Association of Metformin With the Development of Age-Related Macular Degeneration

Importance

Age-related macular degeneration (AMD) is a leading cause of blindness with no treatment available for early stages. Retrospective studies have shown an association between metformin and reduced risk of AMD.

Objective

To investigate the association between metformin use and age-related macular degeneration (AMD).

Design, Setting, and Participants

The Diabetes Prevention Program Outcomes Study is a cross-sectional follow-up phase of a large multicenter randomized clinical trial, Diabetes Prevention Program (1996-2001), to investigate the association of treatment with metformin or an intensive lifestyle modification vs placebo with preventing the onset of type 2 diabetes in a population at high risk for developing diabetes. Participants with retinal imaging at a follow-up visit 16 years posttrial (2017-2019) were included. Analysis took place between October 2019 and May 2022.

Interventions

Participants were randomly distributed between 3 interventional arms: lifestyle, metformin, and placebo.

Main Outcomes and Measures

Prevalence of AMD in the treatment arms.

Results

Of 1592 participants, 514 (32.3%) were in the lifestyle arm, 549 (34.5%) were in the metformin arm, and 529 (33.2%) were in the placebo arm. All 3 arms were balanced for baseline characteristics including age (mean [SD] age at randomization, 49 [9] years), sex (1128 [71%] male), race and ethnicity (784 [49%] White), smoking habits, body mass index, and education level. AMD was identified in 479 participants (30.1%); 229 (14.4%) had early AMD, 218 (13.7%) had intermediate AMD, and 32 (2.0%) had advanced AMD. There was no significant difference in the presence of AMD between the 3 groups: 152 (29.6%) in the lifestyle arm, 165 (30.2%) in the metformin arm, and 162 (30.7%) in the placebo arm. There was also no difference in the distribution of early, intermediate, and advanced AMD between the intervention groups. Mean duration of metformin use was similar for those with and without AMD (mean [SD], 8.0 [9.3] vs 8.5 [9.3] years; P = .69). In the multivariate models, history of smoking was associated with increased risks of AMD (odds ratio, 1.30; 95% CI, 1.05-1.61; P = .02).

Conclusions and Relevance

These data suggest neither metformin nor lifestyle changes initiated for diabetes prevention were associated with the risk of any AMD, with similar results for AMD severity. Duration of metformin use was also not associated with AMD. This analysis does not address the association of metformin with incidence or progression of AMD.

Translating the Diabetes Prevention Program Lifestyle Intervention to the Military Setting

INTRODUCTION

Diabetes and obesity pose a significant burden for the U.S. military beneficiary population, creating a great need to provide evidence-based diabetes and obesity prevention services for military personnel, retirees, and their dependents. Despite increasing dissemination of the Diabetes Prevention Program (DPP) lifestyle intervention nationwide, formal evaluation of implementation of this highly successful program is limited in the military setting. The purpose of this study is to prospectively evaluate delivery of a direct adaptation of a 1-year DPP lifestyle intervention at a U.S. Air Force medical facility, Wright-Patterson Medical Center (WPMC), to determine the feasibility of delivery of the program in a group of at-risk active duty military, retirees, and family members, as well as assess effectiveness in improving weight and other risk factors for type 2 diabetes.

MATERIALS AND METHODS

A pre/post study design was utilized to evaluate feasibility and effectiveness of the DPP Group Lifestyle Balance (GLB), an up-to-date, 22-session direct adaptation of the DPP curriculum, at WPMC. Participants chose to complete the 1-year program either in coach-led face-to-face groups or via DVD with weekly telephonic coach contact. The study was approved by the University of Pittsburgh and WPMC Institutional Review Boards.

RESULTS

A total of 99 individuals enrolled in the study, with 83 (84%) and 77 (78%) completing 6- and 12-month follow-up assessments, respectively. The mean age of participants at baseline was 57 (range 20-85 years), with 63% being female. The group was comprised of individuals who were non-Hispanic White (73.7%), non-Hispanic Black (18.2%), and other race or Hispanic ethnicity (8.1%). Within this group, there were 10 active duty military, 37 retirees, and 52 family members. The DPP-GLB program was shown to be feasible to implement in this military healthcare setting as demonstrated by the high engagement over the course of the year-long program. Significant improvements were shown in the two main behavioral goals: mean weight (-12.8 lbs, -6.3%, P < .001) and mean physical activity (PA) (+18.9 Met-hrs/wk, P < .001). In addition, significant improvements in other diabetes and cardiovascular risk factors including low-density lipoprotein cholesterol, fasting insulin, diastolic blood pressure, and waist circumference were noted, as well as improvement in health-related quality of life.

CONCLUSIONS

These results demonstrate that the DPP-GLB program delivered via face-to-face groups or DVD was feasible and effective in improving weight, PA levels, and diabetes and cardiovascular risk factors in this group of active and retired military personnel and their family members. The program was well received by the program participants as well as the WPMC team. These findings offer a model for provision of the DPP-GLB program throughout the Military Health System.

Participant food and activity costs in a translational Diabetes Prevention Program

The Diabetes Prevention Program (DPP) and its translational adaptations have been shown to be effective. However, individual-level economic impacts, such as the out-of-pocket costs borne by participants due to involvement in these programs have not been consistently and thoroughly evaluated. As cost is an important consideration that will impact the willingness of individuals to participate in such programs, this study examined direct monetary costs to participants in the Group Lifestyle Balance (GLB) DPP. Older adults (n = 134, mean age 62.8 years) with body mass index (BMI) ≥24 kg/m2 and prediabetes and/or metabolic syndrome participated in this GLB intervention, with two-thirds randomized to begin the intervention immediately and one-third functioning as a control for 6 months before receiving the entire intervention. Food and activity time and costs borne by participants were measured by self-report at baseline and after 6 months. Significant improvements in clinical metabolic measures, weight, and physical activity levels were achieved after 6 months in the intervention group compared both with baseline and the controls. Food costs did not increase among intervention participants. Costs related to physical activity did not change consistently over the course of the intervention. This DPP-GLB lifestyle intervention was effective in reducing risk factors for Type 2 diabetes mellitus among a diverse group of older participants without significantly increasing their out-of-pocket costs for food or physical activity over the course of the intervention. These results should help reduce concerns of individuals who are hesitant to participate in similar programs due to costs. The clinical trial registration number of this study is NCT01050205.

Effectiveness of Lifestyle Interventions in an Active Duty Air Force Population

PURPOSE

To examine the effectiveness of 3 lifestyle intervention programs in an active duty military population.

DESIGN

Experimental design with stratified random assignment to 1 of 3 intervention groups. Measures were taken at baseline, 3 months and 6 months.

SETTING

A Military Treatment Facility in the western U.S.

SUBJECTS/INTERVENTION

122 active duty service members were enrolled and randomly assigned to 1 of 3 lifestyle intervention programs: the Diabetes Prevention Program-Group Lifestyle Balance (DPP-GLB), the Better Body Better Life (BBBL) program or the Fitness Improvement Program (FIP).

MEASURES

weight, abdominal circumference, lipid and HbA1c levels, physical activity, and well-being as measured by the RAND SF-36 questionnaire.

ANALYSIS

Statistical analyses were performed to assess changes over time.

RESULTS

83 participants completed the study (BBBL N = 23, FIP N = 30, DPP-GLB N = 30). The DPP-GLB participants had statistically significant decreases in weight (-3.1 pounds, p = .01) and abdominal circumference (-0.9 inches; p = .01) over time. HbA1c was also significantly lower in this group at 6 months compared to baseline (p = .036). There were no statistically significant changes in weight, abdominal circumference, or HbA1c in the FIP or BBBL groups. No significant changes were observed in lipids in any of the groups.

CONCLUSION

Results from this study indicate that the DPP-GLB program may be effective in reducing weight, abdominal circumference, and HbA1c in an active duty U.S. military population.

Group Lifestyle Balance Adapted for Individuals With Impaired Mobility: Outcomes for 6-Month RCT and Combined Groups at 12 Months

INTRODUCTION

This study examines the feasibility and effectiveness of an intensive lifestyle intervention adapted for people with impaired mobility.

STUDY DESIGN

This was a randomized, wait-list controlled trial. The experimental group immediately received the 12-month weight loss program; the wait-list control group received it after a 6-month delay. Between-group comparisons were conducted for the 6-month RCT study design. Repeated measures were conducted for both groups combined after receiving the 12-month intervention. Data were collected August 2015-February 2017 and analyzed in 2017.

SETTING/PARTICIPANTS

A community-based sample received 23, group-based sessions via a mix of telephone and in-person sessions in a hospital-based setting. Participants with impaired mobility (n=66) were middle-aged (49.80 [SD=11.37] years), mostly White (66.7%), female (66.7%), and most commonly had spinal cord injury (47.0%).

INTERVENTION

The 12-month intervention delivered 23 group-based sessions that promoted weight loss through reducing caloric intake and increasing physical activity.

MAIN OUTCOME MEASURES

Primary outcomes were effectiveness measured as change in weight and time spent in moderate physical activity. Feasibility was assessed in 12-month combined group analyses, measured as retention, attendance, and dietary self-monitoring.

RESULTS

The 6-month RCT results showed that the immediate and delayed groups differed significantly (p<0.05) in weight (-1.66 [SD=4.42] kg loss vs 0.05 [SD=4.15] kg gain) and moderate physical activity (52.93 [SD=90.74] minutes/week increase vs -14.22 [SD=96.02] minutes/week decrease), accounting for baseline weight, time with disability, and age of onset. The 12-month results with groups combined demonstrated 74.2% retention and 77.7% core session attendance. Self-monitoring was higher in the delayed group (77.3%), who used a smartphone app, than the immediate group (47.3%), who mostly used paper trackers. Participants achieved significant 12-month weight loss of 3.31 (SD=10.13) kg (d=0.33) in mixed modeling analyses with groups combined yet did not significantly increase moderate physical activity.

CONCLUSIONS

Group Lifestyle Balance Adapted for Individuals with Impaired Mobility is a feasible, effective approach to teach healthy lifestyle skills to individuals with mobility impairment, yielding modest weight loss and enhanced self-efficacy.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03307187.

NKG2D-ligands: Putting everything under the same umbrella can be misleading

NKG2D is a key receptor for the activation of immune effector cells, mainly Natural Killer cells and T lymphocytes, in infection, cancer and autoimmune diseases. Since the detection of ligands for NKG2D in sera of cancer patients is, in many human models, indicative of prognosis, a large number of studies have been undertaken to improve understanding of the biology regulating this receptor and its ligands, with the aim of translating this knowledge into clinical practice. Although it is becoming clear that the NKG2D system can be used as a tool for diagnosis and manipulated for therapy, some questions remain open due to the complexity associated with the existence of a large number of ligands, each one of them displaying distinct biological properties. In this review, we have highlighted some key aspects of this system that differ between humans and mice, including the properties of NKG2D, as well as the genetic and biochemical complexity of NKG2D-ligands. All of these features affect the characteristics of the immune response exerted by NKG2D-expressing cells and are likely to be important factors in the clearance of a tumour or the development of autoimmunity. Implementation of more global analyses, including information on genotype, transcription and protein properties (cellular vs released to the blood stream) of NKG2D-ligands expressed in patients will be necessary to fully understand the links between this system and disease progression.

Evaluation of a Diabetes Prevention Program Lifestyle Intervention in Older Adults: A Randomized Controlled Study in Three Senior/Community Centers of Varying Socioeconomic Status

Purpose The purpose of this study is to evaluate the feasibility and effectiveness of an adapted Diabetes Prevention Program (DPP) lifestyle program, DPP Group Lifestyle Balance (GLB), delivered in 3 economically diverse senior/community centers. Methods The DPP-GLB was implemented in 3 senior/community centers in Allegheny County, PA. A 6-month delayed control intervention design was used. Participants were randomized to begin the DPP-GLB immediately (immediate) or after a 6-month delay (delayed). Adults (n = 134; mean age = 62.8 years) with BMI ≥24 kg/m² and prediabetes and/or the metabolic syndrome took part. Weight, physical activity (PA), and diabetes and cardiovascular disease (CVD) risk factors were assessed at 6, 12, and 18 months from baseline. Results At 6 months, the immediate group demonstrated greater mean weight loss than the delayed control group as well as significantly greater improvements in PA, A1C, fasting insulin, and waist circumference. In pre-post analyses, both randomized groups showed similar success that was maintained at 18 months. Conclusions The DPP-GLB delivered in economically diverse community centers was effective in this group of older adults. These findings support provision of coverage for prevention programs in older adults at risk for diabetes/CVD, which is important considering the large number of individuals who will be Medicare eligible in the near future.

Factors related to lifestyle goal achievement in a diabetes prevention program dissemination study

The U.S. Diabetes Prevention Program (DPP) showed that lifestyle participants who achieved ≥7% weight loss and ≥150 min/week physical activity experienced the greatest reduction in type 2 diabetes incidence. Demographic, clinical, and program factors that are related to achieving both these lifestyle goals have seldom been explored in community-delivered DPP programs. The purpose of this investigation is to examine factors associated with concurrent achievement of weight loss and physical activity goals in a 12-month community DPP lifestyle intervention. Adults [n = 223; age = 58.4 (SD = 11.5); BMI = 33.8 (SD = 6.0)] with glucose or HbA1c values in the pre-diabetes range and/or metabolic syndrome risk factors enrolled from one worksite and three community centers in the Pittsburgh, PA metropolitan area between January 2011 and January 2014. Logistic regression analyses determined the demographic, clinical and program adherence factors related to goal achievement at 6, 12, and 18 months. Participants achieving both intervention goals at 6 months (n = 57) were more likely to attend sessions [Adjusted Odds Ratio (AOR) =1.48], self-weigh (AOR = 1.19), and self-monitor behaviors (AOR = 1.18) than those meeting neither goal (n = 35; all p < 0.05). Baseline BMI (AOR = 0.87, p < 0.01), elevated glycemic status (AOR = 0.49, p < 0.05), and female sex (AOR = 0.52, p < 0.05) were inversely related to goal achievement at 6 months. Meeting either lifestyle goal at 6 months had the strongest association with meeting both goals at 12 and 18 months. Our study supports the importance of early engagement, regular attendance, self-monitoring, and self-weighing for goal achievement. Dissemination efforts should consider alternative approaches for those not meeting goals by 6 months to enhance long-term success.

Reducing barriers to healthy weight: Planned and responsive adaptations to a lifestyle intervention to serve people with impaired mobility

BACKGROUND

People with impaired mobility (IM) disabilities have a higher prevalence of obesity and obesity-related chronic conditions; however, lifestyle interventions that address the unique needs of people with IM are lacking.

OBJECTIVE

This paper describes an adapted evidence-based lifestyle intervention developed through community-based participatory research (CBPR).

METHODS

Individuals with IM, health professionals, disability group representatives, and researchers formed an advisory board to guide the process of thoroughly adapting the Diabetes Prevention Program Group Lifestyle Balance (DPP GLB) intervention after a successful pilot in people with IM. The process involved two phases: 1) planned adaptations to DPP GLB content and delivery, and 2) responsive adaptations to address issues that emerged during intervention delivery.

RESULTS

Planned adaptations included combining in-person sessions with conference calls, providing arm-based activity trackers, and adding content on adaptive cooking, adaptive physical activity, injury prevention, unique health considerations, self-advocacy, and caregiver support. During the intervention, participants encountered numerous barriers, including health and mental health issues, transportation, caregivers, employment, adjusting to disability, and functional limitations. We addressed barriers with responsive adaptations, such as supporting electronic self-monitoring, offering make up sessions, and adding content and activities on goal setting, problem solving, planning, peer support, reflection, and motivation.

CONCLUSIONS

Given the lack of evidence on lifestyle change in people with disabilities, it is critical to involve the community in intervention planning and respond to real-time barriers as participants engage in change. A randomized controlled trial (RCT) is underway to examine the usability, feasibility, and preliminary effectiveness of the adapted intervention.

Impact of a community-based lifestyle intervention program on health-related quality of life

BACKGROUND

The presence of risk factors for type 2 diabetes and cardiovascular disease, or the conditions themselves, contributes to lower health-related quality of life (HRQoL) among adults. Although community-based lifestyle intervention programs have been shown to be effective for improving risk factors for these diseases, the impact of these interventions on HRQoL has rarely been described.

PURPOSE

To examine changes in HRQoL following participation in the Group Lifestyle Balance program, a community translation of the Diabetes Prevention Program lifestyle intervention for adults with prediabetes and/or the metabolic syndrome.

METHODS

Participants enrolled in the 12-month, 22-session intervention program (N = 223) completed the EuroQol Health Questionnaire (EQ-5D-3L) at baseline, 6, and 12 months. Linear mixed-effects regression models determined change in EQ-5D-visual analog scale (VAS) and Index scores post-intervention.

RESULTS

Mean EQ-5D-VAS was improved by +7.38 (SE = 1.03) at 6 months and by +6.73 (SE = 1.06) at 12 months post-intervention (both; p < 0.0001). Mean changes in EQ-5D index values were +0.00 (SE = 0.01; NS) and +0.01 (SE = 0.01; p < 0.05), respectively. Adjusted for age, baseline score, and achieving intervention goals, mean change in EQ-5D-VAS was +11.83 (SE = 1.61) at 6 months and +11.23 (SE = 1.54) at 12 months (both; p < 0.0001). Adjusted mean change in EQ-5D index value was +0.04 (SE = 0.01) at 6 months and +0.05 (SE = 0.01) at 12 months (both; p < 0.01).

CONCLUSION

Participation in a community lifestyle intervention program resulted in improved HRQoL among adults with prediabetes and/or the metabolic syndrome. These benefits to HRQoL, together with improved clinical and behavioral outcomes, should increase the appeal of such programs for improving health.

Physical Activity Levels in a Community Lifestyle Intervention: A Randomized Trial

BACKGROUND

A behavioral lifestyle intervention program with goals of increasing physical activity (PA) and losing weight was shown to be efficacious for preventing type 2 diabetes and decreasing risk for cardiovascular disease in the U.S. Diabetes Prevention Program (DPP). Modified versions of the DPP lifestyle intervention are being translated into diverse community settings and have been successful in decreasing weight and improving metabolic markers. However, comprehensive evaluations of PA levels within these community translation intervention efforts are rare.

PURPOSE

To evaluate the effectiveness of a DPP-based community lifestyle intervention for improving PA levels.

METHODS

223 overweight adults at-risk for type 2 diabetes and/or cardiovascular disease were randomized (immediate or 6-month delayed-start) to a 12-month DPP-based lifestyle intervention. Past-month PA level was assessed at baseline and post-intervention with the Modifiable Activity Questionnaire. Simple and mixed-effects regression models were used to determine changes in PA level between and within groups over time.

RESULTS

The between-group mean difference for change in PA levels from baseline to 6 months indicated significantly greater improvement in the intervention compared to the delayed-start group [+6.72 (SE=3.01) MET-hrs/week; p=0.03]. Examining combined within-group change from baseline to post-intervention, mean PA levels significantly increased by +14.69 (SE=1.43) and +9.50 (SE= 1.40) MET-hrs/week at 6 and 12 months post-intervention, respectively. This PA change offset to approximately +10 MET-hrs/week at both 6 and 12 months after adjusting for baseline PA level and season (all; p<0.01). Other than season, sex impacted on change in PA level.

CONCLUSIONS

This community-based lifestyle intervention significantly increased PA levels among overweight adults at risk for type 2 diabetes and cardiovascular disease, even after adjusting for key variables.

CLINICALTRIALSGOV IDENTIFIER

NCT01050205.

Evaluation of a culturally-adapted lifestyle intervention to treat elevated cardiometabolic risk of Latino adults in primary care (Vida Sana): A randomized controlled trial

Latinos bear a disproportionate burden of the dual pandemic of obesity and diabetes. However, successful interventions addressing this disparity through primary care are lacking. To address this gap, the 5-year Vida Sana (Healthy Life) study tests a culturally adapted and technology-enhanced group-based Diabetes Prevention Program intervention in a randomized controlled trial with overweight/obese Latino adults who have metabolic syndrome and/or pre-diabetes. Eligible, consenting patients (n=186) from a large community-based multispecialty group practice in Northern California will be randomly assigned to receive the culturally-adapted intervention or usual care. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework guided the planned evaluations. The primary aim is to determine the effectiveness of the intervention (the "E" in RE-AIM). We hypothesize that the intervention will lead to a greater mean reduction in weight at 24months (primary endpoint) vs. usual care. Secondary outcomes will include measures of cardiometabolic risk factors (e.g., blood pressure), psychosocial well-being (e.g., health-related quality of life), and behavior change (e.g., physical activity). The secondary aim is to evaluate the other RE-AIM dimensions using mixed methods: reach (e.g., participation rate of the target population), adoption (e.g., participating clinic and provider characteristics), implementation (e.g., intervention fidelity), and maintenance (e.g., sustainability in the practice setting). These findings have real word applicability with value to clinicians, patients, and other decision makers considering effective diabetes prevention programs for primary care that would support the millions of Latino adults who experience a disproportionate burden of diabetes.

TRIAL REGISTRATION

NCT02459691.

Community Trial of a Faith-Based Lifestyle Intervention to Prevent Diabetes Among African-Americans

About 75% of African-Americans (AAs) ages 20 or older are overweight and nearly 50% are obese, but community-based programs to reduce diabetes risk in AAs are rare. Our objective was to reduce weight and fasting plasma glucose (FPG) and increase physical activity (PA) from baseline to week-12 and to month-12 among overweight AA parishioners through a faith-based adaptation of the Diabetes Prevention Program called Fit Body and Soul (FBAS). We conducted a single-blinded, cluster randomized, community trial in 20 AA churches enrolling 604 AAs, aged 20-64 years with BMI ≥ 25 kg/m(2) and without diabetes. The church (and their parishioners) was randomized to FBAS or health education (HE). FBAS participants had a significant difference in adjusted weight loss compared with those in HE (2.62 vs. 0.50 kg, p = 0.001) at 12-weeks and (2.39 vs. -0.465 kg, p = 0.005) at 12-months and were more likely (13%) than HE participants (3%) to achieve a 7% weight loss (p < 0.001) at 12-weeks and a 7% weight loss (19 vs. 8%, p < 0.001) at 12-months. There were no significant differences in FPG and PA between arms. Of the 15.2% of participants with baseline pre-diabetes, those in FBAS had, however, a significant decline in FPG (10.93 mg/dl) at 12-weeks compared with the 4.22 mg/dl increase in HE (p = 0.017), and these differences became larger at 12-months (FBAS, 12.38 mg/dl decrease; HE, 4.44 mg/dl increase) (p = 0.021). Our faith-based adaptation of the DPP led to a significant reduction in weight overall and in FPG among pre-diabetes participants. CLINICALTRIALS.

GOV IDENTIFIER

NCT01730196.

Research aimed at improving both mood and weight (RAINBOW) in primary care: A type 1 hybrid design randomized controlled trial

Effective interventions targeting comorbid obesity and depression are critical given the increasing prevalence and worsened outcomes for patients with both conditions. RAINBOW is a type 1 hybrid design randomized controlled trial. The objective is to evaluate the clinical and cost effectiveness and implementation potential of an integrated, technology-enhanced, collaborative care model for treating comorbid obesity and depression in primary care. Obese and depressed adults (n = 404) will be randomized to usual care enhanced with the provision of a pedometer and information about the health system's services for mood or weight management (control) or with the Integrated Coaching for Better Mood and Weight (I-CARE) program (intervention). The 12-month I-CARE program synergistically integrates two proven behavioral interventions: problem-solving therapy with as-needed intensification of pharmacotherapy for depression (PEARLS) and standardized behavioral treatment for obesity (Group Lifestyle Balance(™)). It utilizes traditional (e.g., office visits and phone consults) and emerging care delivery modalities (e.g., patient web portal and mobile applications). Follow-up assessments will occur at 6, 12, 18, and 24 months. We hypothesize that compared with controls, I-CARE participants will have greater improvements in weight and depression severity measured by the 20-item Depression Symptom Checklist at 12 months, which will be sustained at 24 months. We will also assess I-CARE's cost-effectiveness and use mixed methods to examine its potential for reach, adoption, implementation, and maintenance. This study offers the potential to change how obese and depressed adults are treated-through a new model of accessible and integrative lifestyle medicine and mental health expertise-in primary care.

Improving employee health: evaluation of a worksite lifestyle change program to decrease risk factors for diabetes and cardiovascular disease

OBJECTIVE

To determine whether an evidence-based, behavioral lifestyle intervention program delivered at a worksite setting is effective in improving type 2 diabetes and cardiovascular disease risk factors.

METHODS

A randomized 6-month delayed control design was utilized, with two thirds of the participants assigned to begin intervention immediately, and one third beginning 6 months later. The year-long program (weekly for 3 months transitioning to monthly) focused on weight loss and increasing physical activity.

RESULTS

The immediate intervention group had greater mean weight loss (-10.4 lb, 5.1%, vs -2.3 lb, 1%; P = 0.0001) than the delayed control group at 6 months and relatively greater improvements in activity, HbA1c, and other risk factors. The delayed group experienced similar improvements after completing the intervention program.

CONCLUSIONS

A worksite behavioral lifestyle intervention is feasible and effective in significantly improving risk factors for type 2 diabetes and cardiovascular disease.

Evaluation of a community Diabetes Prevention Program delivered by diabetes educators in the United States: one-year follow up

Strategies for management of pre-diabetes within the community setting are needed. An adaptation of the successful Diabetes Prevention Program lifestyle intervention delivered by trained diabetes educators was evaluated. Results indicate that trained diabetes educators offer an important community resource for health care providers for their patients with pre-diabetes.

Adapting the Group Lifestyle Balance™ Program for Weight Management Within a Large Health Care System Diabetes Education Program

PURPOSE

The purpose of this translation study was to evaluate the feasibility and effectiveness of an adapted Group Lifestyle Balance (GLB) intervention for weight management implemented through an existing diabetes education program within a large health care delivery system for overweight/obese individuals with diabetes, prediabetes, or neither condition.

METHODS

Adults with BMI ≥ 25 kg/m² participated in an adapted GLB intervention designed to be appropriate regardless of diabetes status. Effectiveness was based on changes in weight and minutes of physical activity between baseline and completion of the 12-week core. Differences between subjects based on diabetes status were also examined.

RESULTS

A total of 111 subjects with diabetes, prediabetes, and no diabetes completed baseline survey data and attended at least 9 of the 12 core sessions from April 2010 through December 2011. All achieved significant weight loss, and the proportion of subjects who reported exercising at least 150 minutes/week increased.

CONCLUSIONS

The adapted GLB intervention for weight management implemented through an existing diabetes education program in a large health care system was feasible and effective in the population, regardless of participants' diabetes status.

Diabetes Prevention Program community outreach: perspectives on lifestyle training and translation

The gap between what is known from clinical efficacy research and the systematic community translation of diabetes prevention programs is narrowing. During the past 5 years, numerous randomized and nonrandomized dissemination studies have evaluated the modified delivery of structured Diabetes Prevention Program (DPP) interventions in diverse real-world settings. Programs of sufficient dose and duration, implemented with fidelity, have reported weight losses in the range of 4%-7% with associated improvements in cardiometabolic risk factors at 6 and 12 months from baseline. The current article describes some of the experiences and perspectives of a team of University of Pittsburgh researchers as they have engaged in these efforts.

Design of a cluster-randomized controlled trial of a diabetes prevention program within African-American churches: The Fit Body and Soul study

Evidence from varied community settings has shown that the Group Lifestyle Balance (GLB) Program and other adaptations of the Diabetes Prevention Program (DPP) intervention are effective in lowering diabetes risk. Most DPP data originated from studies of pre-diabetic whites, with only sparse evidence of the effect of DPP in African Americans (AAs) in community settings. This paper describes the design, methods, baseline characteristics and cost effective measures, of a single-blinded, cluster-randomized trial of a faith-based adaptation of the GLB program, Fit Body and Soul (FBAS). The major aims are to test efficacy and cost utility of FBAS in twenty AA churches. Randomization occurred at the church level and 604 AA overweight/obese (BMI≥25kg/m(2)) adults with fasting plasma glucose range from normal to pre-diabetic received either FBAS or a health-education comparison program. FBAS is a group-based, multi-level intervention delivered by trained church health advisors (health professionals from within the church), with the goal of ≥7% weight loss, achieved through increasing physical activity, healthy eating and behavior modification. The primary outcome is weight change at 12weeks post intervention. Secondary outcomes include hemoglobin A1C, fasting plasma glucose, waist circumference, blood pressure, physical activity level, quality of life measures, and cost-effectiveness. FBAS is the largest known cohort of AAs enrolled in a faith-based DPP translation. Reliance on health professionals from within the church for program implementation and the cost analysis are unique aspects of this trial. The design provides a model for faith-based DPPs and holds promise for program sustainability and widespread dissemination.

Necessary components for lifestyle modification interventions to reduce diabetes risk

Several efficacy trials and subsequent dissemination studies indicate that behavioral lifestyle interventions for diabetes risk reduction require, at a minimum, provision of 4 to 6 months of frequent intervention contact to induce clinically meaningful weight losses of at least 5% of initial body weight. Weekly contact during the first several months of intervention, followed by less frequent but regular therapeutic contact for a longer time period, appears necessary for participants to adopt and enact behavioral self-regulatory skills such as the self-monitoring of diet, weight, and physical activity and the problem solving of common physical, social, and cognitive barriers that impede sustained weight loss. In-person contact is associated with the largest effect sizes but may not be a necessary component for clinically meaningful weight loss. Regardless of intervention mode, setting, or provider, the interactive process of feedback and social support is crucial for skill development and sustained weight loss.

A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators

PURPOSE

With growing numbers of people at risk for diabetes and cardiovascular disease, diabetes educators report increasing referrals for intervention in prevention of these conditions. Diabetes educators have expertise in diabetes self-management education; however, they are generally not prepared for delivery of chronic disease primary prevention. The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease.

METHODS

Diabetes educators in 3 outpatient-hospital programs (urban, suburban, and rural) received training and support for implementation of the Group Lifestyle Balance program, an adaptation of the Diabetes Prevention Program lifestyle intervention, from the Diabetes Prevention Support Center of the University of Pittsburgh. Adults with prediabetes and/or the metabolic syndrome were eligible to enroll in the program with physician referral. With use of existing diabetes educator networks, recruitment was completed via on-site physician in-services, informative letters, and e-mail contact as well as participant-directed newspaper advertisement.

RESULTS

Eighty-one participants enrolled in the study (71 women, 10 men). Mean overall weight loss was 11.3 lb (5.1%, P < .001); in addition, significant decreases were noted in fasting plasma glucose, low-density lipoprotein cholesterol, triglycerides, and blood pressure.

CONCLUSIONS

These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals. Furthermore, diabetes educators, already integrated within the existing health care system, provide yet another resource for delivery of primary prevention programs in the community.

A novel approach to diabetes prevention: evaluation of the Group Lifestyle Balance program delivered via DVD

This pilot project evaluated the Group Lifestyle Balance program (GLB), an adaptation of the DPP lifestyle intervention, delivered via DVD with remote participant support provided by the University of Pittsburgh Diabetes Prevention Support Center. Results suggest that GLB-DVD with remote support may provide an effective alternative for GLB delivery.

Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005-2007

INTRODUCTION

We assessed the cost-effectiveness of a community-based, modified Diabetes Prevention Program (DPP) designed to reduce risk factors for type 2 diabetes and cardiovascular disease.

METHODS

We developed a Markov decision model to compare costs and effectiveness of a modified DPP intervention with usual care during a 3-year period. Input parameters included costs and outcomes from 2 projects that implemented a community-based modified DPP for participants with metabolic syndrome, and from other sources. The model discounted future costs and benefits by 3% annually.

RESULTS

At 12 months, usual care reduced relative risk of metabolic syndrome by 12.1%. A modified DPP intervention reduced relative risk by 16.2% and yielded life expectancy gains of 0.01 quality-adjusted life-years (3.67 days) at an incremental cost of $34.50 ($3,420 per quality-adjusted life-year gained). In 1-way sensitivity analyses, results were sensitive to probabilities that risk factors would be reduced with or without a modified DPP and that patients would enroll in an intervention, undergo testing, and acquire diabetes with or without an intervention if they were risk-factor-positive. Results were also sensitive to utilities for risk-factor-positive patients. In probabilistic sensitivity analysis, the intervention cost less than $20,000 per quality-adjusted life-year gained in approximately 78% of model iterations.

CONCLUSION

We consider the modified DPP delivered in community and primary care settings a sound investment.

Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery

BACKGROUND

The Diabetes Prevention Program (DPP) demonstrated that lifestyle intervention reduces risk for type 2 diabetes and the metabolic syndrome. A universal framework for translation of multiple aspects of the DPP intervention, including training, support, and evaluation is needed to enhance treatment fidelity in a variety of settings.

PURPOSE

This study aims to develop a comprehensive model for diabetes prevention translation using a modified DPP lifestyle intervention.

METHODS

The DPP lifestyle intervention was adapted to a 12-session group-based program called Group Lifestyle Balance for implementation in the community setting. A model for training and support mirroring that of the DPP was developed for prevention professionals administering the program. The process of training/support and program implementation was evaluated for feasibility and effectiveness using a nonrandomized prospective design in two phases (N=51, Phase 1: 2005-2006; N=42, Phase 2: 2007-2009; data analysis completed 2008-2009). A total of 93 nondiabetic individuals with BMI >or=25 kg/m(2) and the metabolic syndrome or prediabetes participated. Measures were collected at baseline and post-intervention for all and 6 and 12 months post-intervention for Phase 2.

RESULTS

Significant decreases in weight, waist circumference, and BMI were noted in both phases from baseline. Participants in Phase 2 also demonstrated decreases in total cholesterol, non-HDL cholesterol, and systolic and diastolic blood pressure that were maintained at 12 months. Average combined weight loss for both groups over the course of the 3-month intervention was 7.4 pounds (3.5% relative loss, p<0.001); 23.8% and 52.2% of those who completed the program reached 7% and 5% weight loss, respectively. More than 80% of those achieving 7% weight loss in the Phase-2 group maintained their weight loss at 6 months.

CONCLUSIONS

A comprehensive diabetes prevention model for training, intervention delivery, and support was shown to be successful and was effective in reducing diabetes and cardiovascular disease risk factors in this group of high-risk individuals.

Fit body and soul: a church-based behavioral lifestyle program for diabetes prevention in African Americans

Faith-based initiatives for lifestyle change show promise in helping to promote healthy behaviors in African American communities. It has been suggested that faith communities and programs within faith communities can influence health care practices and health care planning especially in high risk, minority populations. African American individuals are more likely to attend and participate in faith-based services than Whites from similar backgrounds. Our proposed intervention, Fit Body and Soul, has been adopted and modified from the proven diabetes prevention program (DPP) lifestyle intervention program, and uses the church-community experiences of the "Body and Soul" study as a faith-based effort. The intervention has been developed keeping in mind the church mission and goal of being spiritually healthy and has adopted bible scripture to develop a 12-session intervention. In this article, we present the development of the church-based Fit Body and Soul behavioral lifestyle intervention using community-based participatory research in partnership with African American churches.

Adherence to preventive medications: predictors and outcomes in the Diabetes Prevention Program

OBJECTIVE

To evaluate barriers to and strategies for medication adherence and predictors of adherence and the primary outcome in the Diabetes Prevention Program (DPP).

RESEARCH DESIGN AND METHODS

Within a randomized, controlled primary prevention study for type 2 diabetes, we collected data on study medication adherence, its predictors, and health outcomes in 27 clinical centers across mainland U.S. and Hawaii. Medication arm participants included 2,155 adults with impaired glucose tolerance randomly assigned to either metformin or matched placebo treatment arms. Structured interviews were used to promote medication adherence and to collect data regarding adherence. Adherence was measured by pill count. The primary DPP outcome of type 2 diabetes was assessed by fasting plasma glucose and oral glucose tolerance test.

RESULTS

Older age-groups were more adherent than the youngest group (P = 0.01) in the metformin group. The most frequently reported barrier to adherence was "forgetting" (22%). Women reported more adverse effects of metformin (15 vs. 10%, P = 0.002) in the metformin group. Odds of nonadherence increased as participants reported more than one barrier (odds ratio 19.1, P < 0.001). Odds of adherence increased as participants reported multiple strategies to take medication (2.69, P < 0.0001). There was a 38.2% risk reduction for developing diabetes for those adherent to metformin compared with those adherent to placebo (P < 0.0003).

CONCLUSIONS

DPP medication adherence results are unique in primary prevention for a chronic disease in a large multiethnic sample. Our finding that adherence was associated with risk reduction for diabetes supports the development of brief interventions in clinical settings where medication adherence is a challenge.

Previous exposure to VTA amphetamine enhances cocaine self-administration under a progressive ratio schedule in a D1 dopamine receptor dependent manner

The effect of previous exposure to amphetamine (AMPH) in the ventral tegmental area (VTA) on the subsequent self-administration of cocaine was assessed. Rats in different groups were pre-exposed to three injections into the VTA of either saline (0.5 microl/side) or AMPH (2.5 microg/0.5 microl/side). Injections were given once every third day. Starting 7-10 days after the last pre-exposure injection, rats were trained to self-administer cocaine (0.3 mg/kg/infusion) under fixed ratio 1 and 2 (FR1 and FR2) schedules and then tested under a progressive ratio (PR) schedule of reinforcement for six consecutive days. No differences between groups were observed during self-administration training under the FR schedules of reinforcement. However, when tested under the PR schedule, VTA AMPH pre-exposed rats worked more and, as a result, obtained more infusions of cocaine than saline pre-exposed rats. Rats in a separate group pre-exposed to VTA AMPH but co-infused with the D(1)-like dopamine (DA) receptor antagonist SCH23390 (0.25 microg/0.5 microl/side) did not show enhanced cocaine self-administration. These rats, as well as others pre-exposed to VTA SCH23390 alone showed levels of cocaine self-administration similar to saline pre-exposed rats. Thus, in a manner paralleling the sensitization of AMPH-induced locomotion and nucleus accumbens DA overflow, previous exposure to AMPH in the VTA leads to enhanced intravenous self-administration of cocaine and activation of D(1) DA receptors in this site during pre-exposure is necessary for the production of this effect.

A trio to treasure: the elderly, the nurse, and music

Music is a powerful tool for maintaining and restoring health and is particularly suited to elder care. Music can be used to induce relaxation, alter moods, and create distraction. Music's effect is attributed to its vibrational properties, which are processed through the senses and integrated within the central nervous system. Nurses have a major responsibility to understand, appreciate, and use music in their practice.

Hashimoto's thyroiditis and insulin-dependent diabetes mellitus: differences among individuals with and without abnormal thyroid function

Insulin-dependent diabetes mellitus probands from the Familial Autoimmune and Diabetes Study were evaluated for autoimmune thyroid disease (n = 265). The prevalence of Hashimoto's thyroiditis was 26.6%; 42.0% of these individuals were euthyroid, and 58.0% were hypothyroid. There was a female predominance among hypothyroid and euthyroid Hashimoto's cases compared to those with no thyroid disease (75% vs. 72.4% vs. 41.6%; P < 0.001). Insulin-dependent diabetes mellitus patients with hypothyroid Hashimoto's thyroiditis were more likely to report another autoimmune disease compared to euthyroid Hashimoto's patients or individuals with no thyroid disease (30.8% vs. 17.2% vs. 13.9%; P < 0.01). Sex-specific analysis revealed that this difference was significant for men but not for women. Both euthyroid and hypothyroid Hashimoto's cases were more likely to have a family history of the disease (66.7% vs. 69.2% vs. 47.7%; P < 0.05). No differences were observed in the prevalence of DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302 across the three groups. Body mass index, lipid levels, glycemic control, and diabetes complications were also similar. However, euthyroid Hashimoto's women were more likely to report spontaneous abortions than those with hypothyroid Hashimoto's thyroiditis or no thyroid disease (23.8% vs. 61.5% vs. 29.1%; P < 0.05). These data suggest that gender-specific risk factors may be primary determinants of Hashimoto's thyroiditis and other autoimmune diseases among women. However, disease-specific determinants may also increase susceptibility to other autoimmune diseases.

Molecular epidemiology of autoimmune thyroid disease

This paper presents preliminary data regarding the prevalence and risk factors for autoimmune thyroid disease in IDDM probands ascertained from the Children's Hospital of Pittsburgh IDDM Registry for 1950-1965 (n = 669). Living IDDM probands who participated in the 1990 follow-up survey (n = 380) were recruited for the Familial Autoimmune and Diabetes Study. Siblings and parents were also invited to participate. To date, 255 IDDM probands and 597 parents and siblings have been evaluated. The diagnosis of autoimmune thyroid disease was based on a clinical evaluation, medical history, and laboratory determinations. Graves disease was rare in this cohort (n = 5). However, Hashimoto's thyroiditis was common among women. Prevalence rates ranged from 54% for IDDM women age < 40 years to 75% for those > 50 years. Corresponding age-specific estimates for female relatives were 22% and 44%, respectively. Approximately one-half of the Hashimoto's individuals were euthyroid; they were more likely to have other autoantibodies and a positive family history than those who were hypothyroid or had no thyroid disease. Genetic analyses revealed a 2-fold increase in DQA1*0501-DQB1*0201 among the Hashimoto's compared to the non-Hashimoto's haplotypes. These findings suggested that Hashimoto's thyroiditis was common in IDDM families, which may be due, in part, to common disease susceptibility genes.

Association of retinol binding protein in multiple-case families with insulin-dependent diabetes

We performed a family study to investigate the heritability of reduced serum retinol levels observed in type 1 diabetes cases. Diet and serum factors, including retinol, total carotene, malondialdehyde, and retinol binding protein levels, were measured in 11 multiple-case families. The mean serum retinol level of the diabetics (46 ug/dl) was significantly less than the mean serum retinol level of the nondiabetics (60.9 ug/dl). The level of retinol binding protein was also significantly lower in diabetics (6.2 mg/dl) than in nondiabetics (7.6 mg/dl). The serum values of retinol binding protein were closely related within families, including both diabetic and nondiabetic family members. A characteristic shared between diabetics and one-third of their family members was a low ratio of serum retinol to total carotene, suggesting a low conversion of dietary carotene into retinol. Analysis of food frequency reports showed no difference between dietary retinol or total carotene level in diabetics or their relatives. This study offers evidence that heritability and the reduced conversion of carotene may play a role in the level of serum retinol in type 1 diabetes cases.

Molecular IDDM epidemiology: international studies. WHO DiaMond Molecular Epidemiology Sub-Project Group

The WHO DiaMond Molecular Epidemiology Sub-Project is testing the hypothesis that the geographic differences in IDDM incidence reflect population variation in the frequency of IDDM susceptibility genes (i.e., DQA1 and DQB1 alleles with sequences coding for arginine (R) in position 52 of the DQ alpha-chain, and an amino acid other than aspartic acid (ND) in position 57 of the DQ beta-chain, respectively) using a standardized case-control design. Data from twelve populations which have completed (or have nearly completed) recruitment and HLA molecular analyses are presented. There was an approximate 2-fold increase in the frequencies of DGA1*0301, DQB1*0201 and DQB11*0302 among IDDM cases compared to non-diabetic controls in most populations. Interestingly, DQA*0301 was more common in low versus moderate-high incidence countries. DQB1*0201 and DQB1*0302 were more prevalent in the moderate-high incidence areas. DQA1*R and DQB1*ND were both consistent markers of IDDM risk, with stronger associations in moderate-high versus low incidence areas. In general, individuals homozygous for both DQA1*R and DQB1*ND had the highest genotype-specific IDDM incidence rates, which approximated risk estimates for first degree relatives in several countries. These data revealed considerable variation in the frequencies of DQB1 and DQA1 alleles across countries, which likely contribute to the global patterns of IDDM incidence.

Concept Clarification and Critical Thinking: Integrated Processes

Concept clarification is centrally important to theory development. While often understood as a formula-driven task, concept clarification is really a process that engages critical thinking. Clarification creates multiple meanings through: (1) formulating purposes, (2) choosing, examining, and integrating data sources, and (3) representing a final conceptualization that can also be examined for adequacy. Within each of these processes, critical thinking is engaged as: (1) assumptions are identified and challenged, (2) the importance of context in creating meaning is revealed, (3) alternative interpretations are imagined and explored, and (4) reflective skepticism is cultivated. The central challenge in concept clarification is to understand how words create things.

Phobic anxiety and irrational belief systems

In a test of the hypothesis that irrational thinking is associated with phobic anxiety, the Rational Behavior Inventory and the Fear Survey Schedule were administered to 128 undergraduates. Although a statistically significant correlation between irrationality and phobic anxiety was found, the result appears to have little clinical meaning. Other evidence is cited which suggests that rational emotive therapy is best suited for the treatment of generalized anxiety, whereas deconditioning treatments are appropriate for most cases of phobic anxiety.