Emily A. Finch

Translating the Diabetes Prevention Program into the Community The DEPLOY Pilot Study

BACKGROUND The Diabetes Prevention Program (DPP) found that an intensive lifestyle intervention can reduce the development of diabetes by more than half in adults with prediabetes, but there is little information about the feasibility of offering such an intervention in community settings. This study evaluated the delivery of a group-based DPP lifestyle intervention in partnership with the YMCA. METHODS This pilot cluster-randomized trial was designed to compare group-based DPP lifestyle intervention delivery by the YMCA to brief counseling alone (control) in adults who attended a diabetes risk-screening event at one of two semi-urban YMCA facilities and who had a BMI>or=24 kg/m2, >or=2 diabetes risk factors, and a random capillary blood glucose of 110-199 mg/dL. Multivariate regression was used to compare between-group differences in changes in body weight, blood pressures, HbA1c, total cholesterol, and HDL-cholesterol after 6 and 12 months. RESULTS Among 92 participants, controls were more often women (61% vs 50%) and of nonwhite race (29% vs 7%). After 6 months, body weight decreased by 6.0% (95% CI=4.7, 7.3) in intervention participants and 2.0% (95% CI=0.6, 3.3) in controls (p<0.001; difference between groups). Intervention participants also had greater changes in total cholesterol (-22 mg/dL vs +6 mg/dL controls; p<0.001). These differences were sustained after 12 months, and adjustment for differences in race and gender did not alter these findings. With only two matched YMCA sites, it was not possible to adjust for potential clustering by site. CONCLUSIONS The YMCA may be a promising channel for wide-scale dissemination of a low-cost approach to lifestyle diabetes prevention.

Association between obesity and depression in middle-aged women

OBJECTIVE Evaluate the association between obesity and depression among middle-aged women. METHODS A total of 4641 female health plan enrollees aged 40-65 years completed a structured telephone interview including self-reported height and weight, the Patient Health Questionnaire (PHQ) assessment of depression; a brief measure of rate was 62%. RESULTS Prevalence of moderate or severe depression increased from 6.5% among those with body mass index (BMI) under 25 to 25.9% among those with BMI over 35. Prevalence of obesity increased from 25.4% among those with no depressive symptoms to 57.8% among those with moderate to severe depression. Independent of obesity, depression was associated with significant reductions in frequency of moderate (4.6 vs. 5.4 times per week) or vigorous (2.8 vs. 3.7 times per week) physical activity. Depression was associated with significantly higher daily caloric intake (1831 vs. 1543) among those with BMI over 30. CONCLUSIONS Among middle-aged women, depression is strongly and consistently associated with obesity, lower physical activity and (among the obese) higher caloric intake. Public health approaches to reducing the burden of obesity or depression must consider the strong association between these two common conditions.

Specifying the determinants of the initiation and maintenance of behavior change: An examination of self-efficacy, satisfaction, and smoking cessation

Using data from smokers (N = 591) who enrolled in an 8-week smoking cessation program and were then followed for 15 months, the authors tested the thesis that self-efficacy guides the decision to initiate smoking cessation but that satisfaction with the outcomes afforded by quitting guides the decision to maintain cessation. Measures of self-efficacy and satisfaction assessed at the end of the program, 2 months, and 9 months were used to predict quit status at 2, 9, and 15 months, respectively. At each point, participants were categorized as either initiators or maintainers on the basis of their pattern of cessation behavior. Across time, self-efficacy predicted future quit status for initiators, whereas satisfaction generally predicted future quit status for maintainers. Implications for models of behavior change and behavioral interventions are discussed.

Behavioral Intervention for the Treatment of Obesity: Strategies and Effectiveness Data

The obesity epidemic has been recognized in the professional and lay public as a major health problem in the United States and many other cultures. The gastroenterology literature has recently paid attention to this problem, focusing primarily on either physiological mechanisms of obesity or surgical remedies for obesity. However, behavioral strategies developed from social learning theory have been the most thoroughly tested interventions for the treatment of obesity, as well as the interventions shown most clearly to have clinical benefit. Nevertheless, descriptions of behavioral techniques and their theoretical underpinnings have been minimal in the gastroenterology literature. Here, a brief history and presentation of the theoretical underpinnings of behavioral strategies for obesity management is summarized, emphasizing some of the key components, treatment effectiveness data, and needed areas for further research. Overall, it is concluded that behavior therapy is both the most studied and most effective therapy for treating obesity at present. Gastroenterologists are encouraged to use it as a first line of treatment for most obese patients, and as a key component of therapies that involve pharmacologic and surgical components.

Reported food choices in older women in relation to body mass index and depressive symptoms

This paper examines the relationships among reports of depressive symptoms, BMI and frequency of consumption of 30 foods in 4655 middle-aged women. Food was grouped into three categories: high-calorie sweet, high-calorie nonsweet, and low-calorie. Controlling for total energy intake, BMI and depressive symptoms were both inversely associated with a higher frequency of consumption of low-calorie foods. BMI was positively associated with consumption of high-calorie nonsweet foods and negatively related to consumption of high-calorie sweet foods. Depressive symptoms were positively associated with sweet foods consumption and negatively associated with nonsweet foods consumption. These findings suggest that the positive association between BMI and depression in women may be mediated by sweets consumption. This is consistent with the hypothesis that eating sweet foods reduces negative affect.

A theoretically grounded systematic review of material incentives for weight loss: implications for interventions

BackgroundProviding material incentives for weight loss is a class of intervention strategies that has received considerable attention; however, the effectiveness of this class of strategies is uncertain. Attending to distinctions among incentive strategies may clarify our understanding of prior work and inform the design of future interventions.PurposeA theoretical framework is proposed that distinguishes between four classes of incentive strategies and is used to organize randomized controlled trials of material incentives for weight loss.MethodsA systematic literature review was conducted.ResultsFindings were mixed with regards to the overall efficacy of material incentives for weight loss. Three of the four proposed incentive categories are represented in the literature. Heterogeneous methods were used across studies rendering comparisons between studies difficult.ConclusionsDefinitive conclusions about the usefulness of material incentives for weight loss could not be drawn. A theoretically grounded approach to designing and testing incentive strategies is encouraged.

A Randomized Comparative Effectiveness Trial for Preventing Type 2 Diabetes

OBJECTIVES We evaluated the weight loss effectiveness of a YMCA model for the Diabetes Prevention Program (DPP) lifestyle intervention. METHODS Between July 2008 and November 2010, we individually randomized 509 overweight or obese, low-income, nondiabetic adults with elevated blood glucose in Indianapolis, Indiana, to receive standard care plus brief lifestyle counseling or be offered a group-based YMCA adaptation of the DPP (YDPP). Primary outcome was mean weight loss difference at 12 months. In our intention-to-treat analyses, we used longitudinal linear or logistic regression, multiply imputing missing observations. We used instrumental variables regression to estimate weight loss effectiveness among participants completing 9 or more intervention lessons. RESULTS In the YDPP arm, 161 (62.6%) participants attended ≥ 1 lesson and 103 (40.0%) completed 9 or more lessons. In intention-to-treat analysis, mean 12-month weight loss was 2.3 kilograms (95% confidence interval [CI] = 1.1, 3.4 kg) more for the YDPP arm than for standard care participants. In instrumental variable analyses, persons attending 9 or more lessons had a 5.3-kilogram (95% CI = 2.8, 7.9 kg) greater weight loss than did those with standard care alone. CONCLUSIONS The YMCA model for DPP delivery achieves meaningful weight loss at 12 months among low-income adults.

Long-term effects of a community-based lifestyle intervention to prevent type 2 diabetes: the DEPLOY extension pilot study:

Objective: The US Diabetes Prevention Program (DPP) and other large trials internationally have shown that an intensive lifestyle intervention can reduce the development of type 2 diabetes. We evaluated long-term effects of a lower cost, group-based adaption of the DPP lifestyle intervention offered by the YMCA. Methods: Participants were adults with BMI ≥24 kg/m2 and random capillary blood glucose 6.1–11.1 mmol/L who had been previously enrolled in a cluster-randomized trial comparing a group-based DPP lifestyle intervention versus brief advice alone. Four to 12 months after completion of the initial trial, 72% of 92 participants enrolled in an extension study, and all were offered a group lifestyle maintenance program at the YMCA. Paired t-tests were used to assess within-group changes; ANCOVA with adjustment was used for between-group comparisons. Results: At 28 months, after both arms were offered the same 8-month lifestyle maintenance intervention, both arms had statistically significant weight losses compared to baseline (brief advice controls: −3.6%; 95% CI: −5.8 to −1.4; intensive lifestyle: −6.0%; 95% CI: −8.8 to −3.2). Participants initially assigned to the DPP also experienced significant improvements in blood pressure and total cholesterol. Discussion: The YMCA is a promising channel for dissemination of a low-cost model for lifestyle diabetes prevention. Future studies are needed to verify these findings.

A comparison of maintenance-tailored therapy (MTT) and standard behavior therapy (SBT) for the treatment of obesity

OBJECTIVE To evaluate a maintenance-tailored therapy (MTT) compared to standard behavior therapy (SBT) for treatment of obesity. MAIN OUTCOME MEASURE change in body weight. METHOD A non-blinded, randomized trial comparing effectiveness of MTT and SBT in facilitating sustained weight loss over 18 months; 213 adult volunteers> or =18 years participated. SBT had fixed behavioral goals, MTT goals varied over time. Study conducted at the University of Minnesota, School of Public Health, January 2005 through September 2007. RESULTS Mean (SD) weight losses at 6, 12, and 18 months were 5.7 (5.0) kg, 8.2 (8.6) kg and 8.3 (8.9) kg for MTT and 7.4 (3.9) kg, 10.7 (8.2) kg and 9.3 (8.8) kg for SBT. Total weight loss did not differ by group at 18 months, but the time pattern differed significantly (p<0.001). The SBT group lost more weight in the first 6 months. Both groups lost similar amounts between 6 and 12 months; MTT had stable weight between 12 and 18 months, while SBT experienced significant weight gain. CONCLUSIONS The MTT approach produced sustained weight loss for an unusually long period of time and not achieved in previous trials of behavioral treatment for weight loss. The MTT approach, therefore, deserves further study.

Reduced 10-year risk of coronary heart disease in patients who participated in a community-based diabetes prevention program: the DEPLOY pilot study.

OBJECTIVE—We evaluated whether participation in a community-based group diabetes prevention program might lead to relative changes in composite 10-year coronary heart disease (CHD) risk for overweight adults with abnormal glucose metabolism. RESEARCH DESIGN AND METHODS—We used the UK Prospective Diabetes Study engine to estimate CHD risk for group-lifestyle and brief counseling (control) groups. Between-group risk changes after 4 and 12 months were compared using ANCOVA. RESULTS—Baseline 10-year risk was similar between treatment groups (P = 0.667). At 4 and 12 months, the intervention group experienced significant decreases in 10-year risk from baseline (−3.28%, P < 0.001; and −2.23%, P = 0.037) compared with control subjects (−0.78%, P = 0.339; and +1.88%, P = 0.073). Between-group differences were statistically significant and increased from the 4- to 12-month visits. CONCLUSIONS—Community-based delivery of the Diabetes Prevention Program lifestyle intervention could be a promising strategy to prevent both CHD and type 2 diabetes in adults with pre-diabetes.