Yvette Roubideaux

Translating the Diabetes Prevention Program Into American Indian and Alaska Native Communities Results from the Special Diabetes Program for Indians Diabetes Prevention demonstration project

OBJECTIVE The landmark Diabetes Prevention Program (DPP) showed that lifestyle intervention can prevent or delay the onset of diabetes for those at risk. We evaluated a translational implementation of this intervention in a diverse set of American Indian and Alaska Native (AI/AN) communities. RESEARCH DESIGN AND METHODS The Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented the DPP lifestyle intervention among 36 health care programs serving 80 tribes. A total of 2,553 participants with prediabetes were recruited and started intervention by 31 July 2008. They were offered the 16-session Lifestyle Balance Curriculum and underwent a thorough clinical assessment for evaluation of their diabetes status and risk at baseline, soon after completing the curriculum (postcurriculum), and annually for up to 3 years. Diabetes incidence was estimated. Weight loss, changes in blood pressure and lipid levels, and lifestyle changes after intervention were also evaluated. RESULTS The completion rates of SDPI-DP were 74, 59, 42, and 33% for the postcurriculum and year 1, 2, and 3 assessments, respectively. The crude incidence of diabetes among SDPI-DP participants was 4.0% per year. Significant improvements in weight, blood pressure, and lipid levels were observed immediately after the intervention and annually thereafter for 3 years. Class attendance strongly correlated with diabetes incidence rate, weight loss, and change in systolic blood pressure. CONCLUSIONS Our findings demonstrate the feasibility and potential of translating the lifestyle intervention in diverse AI/AN communities. They have important implications for future dissemination and institutionalization of the intervention throughout the Native American health system.

Mechanisms underlying the relationship between health literacy and glycemic control in American Indians and Alaska Natives.

OBJECTIVEnResearch suggests that health literacy (HL) is associated with clinical outcomes. Few studies, however, have examined the mechanisms accounting for this relationship. To understand why HL is related to outcomes, we tested a theoretical framework proposing that diabetes-related knowledge and behavior mediate (explain) the relationship between HL and glycemic control (i.e., A1c).nnnMETHODSnAnalyses used baseline data from the Special Diabetes Program for Indians Healthy Heart Project (N=2594), an intervention to reduce cardiovascular risk among American Indians/Alaska Natives (AI/ANs) with diabetes. Three nested structural equation models tested the theoretical framework.nnnRESULTSnModel 1 demonstrated that participants with stronger HL skills had better glycemic control. Model 2 tested whether diabetes-related behaviors accounted for this relationship. Self-monitoring of blood glucose significantly mediated the HL-A1c relationship. Model 3 examined the role of diabetes knowledge, showing that it mediated the relationship between HL and dietary behavior. When knowledge was included, behavior was no longer a significant mediator, suggesting that knowledge was the main driver of the relationship between HL with A1c.nnnCONCLUSIONnInterventions to improve knowledge may be particularly important in enhancing outcomes among AI/ANs with diabetes.nnnPRACTICE IMPLICATIONSnStrategies known to enhance patient comprehension may enable low-literate patients to develop needed diabetes knowledge.

Special Diabetes Program for Indians: Retention in Cardiovascular Risk Reduction

PURPOSEnThis study examined the associations between participant and site characteristics and retention in a multisite cardiovascular disease risk reduction project.nnnDESIGN AND METHODSnData were derived from the Special Diabetes Program for Indians Healthy Heart Demonstration Project, an intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. In 2006, a total of 1,072 participants from 30 participating sites completed baseline questionnaires measuring demographics and sociobehavioral factors. They also underwent a medical examination at baseline and were reassessed annually after baseline. A Provider Annual Questionnaire was administered to staff members of each grantee site at the end of each year to assess site characteristics. Generalized estimating equation models were used to evaluate the relationships between participant and site characteristics and retention 1 year after baseline.nnnRESULTSnAmong enrolled participants, 792 (74%) completed their first annual assessment. Participants who completed the first annual assessment tended to be older and had, at baseline, higher body mass index and higher level of physical activity. Site characteristics associated with retention included average age of staff, proportion of female staff members, and percentage of staff members having completed graduate or professional school.nnnIMPLICATIONSnUnderstanding successful retention must reach beyond individual characteristics of participants to include features of the settings that house the interventions.

Latent Class Analysis of Stages of Change for Multiple Health Behaviors: Results from the Special Diabetes Program for Indians Diabetes Prevention Program

This study sought to identify latent subgroups among American Indian and Alaska Native (AI/AN) patients with pre-diabetes based on their stages of change for multiple health behaviors. We analyzed baseline data from participants of the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, a lifestyle intervention program to prevent diabetes among AI/ANs. A total of 3,135 participants completed baseline questionnaires assessing stages of change for multiple health behaviors, specifically exercise, healthy eating, and weight loss. Latent class analysis was used to identify subgroups of people based on their answers to stages of change questions. Covariates were added to the latent class analyses to investigate how class membership was related to sociodemographic, behavioral, and psychosocial factors. Three classes were identified based on the distributions of the stages of change variables: Contemplation, Preparation, and Action/Maintenance classes. Male and retired participants were more likely to be in more advanced stages. Those who exercised more, ate healthier diets, and weighed less were significantly more likely to be in the Action/Maintenance class. Further, the participants who had higher self-efficacy, stronger family support, and better health-related quality of life had higher odds of being in the Action/Maintenance class. In conclusion, we found that stages of change for multiple behaviors can be summarized by a three-class model in this sample. Investigating the relationships between latent classes and intervention outcomes represents important next steps to extend the findings of the current study.

Participant and Site Characteristics Related to Participant Retention in a Diabetes Prevention Translational Project

Using multilevel analysis, this study investigated participant and site characteristics associated with participant retention in a multisite diabetes prevention translational project among American Indian and Alaska Native (AI/AN) people. We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention Program (SDPI-DP), a lifestyle intervention to prevent diabetes implemented in 36 AI/AN grantee sites. A total of 2,553 participants were recruited and started the intervention between January 1, 2006 and July 31, 2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16–24xa0weeks of intervention. Generalized estimating equation models and proportional hazards models with robust standard error estimates were used to evaluate the relationships of participant and site characteristics with retention. As of July 31, 2009, about 50xa0% of SDPI-DP participants were lost to follow-up. Those who were younger, male, with lower household income, no family support person, and more baseline chronic pain were at higher risk for both short-term and long-term retention failure (i.e., not completing all 16 DPP sessions and loss to follow-up, respectively). Sites with large user populations and younger staff had lower likelihood of retaining participants successfully. Other site characteristics related to higher risk for retention failure included staff rating of participant disinterest in SDPI-DP and barriers to participant transportation and child/elder care. Future translational initiatives need to pay attention to both participant- and site-level factors in order to maximize participant retention.

Demographic characteristics and food choices of participants in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project

Objective. American Indians and Alaska Natives (AI/ANs) suffer a disproportionate burden of diabetes. Identifying food choices of AI/ANs at risk of type 2 diabetes, living in both rural and urban settings, is critical to the development of culturally relevant, evidence-based education strategies designed to reduce morbidity and mortality in this population. Design. At baseline, 3135 AI/AN adults participating in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project (SDPI-DP) completed a socio-demographic survey and a 27-item food frequency questionnaire (FFQ). The primary dietary behavior goal of SDPI-DP education sessions and lifestyle coaching is changes in food choices, i.e., increased fruits, vegetables and whole grains, decreased high sugar beverages, red meat, and processed foods. Subsequently, program assessment focuses on changes in food types. Foods were delineated using a ‘healthy’ and ‘unhealthy’ classification as defined by the educators advising participants. Urban and rural differences were examined using χ2 tests and two sample t-tests. Multiple linear regressions and linear mixed models were used to assess the association between socio-demographic factors and food choice. Results. Retired participants, those living in urban areas and with high income and education selected healthy foods most frequently. Young males, those with low income and education consumed unhealthy foods most frequently. Selection of unhealthy foods did not differ by urban and rural setting. Conclusions. The ubiquitous nature of unhealthy food choices makes them hard to avoid. Food choice differences by gender, age, income, and setting suggest that nutrition education should more effectively target and meets the needs of young AI/AN males.

Socioeconomic Disparities in Weight and Behavioral Outcomes Among American Indian and Alaska Native Participants of a Translational Lifestyle Intervention Project

OBJECTIVE To investigate possible socioeconomic disparities in weight and behavioral outcomes among American Indian and Alaska Native (AI/AN) participants in a translational diabetes prevention project. RESEARCH DESIGN AND METHODS We analyzed data from the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, an evidence-based lifestyle intervention to prevent diabetes in 36 AI/AN grantee sites. A total of 2,553 participants started the 16-session Lifestyle Balance Curriculum between 1 January 2006 and 31 July 2008. Linear mixed models were used to evaluate the relationships of participant and staff socioeconomic characteristics with weight and behavioral outcomes at the end of the curriculum. RESULTS A strong, graded association existed between lower household income and less BMI reduction, which remained significant after adjusting for other socioeconomic characteristics. Compared with others, participants with annual income <

Comment on Knowler et al. Preventing Diabetes in American Indian Communities. Diabetes Care 2013;36:1820–1822

15,000 also had less improvement in physical activity and unhealthy food consumption in bivariate models, but the relationships were only marginally significant in multivariate regressions. Furthermore, grantee sites with fewer professionally prepared staff were less successful at improving participant BMI and healthy food consumption than the other sites. The strong association between income and BMI reduction was reduced by 20–30% in the models with changes in diet variables but was unrelated to changes in physical activity. CONCLUSIONS Significant socioeconomic disparities exist in weight outcomes of lifestyle intervention at both participant and site staff levels. Helping low-income participants choose more affordable healthy foods and increasing the proportion of professionally trained staff might be practical ways to maximize the effectiveness of lifestyle interventions implemented in “real-world” settings.

Special diabetes program for Indians: reliability and validity of brief measures of print literacy and numeracy

Knowler and Ackermann (1) provided a commentary regarding our article reporting the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project (2). We deeply appreciate the efforts of the editorial staff in recruiting such a knowledgeable group of diabetes prevention experts to comment on this article. We are especially grateful to the authors for underscoring the contribution that the Indian Health Service has made, which includes the SDPI-DP, to lessen the daunting diabetes disparities that face American Indian and Alaska Natives.nnThe commentary correctly pointed out difficulties in quantifying the benefits of the intervention among SDPI-DP participants absent a control group. However, as we sought to communicate, the primary purpose of the SDPI-DP was to …