A Community-Based Diabetes Prevention Program

Transcription

1 A Community-Based Diabetes Prevention Program 659 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 communitybased 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 contact as well as participant-directed newspaper advertisement. M. Kaye Kramer, RN, DrPH, CCRC Janis R. McWilliams, RN, MSN, CDE, BC-ADM Hsiang-Yu Chen, MS Linda M. Siminerio, RN, PhD, CDE From the Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Kramer, Ms Chen), the University of Pittsburgh Medical Center (Ms McWilliams) Pittsburgh, Pennsylvania, and the School of Medicine and Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Siminerio). Correspondence to M. Kaye Kramer, RN, DrPH, CCRC, University of Pittsburgh, Graduate School of Public Health, 3512 Fifth Avenue, Pittsburgh, PA (mkk3@pitt.edu). Acknowledgments: Project funding provided by Sanofi-Aventis, US. We would like to acknowledge the diabetes educators who completed this project: LuAnn Berry, RD, LDN, CDE, Julie Carothers, MS, RD, LDN, CDE, Carla DeJesus, MS, RD, LDN, CDE, Deb Dowling, RN, BSN, CDE, Janice Koshinsky, RN, MS, CDE, and Patrick McCarthy, RN, as well as Amy Uhler, RN, BSN, MBA, for her assistance. In addition, we acknowledge the faculty of the Diabetes Prevention Support Center of the University of Pittsburgh for providing the Group Lifestyle Balance training for the diabetes educators. DOI: / The Author(s) Results Eighty-one participants enrolled in the study (71 women, 10 men). Mean overall weight loss was 11.3 lb (5.1%, Kramer et al

2 The Diabetes EDUCATOR 660 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. An estimated 79 million adults aged 20 years and older in the United States have prediabetes. 1 With rates of obesity and inactivity on the rise, these numbers will likely grow. Increasingly in practice, diabetes educators are receiving referrals to educate individuals with prediabetes. Although diabetes educators are well prepared for provision of diabetes self-management education (DSME) in general, they do not receive training for delivery of structured behavioral lifestyle intervention for the primary prevention of type 2 diabetes. Several clinical trials have demonstrated the development and successful implementation of lifestyle intervention for the prevention of diabetes. 2-5 All of these trials incorporated balanced nutrition and dietary measures, weight loss, and physical activity as the core of their intervention strategies for the prevention of type 2 diabetes for individuals at risk. The Diabetes Prevention Program (DPP), a randomized controlled diabetes prevention trial conducted with 3234 overweight individuals aged 25 years and older, demonstrated that intensive lifestyle intervention reduced risk for the development of type 2 diabetes and the metabolic syndrome in high-risk individuals. 4,6 The lifestyle intervention used in the DPP was also effective in the reduction of cardiovascular disease risk factors. 7 While translation efforts have focused on delivery of adaptations of the DPP lifestyle intervention by a variety of individuals, 8-14 implementation by trained diabetes educators using their existing physician referral networks has not been widely examined. With the growing number of people at risk for type 2 diabetes and cardiovascular disease, 15 it will become increasingly more important to enhance the skill set of individuals already providing community-based health care services. Diabetes educators, with readily accessible networks for physician referral and connectivity within the community, offer another important link in planning for diabetes prevention on a large scale. Through a partnership with the military and with support from the Department of Defense, the Diabetes Prevention Support Center of the University of Pittsburgh was established to provide prevention services to both military and general populations. Subsequently, the center is following the successful intervention training and support scheme utilized in the DPP by acting as a central training center for intervention delivery via workshops, as well as provision of subsequent posttraining support for implementation. 13 At the core of these workshops is training in the delivery of a 12-session group-based behavioral lifestyle intervention called the Group Lifestyle Balance (GLB) program, which is modeled closely on the original 16-session DPP individual intervention. The GLB program, delivered by Diabetes Prevention Support Center trained prevention professionals, has been effectively implemented in several settings within the community 9,11,13,16 ; however, delivery of the GLB program by trained diabetes educators using existing physician referral networks has not been examined. The purpose of this project was to determine if highrisk individuals with prediabetes and/or the metabolic syndrome who participate in a GLB program delivered by trained diabetes educators at existing DSME communitybased program sites can reduce their risk factors for type 2 diabetes and cardiovascular disease. Methods Design This was a 1-group nonrandomized prospective pretest-posttest study design. The study design was specifically selected for evaluation of the effectiveness of the GLB program in this real-world setting, rather than a randomized controlled trial. While the randomized controlled trial design is fitting for clinical research trials evaluating efficacy of an intervention, it may be less appropriate in real-world translational research examining intervention effectiveness (National Institutes of Health, From Clinical Trials to Community conference, January Volume 37, Number 5, September/October 2011

3 A Community-Based Diabetes Prevention Program , 2004; 864EE73D-C876-4B30-A0EB-14E3911E2499/4589/ Confpublication.pdf). There are many barriers to randomized designs in the translational research setting, including political, practical, and ethical considerations. Because behavioral lifestyle intervention has already been shown to be efficacious in lowering risk for diabetes and cardiovascular disease, it could be perceived as being unethical to assign at-risk individuals to a control group. Setting This project was completed at 3 University of Pittsburgh Medical Center community-based DSME program sites. The first is located at a community hospital in a rural area about 2 hours north of Pittsburgh. The other sites are located in outpatient clinics within community hospitals: one in a suburban area outside of Pittsburgh and the other in an urban area near the city. Each site is an American Diabetes Association recognized DSME program, with nurse and dietitian diabetes educators who participated in this project. All but one of the educators was a certified diabetes educator. These sites receive a varying number of referrals for diabetes education each year, approximately 250 to 600 per year. Training All the diabetes educators attended a 2-day GLB training workshop provided by the Diabetes Prevention Support Center, which has been described previously. 13 Briefly, the center offers GLB training workshops for health care professionals, which cover all aspects of delivering the individual sessions, as well as the background and rationale for the DPP program and lifestyle goals. One component of the workshop focuses on leading groups as well as interactive discussion regarding implementation of the program in the attendee s local setting. Nurses and dietitians receive 12.5 contact hours for continuing education upon completion of the workshop, and all workshop attendees receive certificates of completion. After completion of the training workshop, the educators for this project were required to achieve a passing score of at least 85% on a comprehensive examination regarding the GLB program, and they were provided with a taped DVD series of the GLB to allow for review before delivery of the program as needed. Eligibility In keeping with a translational model, the eligibility requirements for this project were intentionally broad to allow for widespread recruitment of high-risk individuals from the community while ensuring that any person who was medically inappropriate for a lifestyle change program would be excluded. Nondiabetic individuals at least 25 years old with a body mass index 25 kg/m 2 who had prediabetes (defined as a fasting glucose mg/dl) 17 and/or the metabolic syndrome (National Cholesterol Education Program Adult Treatment Panel III definition) 18 were eligible for enrollment. The metabolic syndrome is defined as a clustering of abdominal obesity, atherogenic dyslipidemia, hypertension, and insulin resistance, and it is determined by having at least 3 of the following 5 conditions: elevated triglycerides ( 150 mg/dl), low HDL (high-density lipoprotein) cholesterol (< 40 mg/dl for men, < 50 mg/dl for women), large waist circumference (> 102 cm for men, > 88 cm for women), blood pressure 130/85 mm Hg (or treatment for hypertension), and elevated fasting plasma glucose ( 100 mg/dl). 18 For eligibility purposes, previous laboratory work completed in the medical setting within the year before enrollment was utilized for documentation of these conditions. Individuals with a previous diagnosis of diabetes, women who were currently (or within the past 6 weeks) pregnant or lactating, any person deemed by one s physician not to be a candidate, and any person planning to leave the area before the end of the study were not eligible. Recruitment Study recruitment began in September Diabetes educators at each site initiated the process of participant recruitment by contacting their existing network of primary care physicians and local endocrinologists with information about the study. The educators sent letters via direct postal mail and and held face-to-face educational sessions for physicians and staff members within the practices. It was anticipated that these physicians, already familiar with the community-based diabetes educators and referral process for patients with diabetes, would refer patients with prediabetes and the metabolic syndrome. To meet the number of participants needed on a tight study timeline, the diabetes educators also advertised in their local newspapers and posted program flyers at several community sites. Thus, physicians identified patients meeting the eligibility criteria and patients self-identified through local advertisement. The study protocol mandated that all interested individuals obtain a referral from their physician to the GLB program, to verify eligibility and to Kramer et al

4 The Diabetes EDUCATOR 662 provide confirmation that they were appropriate candidates for moderate physical activity in the GLB program. At the end of the 10-month recruitment period, a total of 121 referrals were received; 95 individuals were found to meet eligibility criteria; and 81 (85.3%) enrolled in the program. The number of enrolled participants varied by site, with 44, 20, and 17 enrolled in the rural, suburban, and urban sites, respectively. The study protocol received approval from the University of Pittsburgh Institutional Review Board, and all study participants completed informed consent. Intervention The GLB program is a 12-session group lifestyle intervention adapted from the DPP lifestyle intervention with the same goals for weight loss and physical activity as the DPP, including achievement of a weight loss of 7% from starting weight and an increase in physical activity to 150 minutes per week. 13 For the current project, GLBtrained diabetes educators delivered the GLB program over 12 to 14 weeks in groups of 7 to 16 participants. Participants met weekly at the outpatient hospital-based clinics with each session lasting approximately 1 hour; all participants received GLB participant handouts, weekly self-monitoring booklets, a fat- and calorietracking book, and a pedometer. At the conclusion of the 12 weekly sessions, participants were invited to attend group monthly meetings for weigh-in, collection of physical activity minutes, and review of relevant topics. Outcome Measures The primary outcomes of the intervention were weight loss and achievement of the study goals. Secondary outcome measures included changes in glucose, HDL cholesterol, low-density lipoprotein (LDL) cholesterol, and triglyceride levels, as well as abdominal obesity and hypertension status. Enrolled participants completed baseline and postintervention assessment visits. The postintervention visit occurred approximately 3 to 4 months postenrollment upon conclusion of the 12 sessions. The follow-up of participants, including 6- and 12-month postintervention assessments, is ongoing. The diabetes educators received training from the Diabetes Prevention Support Center in outcomes measures assessment and collected all clinical measures for the project. Blood pressure was measured in a sitting position in the right arm after resting for 5 minutes. First-appearance and last-heard (phase V) Korotkoff sounds were used to define the pressure readings; the measures were repeated twice, with a 30-second wait between each reading. 19 An average of the first and second readings was computed. Height and weight were measured twice without shoes, with the average computed; body mass index was calculated as average weight divided by average height squared (kg/m 2 ). Waist circumference was measured at the midpoint between the lower rib margin and the iliac crest; the measurement was repeated twice and the average computed. Total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, and fasting plasma glucose were measured after at least an 8-hour fast at local laboratories, and medication use was assessed via participant interview. In addition, participants were weighed weekly at each group session. Statistical Analysis The GLB program was shown to be effective in reducing weight, waist circumference, body mass index, and glucose from previous evaluations. 13 Based on the weight loss seen and similar to the trend seen in the DPP at approximately 3 months, it was estimated that enrollment of 96 participants would permit > 99% power with α = 0.05 to detect a 3.5% and/or 7% weight loss and > 92% power to detect a 6% change in glucose. As such, these numbers would allow for 25% participant attrition, still permitting > 99% power for 3.5% and for 7% weight loss and 85% power for change in glucose. Preintervention and postintervention measures of the achievement of a 7% weight loss were assessed. In addition, the presence of the metabolic syndrome was examined. Primary analyses were conducted on an intention-totreat basis, which means that all participants were included regardless of whether they completed the follow-up assessment visit (n = 81). To handle missing data, we used methodology based on last observation carried forward for participants who did not attend the postassessment visit. Secondary subgroup (per protocol) analyses were also performed for those who attended the postassessment visit (n = 68). The mean change between preintervention and postintervention measures was analyzed using the t test when change data were normally distributed (intention-totreat population: diastolic blood pressure; per protocol population: systolic blood pressure, diastolic blood pressure, HDL cholesterol); however, for most measures, the nonparametric Wilcoxon matched-pairs signed-rank test Volume 37, Number 5, September/October 2011

5 A Community-Based Diabetes Prevention Program 663 Table 1 Baseline Characteristics for Total Group Male (n = 10) n (%) Female (n = 71) n (%) Total (n = 81) n (%) Age, y a 52.3 (39-66) 53.0 (26-80) 52.9 (26-80) White 9 (90) 69 (97) 78 (96) Employed full-time/part-time 6 (60) 54 (76) 60 (74) Education High school/ged 1 (10) 17 (24) 18 (22) Some college/technical school 5 (50) 32 (45) 37 (46) College graduate 1 (10) 17 (24) 18 (22) Graduate degree 3 (30) 5 (7) 8 (10) Smoking 1 (10) 6 (8) 7 (9) Family history Diabetes 4 (40) 38 (54) 42 (52) Heart disease 2 (20) 49 (69) 51 (63) Prediabetes (glucose, mg/dl) 6 (7) 34 (42) 40 (49) a Mean (range). was used. Correlations between number of sessions attended and continuous demographics were calculated with Spearman correlation coefficient r since the number of attended sessions was not normally distributed. Correlations for categorical demographics were analyzed with the Wilcoxon test. Mixed-model analysis was used to evaluate the change of weight during the intervention to control for relevant covariates. McNemar test was used to assess the change of categorical variables (eg, lifestyle) between preintervention and postintervention. Participants with changes in medication use during the course of the intervention for the condition evaluated were excluded from appropriate specific analyses. Analyses were carried out using the SAS statistical package (version 9.1, SAS Institute, Cary North Carolina, USA). Results Baseline characteristics for the 81 participants in the study are presented in Table 1. The majority were non- Hispanic white (n = 78, 96%), female (n = 71, 88%), and an average of 53 years old (range, years). Approximately three-fourths of the group were employed full-time or part-time, and about one-third had received a college degree or higher. Fifty-two percent reported a family history of diabetes, and 63% reported a family history of heart disease. Only 7 participants (9%) reported smoking. Almost half the participants demonstrated a fasting glucose in the prediabetes range at baseline (n = 40, 49%). Participants attended a median of 10 of the 12 sessions, with 84% (n = 68) attending at least half the sessions (median number of sessions for this group equaled 11). The number of sessions attended was positively correlated with weight loss (P <.001). Attendance was also correlated with sex; men attended a higher median number of sessions than women (P =.04). Attendance was not related to age, employment status, education, or family history of diabetes or heart disease. Specific results of the baseline and postintervention comparisons for the entire group are shown in Table 2. Overall weight loss for the group was 5.1% ( 11.3 lb, P <.001), with a significant decrease in waist circumference Kramer et al

6 The Diabetes EDUCATOR 664 ( 1.8 in., 4.0%, P <.001) and body mass index ( 1.8 kg/m 2, 5.0%, P <.001). In addition, significant decreases were noted in total cholesterol ( 10.9 mg/dl, 5.5%, P =.001), LDL cholesterol ( 4.6 mg/dl, 3.9%, P =.04), triglycerides ( 19.4 mg/dl, 11.3%, P <.001), glucose ( 2.9 mg/ dl, 2.8%, P =.04), systolic blood pressure ( 7.1 mm/hg, 5.5%, P <.001), and diastolic blood pressure ( 2.7 mm/ Hg, 3.3%, P =.001). Based on mixed models, participant weight loss was estimated at 1.1 lb per week (P <.001) after adjusting for starting body weight and participating clinic. Results for those who attended both the baseline and the postassessment visits (n = 68) are also shown in Table 2. Average weight loss for this group was 5.8% ( 13.1 lb, P <.001), with similar significant decreases noted in all the measures noted above. Weight loss achievement was evaluated for the total group as well as for those who completed both baseline and postintervention assessment. For the total group (n = 81), 26 participants (32.1%) reached 7% weight loss at the postintervention assessment, while 34 (42.0%) and 49 (60.5%) achieved 5% and 3.5%, respectively. For the completer group (n = 68), 25 (36.8%) reached 7%; 33 (48.5%) reached 5%; and 48 (70.6%) reached 3.5% weight loss. For participants who completed both baseline and postintervention assessments (n = 68), 35 (51.5%) reported completing an average of at least 150 minutes of physical activity per week at the postintervention assessment. The proportion who reported performing physical activity at least 3 times per week increased significantly between baseline and postintervention assessment (47.0% vs 89.4%, P <.001). In addition, a significantly higher proportion reported tracking physical activity (13.2% vs 89.7%, P <.001), food intake (16.4% vs 92.5%, P <.001), and self-monitoring weight (38.2% vs 92.7%, P <.001) at least once a week between baseline and postintervention assessment. Participant use of medication for treatment of hypertension, hypercholesterolemia, and hypertriglyceridemia was also examined. There was no statistically significant change between baseline and postintervention assessment in the proportion of individuals reporting medication use for treatment of hypertension or hypercholesterolemia; however, a trend for decrease in the proportion of those utilizing medication for treatment of hypertriglyceridemia was noted (7.3% vs 2.9%, P =.08). Cost Although a formal cost evaluation was not completed for this project, cost for delivery of the GLB program by diabetes educators may be estimated. Diabetes educators in Pennsylvania report a median annual income of approximately $ to $ With a midpoint salary of $ plus 30.2% fringe benefit rate, 21 diabetes educators in Pennsylvania cost employers approximately $35 per hour. An estimated 3 hours per week were spent by the diabetes educators in the delivery of the initial 12 sessions, and it is anticipated that the same number of hours per session would be required each month for delivery of the remaining 9 monthly sessions. Thus, the total number of diabetes educator hours needed to deliver the program over the course of 1 year is 63 hours, for a total of $2205 per group. For an average of 8 participants per group, the cost per participant for the yearlong program would be approximately $275 per participant. In addition, the cost of the program materials, including a fat- and calorie-tracking book, pedometer, and participant binder with session handouts, was computed to be approximately $25 per participant. An additional $20 per participant was budgeted to provide a small lifestyle toolbox for healthy foods for taste testing during the sessions, as well as to provide small incentives or enabling items such as table scales, measuring cups and spoons, exercise DVDs, etc. Thus, the total cost per participant for delivery of the GLB program provided by trained diabetes educators for this project over the course of a year is an estimated $320 per participant. Conclusion The results of this translation project demonstrate that trained diabetes educators who delivered the GLB program in their community-based DSME programs are effective in helping high-risk individuals reduce their risk factors within a relatively short time frame (ie, 3-4 months). A significant overall decrease in weight and increase in reported physical activity were noted, as well as significant decreases in multiple risk factors for diabetes and cardiovascular disease. These results are similar to other DPP translation efforts. Amundson et al 12 adapted the DPP for implementation by trained dieticians and exercise science professionals in 4 health care facilities associated with American Diabetes Association recognized Volume 37, Number 5, September/October 2011

7 Table 2 Postintervention Results for Total Group and Completers All Participants (n = 81) Completers (n = 68) Variable n Baseline Posttest Change Change, % P n Baseline Posttest Change Change, % P Weight, lb ± ± ± < ± ± ± <.001 Waist, in ± ± ± < ± ± ± <.001 Body mass index, ± ± ± < ± ± ± <.001 kg/m 2 Cholesterol, mg/dl Total b ± ± ± ± ± ± HDL b ± ± ± ± ± ± LDL b ± ± ± ± ± ± Triglycerides b ± ± ± < ± ± ± <.001 Fasting plasma glucose, b mg/dl ± ± ± ± ± ± Blood pressure, mmhg Systolic b ± ± ± < ± ± ± <.001 Diastolic b ± ± ± ± ± ± <.001 a Results are from the t test. When data were not normally distributed, the nonparametric equivalent (Wilcoxon matched-pairs signed rank test) was used. b Participants with medication changes were excluded from the analysis. 665

8 The Diabetes EDUCATOR 666 diabetes education programs, for adults at high risk for diabetes and cardiovascular disease. The authors reported an average weight loss of 6.7% for those who completed the program, with 45% achieving the 7% weight loss goal. In another DPP community translation, Pagoto et al demonstrated an overall 4.6% weight loss in overweight individuals, with 30% of the study group meeting the 7% weight loss goal in a hospital-based adaptation of the DPP. 22 In a faith-based DPP translation project, study participants lost an average of 3.6% from baseline, 23 while the DEPLOY pilot study demonstrated an average weight loss of 6% in at-risk individuals who completed the baseline and postintervention assessments. 10 There are several benefits in having trained diabetes educators deliver diabetes prevention intervention. The diabetes educator is already an established link between the patient and the physician, which may facilitate the enrollment of at-risk patients into a prevention intervention program. This link may also aid in feedback and communication among the entire health care team to better serve the overall health of the at-risk individual. Furthermore, diabetes educators have experience in management of the comorbidities that are often present in individuals at risk for diabetes; interaction with an educator provides the opportunity to address these health problems simultaneously and possibly sooner than what would otherwise occur. For those who do convert to diabetes, the diabetes educator provides an excellent resource and contact to allow for earlier education for diabetes self-management care. To implement diabetes prevention intervention on a broad scale, it will be essential to consider the cost of prevention delivery in the community. While it is often assumed that delivery of prevention intervention by health professionals will be costly, there is in fact limited information regarding the cost of delivery of diabetes prevention intervention in real-world versus clinical research settings. In a recent publication, the GLB program was shown to be cost-effective when delivered by health care professionals in the community. 24 For the current project, although a formal cost evaluation was not conducted, the average cost for delivery of the GLB program was estimated to be $320 per participant, including 12 weekly and 9 monthly follow-up sessions, as well as materials, supplies, and toolbox items. The GLB program was calculated in a previous report to cost approximately $300 per participant for 1 year when delivered in the primary care practice and clinical setting. 13 These approximated costs are similar to the estimated cost ($275-$325) of the adapted DPP program being implemented within the YMCA by lay workers. 25 While it is essential to consider the cost of the actual delivery of prevention programs, it is critical to take into account the effort required for patient recruitment for lifestyle intervention programs. For this project, patients at risk for diabetes and cardiovascular disease were enrolled in the GLB lifestyle intervention program primarily via physician referral, thus utilizing existing physician networks. This proved to be an effective method for identification of patients at risk for type 2 diabetes and cardiovascular disease. In addition, because of the limited timeline for study recruitment, diabetes educators directly targeted the public via newspaper advertisement for self-identification. This combined effort highlights the importance of a multifaceted plan for recruitment of individuals at high risk, and demonstrates that people may be efficiently identified for lifestyle intervention programs via methods other than conducting large screenings, which would likely involve additional costs for supplies, materials, and staff time. Utilization of a referral system and methods other than screening have been successfully employed in other diabetes prevention translation efforts. 26 As we move forward with widespread community-based efforts for prevention in a variety of settings, it will be increasingly important to examine all components of delivery to determine costeffectiveness. Several limitations should be mentioned. This study did not include a control group but rather utilized a nonrandomized 1-group prospective design. The study sample size was relatively small and was conducted in a predominantly nondiverse population, and although it was conducted in rural, suburban, and urban areas, the results may not be generalizable on a broad scale. Furthermore, while the results of this project are encouraging, the period of evaluation was relatively short. The study participants are being followed over a 12-month period, and evaluation of long-term results is planned. In addition, no formal cost analysis was completed, and the cost estimates, while appropriate for Pennsylvania, may not be applicable to other areas. Finally, the physical activity data collected were self-reported. As lifestyle intervention efforts for diabetes prevention and risk reduction gain momentum, the importance of a diverse environment for intervention program Volume 37, Number 5, September/October 2011

9 A Community-Based Diabetes Prevention Program 667 delivery cannot be overemphasized. To reach the largest number of individuals at risk, a variety of venues for delivery will be needed. Diabetes educators, already integrated within the existing health care system, provide yet another resource for delivery of primary prevention programs in the community and could play an important role in widespread prevention dissemination. Implications The results of this project provide several implications for translation of preventive lifestyle programs in already-established DSME community programs. First, these results suggest that trained diabetes educators can effectively deliver a behavioral lifestyle intervention program for individuals at risk within their existing DSME setting. The use of trained diabetes educators, as well as other health professionals, will be essential as we gear up for large dissemination of prevention efforts. Second, there are several advantages to trained diabetes educators delivering diabetes prevention intervention programs. Most notably, the existing relationship between the diabetes educator and the health care provider may likely facilitate a cohesive relationship among the entire prevention team to improve individual patient care. Third, physician referral appears to be an effective method for identification of individuals at risk for diabetes; diabetes educators are already in position to receive referrals, thus saving cost and time on other recruitment methods such as risk assessment screenings. Other methods that directly target the public, such as local advertisement, may need to be employed in conjunction with physician referral. A 2-pronged approach that focuses on physicians and the public will facilitate awareness and subsequent enrollment of high-risk individuals in preventive lifestyle change programs. Finally, the use of trained diabetes educators for delivery of behavioral lifestyle intervention programs may be similar in cost to programs led by other types of behavioral lifestyle intervention group leaders, including lifestyle programs offered through the YMCA by lay coaches and other DPP adaptations delivered by a variety of health professionals. This may be particularly true when the cost of screening is considered. As we move forward with prevention on a large scale in the United States, it will be critical to ensure that diabetes educators trained in the delivery of behavioral lifestyle intervention are integrated into these efforts. References 1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, Available online at 2. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care. 1997;20: Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344: Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346: Ramachandran A, Snehalatha C, Mary S, et al. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006;49: Orchard TJ, Temprosa M, Goldberg R, et al. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med. 2005;142: Diabetes Prevention Program Research Group. Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Diabetes Care. 2005;28: Whittemore R, Melkus G, Wagner J, et al. Translating the diabetes prevention program to primary care: a pilot study. Nurs Res. 2009;58: Seidel MC, Powell RO, Zgibor JC, Siminerio LM, Piatt GA. Translating the Diabetes Prevention Program into an urban medically underserved community: a nonrandomized prospective intervention study. Diabetes Care. 2008;31: Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the Diabetes Prevention Program into the community: the DEPLOY Pilot Study. Am J Prev Med. 2008;35: McTigue KM, Conroy MB, Bigi L, Murphy C, McNeil M. Weight loss through living well: translating an effective lifestyle intervention into clinical practice. Diabetes Educ. 2009;35: Amundson HA, Butcher MK, Gohdes D, et al. Translating the Diabetes Prevention Program into practice in the general community: findings from the Montana Cardiovascular Disease and Diabetes Prevention Program. Diabetes Educ. 2009;35: Kramer MK, Kriska AM, Venditti EM, et al. Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery. Am J Prev Med. 2009;37: Davis-Smith YM, Boltri JM, Seale JP, et al. Implementing a diabetes prevention program in a rural African-American church. J Natl Med Assoc. 2007;99: Diabetes Atlas Committee. Diabetes Atlas. 4th ed. Montreal, Canada: International Diabetes Federation; Dodani S, Fields JZ. Implementation of the Fit Body and Soul, a church-based life style program for diabetes prevention in highrisk African Americans. Diabetes Educ. 2010;36: Kramer et al

10 The Diabetes EDUCATOR American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2004; 27(suppl 1):S5-S Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285: Bohani N, Kass EH, Langford HG, Payne GH, Remington RD, Stamler J. The Hypertension Detection and Follow-up Program. Prev Med. 1976;5: PayScale. Median salary by state or province. Job: certified diabetes educator (CDE) Job=Certified_Diabetes_Educator_%28CDE%29/Salary/by_State. 21. Employee Benefit Research Institute. Employer benefit costs for all civilian employees benfaq/index.cfm?fa=ovfaq Pagoto SL, Kantor L, Bodenlos JS, Gitkind M, Ma Y. Translating the diabetes prevention program into a hospital-based weight loss program. Health Psychol. 2008;27(1):S91-S Boltri JM, Davis-Smith YM, Seale JP, et al. Diabetes prevention in a faith-based setting: results of translational research. J Public Health Manag Pract. 2008;14: Smith K, Hsu HE, Roberts MS, et al. Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, Prev Chronic Dis. 2010;7(5):A Ackermann RT, Marrero DG. Adapting the Diabetes Prevention Program lifestyle intervention for delivery in the community. Diabetes Educ. 2007;33: Vadheim LM, Brewer KA, Kassner DR, et al. Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community. J Rural Health. 2010;26: For reprints and permission queries, please visit SAGE s Web site at TDE411930The Diabetes EDUCATORA Community-Based Diabetes Prevention Program Volume 37, Number 5, September/October 2011