DPP via online platform successfully demonstrated feasibility and acceptability among Chinese Americans with prediabetes. Further evaluation of the web-based Chinese Diabetes Prevention Program in a larger trial is warranted.

Leveraging a genetically-informative study design to explore depression as a risk factor for type 2 diabetes: Rationale and participant characteristics of the Mood and Immune Regulation in Twins Study

Background

Comorbidity between depression and type 2 diabetes is thought to arise from the joint effects of psychological, behavioral, and biological processes. Studies of monozygotic twins may provide a unique opportunity for clarifying how these processes inter-relate. This paper describes the rationale, characteristics, and initial findings of a longitudinal co-twin study aimed at examining the biopsychosocial mechanisms linking depression and risk of diabetes in mid-life.

Methods

Participants in the Mood and Immune Regulation in Twins (MIRT) Study were recruited from the Mid-Atlantic Twin Registry. MIRT consisted of 94 individuals who do not have diabetes at baseline, representing 43 twin pairs (41 monozygotic and 2 dizygotic), one set of monozygotic triplets, and 5 individuals whose co-twin did not participate. A broad set of variables were assessed including psychological factors (e.g., lifetime history major depression (MD)); social factors (e.g., stress perceptions and experiences); and biological factors, including indicators of metabolic risk (e.g., BMI, blood pressure (BP), HbA1c) and immune functioning (e.g., pro- and anti-inflammatory cytokines), as well as collection of RNA. Participants were re-assessed 6-month later. Intra-class correlation coefficients (ICC) and descriptive comparisons were used to explore variation in these psychological, social, and biological factors across time and within pairs.

Results

Mean age was 53 years, 68% were female, and 77% identified as white. One-third had a history of MD, and 18 sibling sets were discordant for MD. MD was associated with higher systolic (139.1 vs 132.2 mmHg, p=0.05) and diastolic BP (87.2 vs. 80.8 mmHg, p=0.002) and IL-6 (1.47 vs. 0.93 pg/mL, p=0.001). MD was not associated with BMI, HbA1c, or other immune markers. While the biological characteristics of the co-twins were significantly correlated, all within-person ICCs were higher than the within-pair correlations (e.g., HbA1c within-person ICC=0.88 vs. within-pair ICC=0.49; IL-6 within-person ICC=0.64 vs. within-pair=0.54). Among the pairs discordant for MD, depression was not substantially associated with metabolic or immune markers, but was positively associated with stress.

Conclusions

Twin studies have the potential to clarify the biopsychosocial processes linking depression and diabetes, and recently completed processing of RNA samples from MIRT permits future exploration of gene expression as a potential mechanism.

Metabolic labeling unveils alterations in the turnover of HDL-associated proteins during diabetes progression in mice

Several aspects of diabetes pathophysiology and complications result from hyperglycemia-induced alterations in the structure and function of plasma proteins. Furthermore, insulin has a significant influence on protein metabolism by affecting both the synthesis and degradation of proteins in various tissues. To understand the role of progressive hyperglycemia on plasma proteins, in this study, we measured the turnover rates of high-density lipoprotein (HDL)-associated proteins in control (chow diet), prediabetic [a high-fat diet (HFD) for 8 wk] or diabetic [HFD for 8 wk with low-dose streptozotocin (HFD + STZ) in weeks 5-8 of HFD] C57BL/6J mice using heavy water (2H2O)-based metabolic labeling approach. Compared with control mice, HFD and HFD + STZ mice showed elevations of fasting plasma glucose levels in the prediabetic and diabetic range, respectively. Furthermore, the HFD and HFD + STZ mice showed increased hepatic triglyceride (TG) levels, total plasma cholesterol, and plasma TGs. The kinetics of 40 proteins were quantified using the proteome dynamics method, which revealed an increase in the fractional synthesis rate (FSR) of HDL-associated proteins in the prediabetic mice compared with control mice, and a decrease in FSR in the diabetic mice. The pathway analysis revealed that proteins with altered turnover rates were involved in acute-phase response, lipid metabolism, and coagulation. In conclusion, prediabetes and diabetes have distinct effects on the turnover rates of HDL proteins. These findings suggest that an early dysregulation of the HDL proteome dynamics can provide mechanistic insights into the changes in protein levels in these conditions.NEW & NOTEWORTHY This study is the first to examine the role of gradual hyperglycemia during diabetes disease progression on HDL-associated protein dynamics in the prediabetes and diabetic mice. Our results show that the fractional synthesis rate of HDL-associated proteins increased in the prediabetic mice whereas it decreased in the diabetic mice compared with control mice. These kinetic changes can help to elucidate the mechanism of altered protein levels and HDL dysfunction during diabetes disease progression.

Effects of a Diabetes Prevention Program on Type 2 Diabetes Risk Factors and Quality of Life Among Latino Youths With Prediabetes: A Randomized Clinical Trial

Importance

Latino youths are disproportionately impacted by prediabetes and type 2 diabetes (T2D). Lifestyle intervention is the first-line approach for preventing or delaying T2D among adults with prediabetes.

Objective

To assess the efficacy of a diabetes prevention program among Latino youths aged 12 to 16 years with prediabetes.

Design, Setting, and Participants

This 2-group parallel randomized clinical trial with 2:1 randomization assessed a lifestyle intervention against usual care among Latino youths with prediabetes and obesity with 6- and 12-month follow-up. The study was conducted at YMCA facilities in Phoenix, Arizona from May 2016 to March 2020.

Intervention

Participants were randomized to lifestyle intervention (INT) or usual care control (UCC). The 6-month INT included 1 d/wk of nutrition and health education and 3 d/wk of physical activity. UCC included 2 visits with a pediatric endocrinologist and a bilingual, bicultural registered dietitian to discuss diabetes risks and healthy lifestyle changes.

Main Outcomes and Measures

Insulin sensitivity, glucose tolerance, and weight-specific quality of life (YQOL-W) at 6- and 12-month follow-up.

Results

A total of 117 Latino youths (mean [SD] age, 14 [1] years; 47 [40.1%] girls) were included in the analysis. Overall, 79 were randomized to INT and 38 to UCC. At 6 months, the INT led to significant decreases in mean (SE) 2-hour glucose (baseline: 144 [3] mg/dL; 6 months: 132 [3] mg/dL; P = .002) and increases in mean (SE) insulin sensitivity (baseline: 1.9 [0.2]; 6 months: 2.6 [0.3]; P = .001) and YQOL-W (baseline: 75 [2]; 6 months: 80 [2]; P = .006), but these changes were not significantly different from UCC (2-hour glucose: mean difference, -7.2 mg/dL; 95% CI, -19.7 to 5.3 mg/dL; P for interaction = .26; insulin sensitivity: mean difference, 0.1; 95% CI, -0.7 to 0.9; P for interaction = .79; YQOL-W: mean difference, 6.3; 95% CI, -1.1 to 13.7; P for interaction = .10, respectively). Both INT (mean [SE], -15 mg/dL [4.9]; P = .002) and UCC (mean [SE], -15 mg/dL [5.4]; P = .005) had significant 12-month reductions in 2-hour glucose that did not differ significantly from each other (mean difference, -0.3; 95% CI, -14.5 to 14.1 mg/dL; P for interaction = .97). At 12 months, changes in mean (SE) insulin sensitivity in INT (baseline: 1.9 [0.2]; 12 months: 2.3 [0.2]; P = .06) and UCC (baseline: 1.9 [0.3]; 12 months: 2.0 [0.2]; P = .70) were not significantly different (mean difference, 0.3; 95% CI, -0.4 to 1.0; P for interaction = .37). At 12 months, YQOL-W was significantly increased in INT (basline: 75 [2]; 12 months: 82 [2]; P < .001) vs UCC (mean difference, 8.5; 95% CI, 0.8 to 16.2; P for interaction = .03).

Conclusions and Relevance

In this randomized clinical trial, both INT and UCC led to similar changes in T2D risk factors among Latino youths with diabetes; however, YQOL-W was improved in INT compared with UCC. Diabetes prevention interventions that are effective in adults also appeared to be effective in high risk youths.

Trial Registration

ClinicalTrials.gov Identifier: NCT02615353.