Although diabetes-related mortality has declined in recent years, the continued rise in prevalence and incidence has resulted in increases in the overall public health burden and highlights the need for effective diabetes prevention interventions [4
]. While the DPP provided compelling evidence that weight loss achieved through lifestyle behavioral interventions can decrease the risk of diabetes incidence in individuals at high risk for diabetes, additional research is needed to determine whether this approach can be effectively translated into a community-based, cost-effective, and sustainable model.
Several efforts to translate the DPP have recently been published. The DEPLOY study [10
] partnered with local YMCAs to translate the DPP for use in the community. Similar to the present study, this study used a group-based modification of the DPP program; however, trained YMCA wellness staff, as opposed to community health workers, delivered the intervention. Boltri and colleagues [12
] translated the DPP program through an African-American church and used volunteer medical personnel to deliver the intervention. McTigue and colleagues delivered a group-based DPP via a large academic hospital [13
]. The Montana Cardiovascular Disease and Diabetes Prevention Program [14
] utilized a variety of community-health care facility partnerships (e.g., hospital, YMCA) across diverse urban and frontier communities to deliver a group-based modification of the 16-week core DPP intervention. Additionally, the intervention staff were dietitians and health professionals. Estabrooks and colleagues attempted to deliver the DPP via an automated telephone system [11
]. Comparisons across studies are difficult due to a) the diverse methods and translational approaches; b) limited available outcome data; and c) relatively short-term follow up. In general, these approaches have shown to be successful in producing short-term, clinically significant weight loss, but it is unknown at this time whether they are effective at preventing diabetes, the effects are sustainable, or whether they are more cost-effective as compared to the DPP.
Although not a translation of the DPP, the PATHWAYS study should also be noted [45
]. This study delivered a group-based, 14-week weight loss program aimed at diabetes prevention for African-American women at risk for diabetes (n = 39) delivered through churches and led by lay health facilitators. Participants in the weight loss group (n = 15) lost an average of 5% of their baseline weight following treatment. Information on changes in other metabolic and cardiovascular changes was not provided. Although this study demonstrates the efficacy of lay health facilitators in delivering a weight loss intervention, the small sample size and short term follow-up precludes meaningful conclusions regarding large-scale effectiveness.
We believe we have made several unique and important modifications to the DPP to enhance translation and dissemination. First, the overarching goal of the present study is to test a translation of the DPP that is completely administered, implemented, and delivered via existing community resources. The program is administered by an existing DCC and delivered by CHWs. Furthermore, the DCC staff was responsible for CHW training, the on-going supervision of the CHWs, and continuous participant management. Study-specific staff focus on research-specific activities (e.g., recruiting, outcome assessments) and contact with the intervention occurs via DCC staff. Thus, to maximize translation, we are seeking to minimize the contributions of research resources (e.g., research staff, investigators) and maximize the responsibilities of community-based staff (i.e., DCC, CHWs). We seek to create a translational model that can be generalized and implemented in any community with a DCC with minimal influence of the research-specific resources, staff, and investigators.
Second, placing community-based diabetes prevention programs in existing Diabetes Education Programs (DEPs) provides a rapid dissemination channel. DCCs and DEPs already exist in many communities and include staff with most of the skills needed to implement the proposed DPP model. Furthermore, DEPs have access to patients with diabetes mellitus (DM) who have made successful lifestyle changes, and who could be effective CHWs.
It should be noted, however, that our intervention is in some ways more intensive than the original DPP and the aforementioned translational studies. That is, whereas the DPP involved a 16-week core curriculum and monthly maintenance contacts (either in-person or via telephone), we use a 24-week intensive phase and monthly group and telephone contacts for an additional 18 months. However, the DPP also involved supervised, center-based physical activity sessions (2 times per week). The present study does not include supervised physical activity sessions. Although the physical activity sessions provided in the DPP were voluntary, they certainly added to overall consumption of resources and additional participants contacts. We hope to determine whether these differences influence our program effectiveness and costs.
Our partnership with an established diabetes care organization also provides us with widespread potential for dissemination via diabetes professional organizations. The CHW identification and training modules we have developed can be disseminated through the American Association of Diabetes Educators (AADE) to address gaps in the knowledge and skills of diabetes educators, especially the process of identifying, recruiting, training, supporting and monitoring CHWs. The AADE can also disseminate our CHW support materials, including the videos. The use of a group-based, rather than an individual-based, intervention reduces the cost of intervention delivery. If this modified approach is successful, the lower cost will enhance dissemination as well. Use of fasting glucose and body mass index, rather than results from an oral glucose tolerance test, to identify persons eligible for the community-based DPP represents another translation- and dissemination-friendly modification. All of our materials can be disseminated easily through web-based methods and other strategies in partnership with the AADE, the National Diabetes Education Program, and other partners. Successful dissemination will be dependent on changes in reimbursement policies for the services provided. Reimbursement for diabetes education provides a useful model for application to the proposed community-based diabetes prevention education program, as this reimbursement covers a limited number of individual sessions and a greater number of group sessions.
This project will provide critical information regarding the effectiveness of a community-based, intensive behavioral intervention for the prevention of type 2 DM, including metabolic and behavioral outcomes, and cost. If the proposed approach is cost-effective, this information would support the development of health care policies to provide for the reimbursement of community-based diabetes prevention program services, thereby enabling the rapid dissemination of this model to the thousands of communities with DEPs in the US. Because many chronic diseases are influenced by activity and diet, this approach should translate into public health benefits in areas other than type 2 DM, such as obesity, hypertension, cardiovascular health and cancer prevention, thus greatly multiplying the potential benefits for society and serving as a model for community-based health promotion programs.