Linda Siminerio

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.

Predictors of Metabolic Control among Adolescents with Diabetes: A 4-Year Longitudinal Study

OBJECTIVE To employ a risk and resistance framework to examine changes in metabolic control over early to middle adolescence. METHODS We interviewed 70 girls and 62 boys (mean age 12 years) annually for 4 years. Risk and resistance factors, including demographics, disease-related variables, self-care behavior, and psychosocial variables were assessed. Hemoglobin A1c was obtained from medical records. RESULTS Multilevel modeling showed metabolic control deteriorated with age. Self-care behavior interacted with age to predict the decline, such that self-care was more strongly related to poor metabolic control for older adolescents. Eating disturbances, depression, and peer relations were related to poor metabolic control, whereas good family relations were related to better metabolic control for girls. CONCLUSIONS Independent risk factors for poor metabolic control included poor self-care, disturbed eating behavior, depression, and peer relations; parental support was an independent resistance factor for girls. Future research should examine mechanisms by which these relations emerge.

Translating the Diabetes Prevention Program into an urban medically underserved community: a nonrandomized prospective intervention study.

OBJECTIVE—The objective of this study was to determine if a community-based modified Diabetes Prevention Program Group Lifestyle Balance (GLB) intervention, for individuals with metabolic syndrome, was effective in decreasing risk for type 2 diabetes and cardiovascular disease (CVD) in an urban medically underserved community, and subsequently to determine if improvements in clinical outcomes could be sustained in the short term. RESEARCH DESIGN AND METHODS—This nonrandomized prospective intervention study used a one-group design to test the effectiveness of a community-based GLB intervention. Residents from 11 targeted neighborhoods were screened for metabolic syndrome (n = 573) and took part in a 12-week GLB intervention (n = 88) that addressed safe weight loss and physical activity. RESULTS—A marked decline in weight (46.4% lost ≥5% and 26.1% lost ≥7%) was observed in individuals after completion of the intervention. Of these subjects, 87.5% (n = 28) and 66.7% (n = 12) sustained the 5% and 7% reduction, respectively, at the 6-month reassessment. Over one-third of the population (43.5%, n = 30) experienced improvements in one or more component of metabolic syndrome, and 73.3% (n = 22) sustained this improvement at the 6-month reassessment. Additional improvements occurred in waist circumference (P < 0.009) and blood pressure levels (P = 0.04) after adjustment for age, sex, race, mean number of GLB classes attended, and time. CONCLUSIONS—Adults in an urban medically underserved community can decrease their risk for type 2 diabetes and CVD through participation in a GLB intervention, and short-term sustainability is feasible. Future research will include long-term follow-up of these subjects.

Health care and patient-reported outcomes: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study.

OBJECTIVE—The purpose of this study was to assess the relationship of patients’ self-reported well-being, self-management, and diabetes control with factors related to the patient’s health care. RESEARCH DESIGN AND METHODS—This was a cross-sectional survey of national samples of patients with diabetes (n = 5,104) from the multinational study of Diabetes Attitudes, Wishes and Needs (DAWN). Patients from 13 countries in Asia, Australia, Europe, and North America reported their level of well-being, self-management, and diabetes control. Hierarchical multiple regression analysis (blocks are countries, respondent characteristics, and health care features) was used to examine predictors of diabetes-related distress and general well-being, adherence to lifestyle and medical treatment recommendations, and perceived diabetes control and hyperglycemic symptoms. RESULTS—Country, respondent demographic and disease characteristics, and health care features were all associated with patient-reported outcomes. Better patient-provider collaboration was associated with more favorable ratings on all outcomes, and better access to the provider and availability of team care were associated with some positive outcomes. Country differences were only partly accounted for by patient and health care factors. Relationships between health care factors and outcomes varied across countries. CONCLUSIONS—Patients’ reports of well-being, self-management, and diabetes control were related to the countries in which they live, their demographic and disease characteristics, and features of their health care. Opportunities to enhance patient-provider collaboration, access to care, and availability of team care should be pursued.

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.

Deploying the chronic care model to implement and sustain diabetes self-management training programs

PURPOSE The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS The CCM serves as an effective model for implementing and sustaining DSMT programs.

Access to Diabetes Self-management Education Results of National Surveys of Patients, Educators, and Physicians

Purpose To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies. Methods Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel. Results Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)—delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources. Conclusions Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.

Diabetes Self-management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics

D IABETES ISACHRONICDISEASE that requires a person with diabetes to make a multitude of daily self-management decisions and to perform complex care activities. Diabetes self-management education and support (DSME/S) provides the foundation to help people with diabetes to navigate these decisions and activities and has been shown to improve health outcomes. Diabetes self-management education (DSME) is the process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. Diabetes selfmanagement support (DSMS) refers to the support that is required for implementing and sustaining coping skills and behaviors needed to self-manage on an ongoing basis. (See further definitions in Figure 1.) Although different members of the health care team and community can contribute to this process, it is important for health care providers and their practice settings to have the resources and a systematic referral process to ensure that patients with type 2 diabetes receive both DSME and DSMS in a consistent manner. The initial

A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency

Helgeson VS, Honcharuk E, Becker D, Escobar O, Siminerio L. A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency.

Physician and nurse use of psychosocial strategies in diabetes care : Results of the cross-national diabetes attitudes, wishes and needs (DAWN) study

OBJECTIVE—To determine the use of psychosocial strategies by health care providers in treating patients with diabetes and the factors associated with use of these strategies. RESEARCH DESIGN AND METHODS—Cross-sectional survey of national samples of generalist and diabetes specialist physicians (n = 2,705) and nurses (n = 1,122) from the multinational study of Diabetes Attitudes, Wishes and Needs. Respondents were from 13 countries in Asia, Australia, Europe, and North America. Two psychosocial strategies were examined: provider psychosocial care, which provides psychosocial support by diabetes care providers to their own patients, and psychosocial specialist care, which refers diabetic patients to psychosocial specialists. RESULTS—Compared with physicians, nurses perceived significantly higher prevalence and severity of psychosocial problems and used psychosocial strategies significantly more frequently, even though they rated their own psychosocial skills lower. Among both physicians and nurses, diabetes specialists were significantly more likely than generalists to utilize psychosocial strategies. Physicians and nurses used psychosocial strategies significantly more when they believed that more patients have psychosocial problems and that problems interfere more with diabetes control. Referral to psychosocial specialists was significantly more likely when physicians and nurses perceived that professional psychological resources were more available. There were substantial country differences in all factors studied. Compared with other countries, U.S. providers provided more psychosocial care themselves but were less likely to refer to psychosocial specialists. CONCLUSIONS—Psychosocial strategies are important parts of the diabetes care provider repertoire; understanding their determinants may facilitate efforts to increase their use.