The HELP PD study was innovative in successfully translating the Diabetes Prevention Program into a community setting although maintaining significant improvements in intervention outcomes over a 12-month period.18
Relative to the usual care group, quantitative data obtained from intervention participants indicated that their participation in HELP PD more positively influenced the eating and exercise habits of their SSPs. In addition, the amount of weight lost by participants was related to PC in their SSPs’ eating habits, as well as whether or not this change was perceived to be favorable. Though these results are based on participants’ perceptions, they suggest, to some extent, that successfully targeting the eating and exercise habits of individual HELP PD participants may have indirectly resulted in compensatory change in the habits of other nonparticipating members of their social support system.
In qualitative analysis, the 3 emergent themes characterized how participants perceived their participation to influence their SSPs: descriptions of SSP lifestyle changes, methods of knowledge dissemination, and forms of SPPs’ motivation. Within these broad themes, participants expressed ideas concerning SSPs’ eating and exercise behaviors, emotional changes, disease prevention, communication about health behaviors and exchange of information, and direct and indirect methods of SSPs’ motivation. Differences in responses between intervention and control groups included discrepancies in PCs in SSPs’ eating and exercise behaviors, the methods by which participants conveyed information, and the frequency with which participants considered themselves to be role models for the SSPs.
Given that most studies of this nature have examined health benefits gained when subjects in behavioral programs participate concurrently with friends or family members,12-14,16
this study provides a unique perspective on whether such benefits can be disseminated from program participants, like those in HELP PD, to members of their social support system. Although it is important to keep in mind that these data are reflective of participants’ perceptions
of SSP behaviors, the consistency of participant responses suggest that some beneficial influences likely occurred in SSPs’ actual health habits.
A similar study has shown that clinically significant outcomes can be achieved in untreated family members of individuals undergoing a behavioral weight loss program; however, their investigation was limited to spouses residing in the same home as the program participant.15
The current study is the first of its kind to examine the effects of a weight loss program on a variety of untreated persons in an individual's social support system. Furthermore, findings suggest not only a significant association between individuals’ participation in a behavioral lifestyle intervention and their perceived ability to positively influence SSPs’ lifestyles, but also that these perceptions contain recurring and insightful themes.
Although intervention and control participants’ qualitative responses contained many similar themes, there were notable differences in the way intervention participants described mechanisms of knowledge dissemination and their roles as “examples” for SSPs. These results shed light on the key ways in which participation in the intervention may have influenced SSPs. Given that intervention participants reported discussions with SSPs, and also provided advice about eating and exercise with much greater frequency than control participants, participation in the intervention may have enabled participants to more effectively share knowledge acquired from HELP PD. Similarly, as intervention participants often perceived themselves as good examples for their SSPs, it is reasonable to assume that the intervention equipped them with skills and behaviors they then wished to model.
The findings from this study have clinical implications for future behavioral lifestyle interventions. It is well established that over-weight and obese individuals tend to cluster in familial and social groups.9-11
Our findings, coupled with other clinically significant outcomes observed in untreated spouses of weight loss participants,15
suggest that programs could be intentionally tailored to teach participants how to share health information to members of their social support network. Our finding that the amount of weight lost in the LWL intervention was related to participants’ PC and favorability of change in SSP's eating habits, provides an additional perspective to that of other studies, where participants who had some form of social support demonstrated better clinical outcomes.12-14
Therefore, a behavioral lifestyle intervention approach targeting both formally enrolled participants as well as their SSPs may enhance weight loss, and potentially other clinical outcomes, for both parties.
There are several limitations to the current study. Most notably, the qualitative methodology relied on subjective interpretation of questionnaire responses. Furthermore, it is important to note that participants in the HELP PD intervention were not explicitly encouraged to share their knowledge or skills learned in HELP PD, though we anticipate that this may have happened for some, and less for others. The HELP PD intervention included information on identifying social support for lifestyle changes and building an environment for long-term weight loss and weight maintenance. Thus, the nature of this intervention may have had an impact on family and social interactions in the home resulting in change to nutrition, exercise habits, and other weight-related behaviors. If participants did not find it necessary to share information with others in their social networks, it is less likely that these SSPs would have been influenced. In addition, the responses presented here are representations of participants’ perceptions of SSPs rather than actual measured change in behaviors, attitudes, or motivation. This study is also limited as it presumed SSPs to be external to the study, though 2 participants indicated that their SSPs were also HELP PD participants. Thus, it is difficult to know whether participants’ PCs in SSPs were due to the influence of the participant responding, the SSPs’ potential participation in the study, or a combination of both. Finally, this study is limited by sample size, as those who responded to questionnaires represent only a small percentage (24%) of the entire HELP PD study population. Although themes were consistent throughout the data, better insight may have been obtained with a larger sample size. However, it appeared saturation had been achieved, as no additional themes or information emerged as interviews and analysis progressed.
Regarding quantitative methodological limitations, interpretation of results may be limited by the fact that surveys not designed to detect at what time point knowledge dissemination may have occurred during the intervention. Enrollment in HELP PD began in 2007 and ended in 2009, with participants enrolled in groups of 20-25 to allow for formation of an intervention group every 4-6 weeks. This survey was collected during a 3-month period in the summer of 2009 during assessment visits that occurred semiannually. Therefore, participants were surveyed at different time points in their participation, ranging from 6 to 24 months, and had been exposed to the intervention for varying lengths of time. Whether or not this influenced survey responses is indeterminable. Additional limitations of the quantitative component of the HELP PD study at large have been published previously.18-20
These findings present many implications for future research, and contribute to a larger body of work suggesting a clinically significant relationship between those undergoing behavioral lifestyle interventions and members of their social support networks.12-14,16
Although this study provided insight regarding how behavioral intervention participants perceived their influence on SSPs, future interventions would benefit from understanding the actual perceptions of SSPs, as well. This type of inquiry would help determine if participants and SSPs agree on the type of influence exerted on each other, and identify discrepancies in perceptions that have yet to be delineated. Salient themes identified in this study, such as methods of knowledge dissemination and motivation, suggest that certain elements of lifestyle interventions may be specifically targeted to optimize results for both participants and their surrounding social support system. Furthermore, investigations into the role of SSPs in weight loss and diabetes prevention programs could be beneficial to pediatric populations as well. Given that studies of pediatric weight management programs indicate family-based approaches to be the most effective,22-25
investigating the social structure of families could elucidate further information about the role of SSPs within the family, and their influence on both children's and parents’ health behaviors.
The role of social support in behavioral lifestyle changes is still not fully understood. Through a mixed-methods approach, this study quantitatively examined how participants’ perceptions of their SSPs’ lifestyle changes related to their own participation and weight loss, and qualitatively identified themes extant within these perceptions. Results gleaned from this study in participants with prediabetes provide valuable insight on the indirect health influences exerted within social circles, potentially as a corollary of participation in a weight loss program. With such high prevalence of diabetes and obesity, prevention and treatment approaches must have greater reach to make a substantial impact on this epidemic, which may be achieved by influencing social circles. The results of this study provide guidance to those wishing to expand the reach of programs, and insight to the means of influencing the health behaviors of program participants and their support network. Additional research is warranted to fully elucidate the influence of these social interactions in supporting weight loss and diabetes prevention efforts.