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author:("Jiang, luhua")
1.  Demographic characteristics and food choices of participants in the Special Diabetes Program for American Indians Diabetes Prevention Demonstration Project 
Ethnicity & health  2014;20(4):327-340.
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.
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.
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.
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.
PMCID: PMC5108238  PMID: 24954106
American Indians/Alaska Natives; diabetes prevention; food choice
2.  Socioeconomic Disparities in Weight and Behavioral Outcomes Among American Indian and Alaska Native Participants of a Translational Lifestyle Intervention Project 
Diabetes Care  2015;38(11):2090-2099.
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.
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.
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 <$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.
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.
PMCID: PMC4613924  PMID: 26494807
3.  Duration of Adulthood Overweight, Obesity, and Cancer Risk in the Women’s Health Initiative: A Longitudinal Study from the United States 
PLoS Medicine  2016;13(8):e1002081.
High body mass index (BMI) has become the leading risk factor of disease burden in high-income countries. While recent studies have suggested that the risk of cancer related to obesity is mediated by time, insights into the dose-response relationship and the cumulative impact of overweight and obesity during the life course on cancer risk remain scarce. To our knowledge, this study is the first to assess the impact of adulthood overweight and obesity duration on the risk of cancer in a large cohort of postmenopausal women.
Methods and Findings
Participants from the observational study of the Women’s Health Initiative (WHI) with BMI information from at least three occasions during follow-up, free of cancer at baseline, and with complete covariate information were included (n = 73,913). Trajectories of BMI across ages were estimated using a quadratic growth model; overweight duration (BMI ≥ 25 kg/m2), obesity duration (BMI ≥ 30 kg/m2), and weighted cumulative overweight and obese years, which take into account the degree of overweight and obesity over time (a measure similar to pack-years of cigarette smoking), were calculated using predicted BMIs. Cox proportional hazard models were applied to determine the cancer risk associated with overweight and obesity duration. In secondary analyses, the influence of important effect modifiers and confounders, such as smoking status, postmenopausal hormone use, and ethnicity, was assessed. A longer duration of overweight was significantly associated with the incidence of all obesity-related cancers (hazard ratio [HR] per 10-y increment: 1.07, 95% CI 1.06–1.09). For postmenopausal breast and endometrial cancer, every 10-y increase in adulthood overweight duration was associated with a 5% and 17% increase in risk, respectively. On adjusting for intensity of overweight, these figures rose to 8% and 37%, respectively. Risks of postmenopausal breast and endometrial cancer related to overweight duration were much more pronounced in women who never used postmenopausal hormones. This study has limitations because some of the anthropometric information was obtained from retrospective self-reports. Furthermore, data from longitudinal studies with long-term follow-up and repeated anthropometric measures are typically subject to missing data at various time points, which was also the case in this study. Yet, this limitation was partially overcome by using growth curve models, which enabled us to impute data at missing time points for each participant.
In summary, this study showed that a longer duration of overweight and obesity is associated with an increased risk of developing several forms of cancer. Furthermore, the degree of overweight experienced during adulthood seemed to play an important role in the risk of developing cancer, especially for endometrial cancer. Although the observational nature of our study precludes inferring causality or making clinical recommendations, our findings suggest that reducing overweight duration in adulthood could reduce cancer risk and that obesity prevention is important from early onset. If this is true, health care teams should recognize the potential of obesity management in cancer prevention and that excess body weight in women is important to manage regardless of the age of the patient.
In a longitudinal study, Melina Arnold and colleagues assess the relationship between adulthood overweight and obesity duration and cancer risks in postmenopausal women.
Author Summary
Why Was This Study Done?
Excess weight has become the leading risk factor for disease burden in high-income countries and has been offsetting or surpassing the decreasing disease burden attributable to tobacco smoking. Excess weight has been linked to the development of several types of cancer.
To date, most studies exploring the relationship between excess weight and cancer risk looked at cross-sectional exposure information on overweight and obesity, i.e., height and weight measured at one point in time. Insights into the dose-response relationship of the cumulative impact of overweight and obesity during the life course on cancer risk remain scarce.
What Did the Researchers Do and Find?
This study examined how the timing, duration, and intensity of overweight and obesity during adulthood impacts on cancer risk, taking into account important information on other factors related to obesity, such as physical activity, diet, smoking, hormone use, and diabetes history.
A total of 73,913 women were included in the study, and 6,301 obesity-related cancers were diagnosed during a mean follow-up of 12.6 y. About two-thirds of all included women were ever overweight or obese during adulthood.
The study found that being overweight for a longer duration during adulthood significantly increased the incidence of all obesity-related cancers by 7% (for every ten-year increase in adulthood overweight duration), of postmenopausal breast cancer by 5%, and of endometrial cancer by 17%. After adjusting for the intensity of overweight (that is, how overweight individuals were), these figures rose to 8% for postmenopausal breast cancer and 37% for endometrial cancer (for every ten years spent with body mass index ten units above normal weight).
What Do These Findings Mean?
How much of their adult lives women are overweight and how overweight they are play important roles in cancer risk. This finding highlights the importance of obesity prevention at all ages and from early onset.
PMCID: PMC4987008  PMID: 27529652
4.  Translating an Evidence-Based Diabetes Education Approach Into Rural African-American Communities: The “Wisdom, Power, Control” Program 
Purpose. The aim of this exploratory study was to assess the efficacy of the “Wisdom, Power, Control” diabetes self-management education (DSME) program with regard to diabetes knowledge, self-efficacy, self-care, distress level, and A1C in an African-American population.
Methods. A prospective, quasi-experimental, repeated-measure design was employed to measure these outcomes. Study participants were assessed at baseline, 6 weeks post-intervention, and at a 3-month A1C follow-up.
Results. A total of 103 participants were recruited from the intervention counties, and 14 were identified from the control counties. At the post-test, participants in the intervention group reported a significantly higher level of diabetes knowledge (Δ = 9.2%, P <0.0001), higher self-efficacy (Δ = 0.60, P <0.0001), more self-care behaviors (Δ = 0.48, P <0.0001), lower distress level (Δ = –0.15, P = 0.05), and higher health status (Δ = 0.49, P = <0.0001). About 56% of the intervention group completed all six classes, and 25% attended five classes.
Conclusions. Findings from this study demonstrate the initial success of translating a culturally adapted DSME program into rural African-American communities. The study highlights important lessons learned in the process of implementing this type of program in a real-world setting with a minority population.
PMCID: PMC4433078  PMID: 25987809
5.  Participant and Site Characteristics Related to Participant Retention in a Diabetes Prevention Translational Project 
Using multi-level analysis, this study investigated participant and site characteristics associated with participant retention in a multi-site 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 01/01/2006 and 07/31/2008. They were offered the 16-session Lifestyle Balance Curriculum from the Diabetes Prevention Program (DPP) in the first 16-24 weeks 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 07/31/2009, about 50% 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.
PMCID: PMC4081526  PMID: 24384689
Attrition; Dropout; American Indians and Alaska Natives; Lifestyle intervention; Community-based settings
6.  Texercise select effectiveness: an examination of physical activity and nutrition outcomes 
Given the role of physical activity (PA) and good nutrition to delay the onset and progression of most chronic conditions, effective interventions are needed to influence lifestyle behaviors of community-dwelling populations. The purpose of this study is to examine the effectiveness of Texercise Select to improve health indicators, PA, and dietary behaviors, and confidence to engage in healthful behaviors. Texercise Select, a 12-week exercise program, was delivered. Baseline and 12-week follow-up assessments were collected from 220 participants with baseline data who were aged 45 years and older for this non-randomized one-group pre-post design trial. Linear mixed models were fitted for continuous outcome variables and GEE models with logit link function for binary outcome variables. Significant improvements (P < 0.05) were seen in physical activity scores (d = 0.64 for aerobic activity), weekly fruit/vegetable consumption (d = 0.31), daily water consumption (d = 0.29), as well as PA- and nutrition-related confidence (d =0.38 and 0.21, respectively) and social support (d =0.45). Programs rooted in best practices show promise for positively impacting large numbers of participants and becoming sustainably embedded in communities over time.
PMCID: PMC4656227  PMID: 26622916
Program evaluation; Physical activity; Nutrition; Older adults
7.  Psychosocial Predictors of Weight Loss among American Indian and Alaska Native Participants in a Diabetes Prevention Translational Project 
Journal of Diabetes Research  2015;2016:1546939.
The association of psychosocial factors (psychological distress, coping skills, family support, trauma exposure, and spirituality) with initial weight and weight loss among American Indians and Alaska Natives (AI/ANs) in a diabetes prevention translational project was investigated. Participants (n = 3,135) were confirmed as prediabetic and subsequently enrolled in the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) demonstration project implemented at 36 Indian health care programs. Measures were obtained at baseline and after completing a 16-session educational curriculum focusing on weight loss through behavioral changes. At baseline, psychological distress and negative family support were linked to greater weight, whereas cultural spirituality was correlated with lower weight. Furthermore, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss, over the course of the intervention. These bivariate relationships between psychosocial factors and weight remained statistically significant within a multivariate model, after controlling for sociodemographic characteristics. Conversely, coping skills and trauma exposure were not significantly associated with baseline weight or change in weight. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporating adjunctive intervention components.
PMCID: PMC4662977  PMID: 26649314
8.  Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program 
To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization.
Retrospective observational study.
We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119).
Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson’s correlation coefficient were used to evaluate concordance.
The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69–0.79), moderate concordance for ED care utilization (κ = 0.45–0.61), and generally low agreement for number of physician visits (κ ≤ 0.31).
Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.
PMCID: PMC4597005  PMID: 26501047
aging; chronic disease; claims data; disease management; health services
9.  Stress Burden and Diabetes in Two American Indian Reservation Communities 
Diabetes care  2007;31(3):427-429.
To examine the association between psychosocial stress and diabetes in two American Indian reservation communities (Northern Plains and Southwest).
The American Indian Services Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP), a cross-sectional probability sample survey, interviewed 3,084 randomly selected members of two American Indian tribal groups. Included were a psychiatric epidemiological interview, a physical health problems checklist, and an extensive sociodemographic section.
Stress was common in these reservation communities, and the stress burden was greater among those with diabetes. After adjusting for sociodemographic characteristics, early-life interpersonal trauma and community family dysfunction were significantly associated with increased odds of diabetes in the Northern Plains, while discrimination and community addiction problems were significantly associated with increased odds of diabetes in the Southwest.
A number of psychosocial stresses were significantly associated with increased odds of self-reported diabetes in these two American Indian communities.
PMCID: PMC4530979  PMID: 18070997
10.  Multilevel Context of Depression in Two American Indian Tribes 
Depression is a major debilitating disease. For American Indians living in tribal reservations, who endure disproportionately high levels of stress and poverty often associated with depression, determining the patterns and correlates is key to appropriate clinical assessment and intervention development. Yet, little attention has been given to the cultural context of correlates for depression, including the influence of family, cultural traditions or practices, or community conditions.
We used data from a large representative psychiatric epidemiological study among American Indians in two reservation communities to estimate nested individual and multilevel models of past-year Major Depressive Episode (MDE) accounting for family, cultural, and community conditions.
We found that models including culturally informed individual-level measures significantly improved the model fit over demographics alone. We found significant community-level variation in the probability of past-year MDE diagnosis in one tribe even after accounting for individual-level characteristics.
Accounting for culture, family, and community context will facilitate research, clinician assessment, and treatment of depression in diverse settings.
PMCID: PMC4459211  PMID: 24016293
Depression; American Indian; culture; multilevel
11.  Factors Associated with Successful Completion of the Chronic Disease Self-Management Program among Middle-Aged and Older Asian-American Participants: A National Study 
Asian-Americans are a small but fast-growing population in the United States who are increasingly experiencing multiple chronic diseases. While the evidence-based Chronic Disease Self-Management Program (CDSMP) has been disseminated among various racial and ethnic populations, few studies specifically investigate participants with an Asian background. The study aims to identify characteristics of middle-aged and older Asian-American CDSMP participants (older than 50 years) and investigate factors related to successful workshop completion (i.e., attending 4+ of the 6 sessions) among this population. Data were analyzed from 2,716 middle-aged and older Asian-Americans collected during a 2-year national dissemination of CDSMP. Multilevel logistic regression analyses were conducted to identify individual- and workshop-level covariates related to successful workshop completion. The majority of participants were female, living with others, and living in metro areas. The average age was 71.3 years old (±9.2), and the average number of chronic conditions was 2.0 (±1.5). Successful completion of CDSMP workshops among participants was associated with their number of chronic conditions (OR = 1.10, P = 0.011), living in non-metro areas (OR = 1.77, P = 0.009), attending workshops from area agencies on aging (OR = 1.56, P = 0.018), and attending a workshop with higher completion rates (OR = 1.03, P < 0.001). This study is the first large-scale examination of Asian-American participants enrolled in CDSMP and highlights characteristics related to intervention attendance among this under-studied minority population. Knowing such characteristics is important for serving the growing number of Asian-Americans with chronic conditions.
PMCID: PMC4410260  PMID: 25964933
Asian-Americans; chronic disease management; Chronic Disease Self-Management Program; evidence-based programs
12.  Fall Prevention in Community Settings: Results from Implementing Tai Chi: Moving for Better Balance in Three States 
Tai Chi: Moving for Better Balance (TCMBB) is an evidence-based fall prevention exercise program being disseminated in selected communities through state injury prevention programs. This study: (1) describes the personal characteristics of TCMBB participants; (2) quantifies participants’ functional and self-reported health status at enrollment; and (3) measures changes in participants’ functional and self-reported health status post-intervention. There were 421 participants enrolled in 36 TCMBB programs delivered in Colorado, New York, and Oregon. Of the 209 participants who completed both baseline enrollment and post-intervention surveys, the average age of participants was 75.3 (SD ± 8.2) years. Most participants were female (81.3%), non-Hispanic (96.1%), White (94.1%), and described themselves as in excellent or very good health (52.2%). Paired t-test and general estimating equation models assessed changes over the 3-month program period. Pre- and post-assessment self-reported surveys and objective functional data [Timed Up and Go (TUG) test] were collected. On average, TUG test scores decreased (p < 0.001) for all participants; however, the decrease was most noticeable among high-risk participants (mean decreased from 18.5 to 15.7 s). The adjusted odds ratio of reporting feeling confident that a participant could keep themselves from falling was five times greater after completing the program. TCMBB, which addresses gait and balance problems, can be an effective way to reduce falls among the older adult population. By helping older adults maintain their functional abilities, TCMBB can help community-dwelling older adults continue to live independently.
PMCID: PMC4410325  PMID: 25964934
Tai Chi: Moving for Better Balance; fall prevention; fall prevention program; community setting; older adults
13.  Gait Speed among Older Participants Enrolled in an Evidence-Based Fall Risk Reduction Program: A Subgroup Analysis 
Functional decline is a primary risk factor for institutionalization and mortality among older adults. Although community-based fall risk reduction programs have been widely disseminated, little is known about their impact on gait speed, a key indicator of functional performance. Changes in functional performance between baseline and post-intervention were examined by means of timed up and go (TUG), a standardized functional assessment test administered to participants enrolled in A Matter of Balance/Volunteer Lay Leader (AMOB/VLL) model, an evidence-based fall risk reduction program.
This study included 71 participants enrolled in an AMOB/VLL program in the Brazos Valley and South Plain regions of Texas. Paired t-tests were employed to assess program effects on gait speed at baseline and post-intervention for all participants and by subgroups of age, sex, living status, delivery sites, and self-rated health. The Bonferroni correction was applied to adjust inflated Type I error rate associated with performing multiple t-tests, for which p-values <0.0042 (i.e., 0.5/12 comparisons) were deemed statistically significant.
Overall, gait speed of enrolled participants improved from baseline to post-intervention (t = 3.22, p = 0.002). Significant changes in TUG scores were observed among participants who lived with others (t = 4.45, p < 0.001), rated their health as excellent, very good, or good (t = 3.05, p = 0.003), and attended program workshops at senior centers (t = 3.52, p = 0.003).
Findings suggest community-based fall risk reduction programs can improve gait speed for older adults. More translational research is needed to understand factors related to the effectiveness of fall risk reduction programs in various populations and settings.
PMCID: PMC4410334  PMID: 25964944
older adults; A Matter of Balance/Volunteer Lay Leader model; timed up and go
14.  The Role of Session Zero in Successful Completion of Chronic Disease Self-Management Program Workshops 
Background: The Chronic Disease Self-Management Program (CDSMP) has been widely disseminated among various racial and ethnic populations. In addition to the six required CDSMP workshop sessions, the delivery sites have the option to offer a Session Zero (or zero class), an information session offered prior to Session One as a marketing tool. Despite assumptions that a zero class is helpful, little is known about the prevalence of these additional sessions or their impact on retaining participants in CDSMP workshops. This study aims to describe the proportion of CDSMP workshops that offered Session Zero and examine the association between Session Zero and workshop completion rates.
Methods: Data were analyzed from 80,987 middle-aged and older adults collected during a two-year national dissemination of CDSMP. Generalized estimating equation regression analyses were conducted to assess the association between Session Zero and successful workshop completion (attending four or more of the six workshop sessions).
Results: On average, 21.04% of the participants attended workshops that offered Session Zero, and 75.33% successfully completed the CDSMP workshop. The participants of the workshops that offered Session Zero had significantly higher odds of completing CDSMP workshops than those who were not offered Session Zero (OR = 1.099, P = <0.001) after controlling for participants’ demographic characteristics, race, ethnicity, living status, household income, number of chronic conditions, and workshop delivery type.
Conclusion: As one of the first studies reporting the importance of an orientation session for participant retention in chronic disease management intervention projects, our findings suggest offering an orientation session may increase participant retention in similar translational efforts.
PMCID: PMC4410344  PMID: 25964918
attrition; retention; orientation session; evidence-based programs; chronic disease self-management program
15.  National Dissemination of Chronic Disease Self-Management Education Programs: An Incremental Examination of Delivery Characteristics 
With a near 20-year developmental history as an evidence-based program, the suite of Chronic Disease Self-Management Education (CDSME) programs were selected in 2010 for grand-scale dissemination in a federally supported initiative to improve the health of older Americans. The primary charge of this national effort was to establish a sustainable program delivery system for empowering American adults with one or more chronic conditions to better manage their health. The current study focused on a series of dissemination and implementation science research questions to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time. Findings show a strengthening of the workshop delivery infrastructure in that it took 9.4 months to reach the first 25,000 participants in 853 counties compared to 5.4 months to reach the last 25,000 participants in 1,109 counties. The workshop delivery characteristics and participant characteristics remained relatively consistent across increments of 25,000 participants reached, although general trends were observed for some variables. For example, after reaching the first 25,000 participants, subsequent groups of 25,000 participants were reached more quickly. Additionally, workshops were increasingly delivered in ZIP Codes with higher percentages of families residing below the federal poverty line. As more participants were reached, more participants with chronic conditions were enrolled. This national translational study illustrates the rapid expansion of CDSME programs throughout the United States and capability to reach diverse populations in a variety of settings.
PMCID: PMC4410345  PMID: 25964923
chronic disease self-management; evidence-based program; older adults; sustainability; program implementation; program reach; evaluation
16.  Fall Prevention in Community Settings: Results from Implementing Stepping On in Three States 
Stepping On is a community-based intervention that has been shown in a randomized controlled trial to reduce fall risk. The Wisconsin Institute for Healthy Aging adapted Stepping On for use in the United States and developed a training infrastructure to enable dissemination. The purpose of this study is to: (1) describe the personal characteristics of Stepping On participants; (2) quantify participants’ functional and self-reported health status at enrollment, and (3) measure changes in participants’ functional and self-reported health status after completing the program. Both survey and observed functional status [timed up and go (TUG) test] data were collected between September 2011 and December 2013 for 366 participants enrolled in 32 Stepping On programs delivered in Colorado, New York, and Oregon. Paired t-tests and general estimating equations models adjusted for socio-demographic factors were performed to assess changes over the program period. Among the 266 participants with pre–post survey data, the average participant age was 78.7 (SD ± 8.0) years. Most participants were female (83.4%), white (96.9%), and in good health (49.4%). The TUG test scores decreased significantly (p < 0.001) for all 254 participants with pre–post data. The change was most noticeable among high risk participants where TUG time decreased from 17.6 to 14.4 s. The adjusted odds ratio of feeling confident about keeping from falling was more than three times greater after completing Stepping On. Further, the adjusted odds ratios of reporting “no difficulty” for getting out of a straight back chair increased by 89%. Intended for older adults who have fallen in the past or are afraid of falling, Stepping On has the potential to reduce the frequency and burden of older adult falls.
PMCID: PMC4410346  PMID: 25964924
fall prevention; evidence-based program; Stepping On; older adult
17.  Workshop Characteristics Related to Chronic Disease Self-Management Education Program Attendance 
Using the national dissemination of Chronic Disease Self-Management Education (CDSME) programs, the purposes of this study were to (1) document intervention attendance rates as related to the number of participants enrolled in the workshop and (2) compare the relationship between workshop attendance and workshop size by delivery site rurality and type. Data were analyzed from the first 100,000 middle-aged and older adults who participated in CDSME workshops spanning 45 states, Puerto Rico, and the District of Columbia as part of the American Recovery and Reinvestment Act of 2009 Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative. Descriptive statistics are reported for all participants, then separately by each delivery site type. Ratios between the number of workshop participants and the number of workshop sessions attended were calculated and graphed based on the rurality of delivery and separately for the leading five delivery site types. Associations between the number of workshop participants and the number of sessions attended differed by delivery site rurality and type. Findings have implications for participant retention and workshop delivery costs, which can assist program deliverers to strategically plan implementation efforts in their areas.
PMCID: PMC4410350  PMID: 25964943
chronic disease self-management; evidence-based program; older adults; intervention dose; evaluation
18.  Translation of Fit & Strong! for Middle-Aged and Older Adults: Examining Implementation and Effectiveness of a Lay-Led Model in Central Texas 
The Fit & Strong! program is an evidence-based, multi-component program promoting physical activity among older adults, particularly those suffering from lower-extremity osteoarthritis. The primary purpose of the study is to examine if the Fit & Strong! program translated into a lay-leader model can produce comparable outcomes to the original program taught by physical therapists and/or certified exercise instructors. A single-group, pre–post study design was employed, and data were collected at the baseline (n = 136 participants) and the intervention conclusion (n = 71) with both baseline and post-intervention data. The measurements included socio-demographic information, health- and behavior-related information, and health-related quality of life. Various statistical tests were used for the program impact analysis and examination of the association between participant characteristics and program completion. As in the original study, there were statistically significant (p < 0.05) improvements in self-efficacy for exercise, aerobic capacity, joint stiffness, level of energy, and amount and intensity of physical activities. The odds of completing the program were significantly lower for the participants from rural areas and those having multiple chronic conditions. Successful adaptation of the Fit & Strong! program to a lay-leader model can increase the likelihood of program dissemination by broadening the selection pool of instructors and, hence, reducing the potential issue of resource limitation. However, high program attrition rates (54.1%) emphasize the importance of adopting evidence-based strategies for improving the retention of the participants from rural areas and those with multiple chronic conditions.
PMCID: PMC4410407  PMID: 25964912
evidence-based program; aging; exercise; implementation research
19.  Linking Evidence-Based Program Participant Data with Medicare Data: The Consenting Process and Correlates of Retrospective Participant Consents 
As part of a nation-wide study of the Chronic Disease Self-Management Program (National Study), older participants were asked to consent to have their Medicare data matched with study data. This provided an opportunity to examine the consenting process and compare consenters, refusers, and non-responders. We compared the three groups on a large number of variables. These included demographic, National Study participation, health indicator, health behavior, and health-care utilization variables. We assessed differences in 6-month change scores for time-varying variables. We also examined whether asking participants to consent prior to the final questionnaire impacted completion of that questionnaire. Of 616 possible participants, 42% consented, 44% refused, and 14% failed to respond. Differences by ethnicity were found, with Hispanics more likely to consent. There was a consistent tendency for those who participated most in the National Study to consent. With the exception of number of chronic diseases, there was no evidence of health indicators or health behaviors being associated with consenting. Participants with more physician visits and more nights in the hospital were also more likely to consent. Those asked to consent before the 12-month follow-up questionnaire were less likely to complete that questionnaire than those who were asked after. Fewer than half consented to link to their Medicare data. The greater willingness to consent by those who participated most suggests that willingness to consent may be part of program engagement. Consenters had more diseases, more MD visits, and more nights in the hospital, suggesting that greater contact with the medical system may be associated with willingness to consent. This indicates that examinations of Medicare data based only on those willing to consent could introduce bias. Asking for consent appears to reduce participation in the larger study.
PMCID: PMC4410409  PMID: 25964908
chronic disease self-management; patient education; Medicare; consenting; cost analysis
20.  Fit & Strong! Promotes Physical Activity and Well-Being in Older Cancer Survivors 
Physical activity reduces fatigue and depression while improving quality of life in cancer survivors. Exercise is generally considered safe and is recommended to survivors of all ages. Despite the high prevalence of cancer in the elderly, few studies address physical activity interventions targeting this older population. Fit & Strong! is an evidence-based physical activity program shown to improve level of physical activity, exercise-self-efficacy, and mood in older adults with osteoarthritis. This study tests the feasibility and short-term impact of the Fit & Strong! exercise program adapted for older cancer survivors.
Participants were cancer survivors at least 50 years of age who were not on active treatment with intravenous chemotherapy or radiation. They participated in the 8-week Fit & Strong! program, which included three 90-min sessions per week; 60 min of group physical activity and 30 min of education. Education on osteoarthritis was removed from the Fit & Strong! program and replaced with relevant topics on cancer survivorship issues. Feasibility was measured by the ability to recruit and retain older cancer survivors. Pre and post-intervention surveys evaluated the effect of the intervention on physical activity and quality of life.
The study enrolled 72 cancer survivors to participate in an 8-week exercise program. The mean age of participants was 70. Over two-thirds (68%) of participants completed the program and with a mean attendance rate of 75% (18 of 24 sessions). No safety issues occurred. Improvements from baseline to post-intervention were observed for self-reported minutes of physical activity per week, self-efficacy for aerobic exercise, and symptoms related to depression and anxiety.
This study was successful in recruiting and retaining a population of older cancer survivors to participate in a group exercise program. Significant improvement in level of physical activity and mood suggests this evidence-based physical activity intervention can be adapted to promote health benefits in cancer survivors. Additional studies are necessary to confirm efficacy and assess long-term benefits.
PMCID: PMC4410419  PMID: 25964905
evidenced based intervention; older cancer survivors; physical activity; exercise; cancer survivorship
21.  Chronic Disease Self-Management Education (CDSME) Program Delivery and Attendance among Urban-Dwelling African Americans 
Older African Americans carry a disproportionate share of chronic diseases. The purpose of this study was to identify the characteristics of urban-dwelling African Americans with chronic disease participating in Chronic Disease Self-Management Education (CDSME) programs and to examine factors related to successful program completion (i.e., attending at least four of the six sessions).
Data were analyzed from 11,895 African Americans who attended a CDSME program at one of the five leading delivery sites (i.e., senior center, health care organization, residential facility, community location, faith-based organization). Logistic regression analyses were used to assess the associations of demographic, delivery site, and neighborhood characteristics with CDSME program successful completion.
Approximately, half of the African American participants were aged 65–79 years, 83% were female, and 92% lived alone. Approximately, 44% of participants had three or more chronic conditions and 35% resided in an impoverished area (i.e., 200% below federal poverty level). Successful completion of the CDSME program was associated with being between the ages of 50–64 and 65–79 years, being female, living alone, living in an impoverished community, and attending a CDSME program at a residential facility or community center.
Findings highlight the unique patterns of attendance and delivery within the context of self-management interventions among this unique and traditionally underserved target population. Understanding such patterns can inform policy and practice efforts to engage more organizations in urban areas to increase CDSME program adoption. Particularly, employing strategies to implement CDSME programs across all delivery site types may increase reach to African American participants.
PMCID: PMC4410424  PMID: 25964907
African American; urban; chronic disease self-management; delivery site; evidence-based program
22.  Factors Associated with Hispanic Adults Attending Spanish-Language Disease Self-Management Program Workshops and Workshop Completion 
Many factors influence ways in which middle-aged and older Hispanic adults prefer to receive health-related information. While Spanish-language disease management programs are increasingly offered in community and healthcare settings, less is known about their utilization among the Hispanic population. This study aimed to identify participant and workshop factors associated with middle-aged and older Hispanic adults attending Spanish-language disease self-management program workshops and receiving the recommended intervention dose (i.e., successful workshop completion is defined as attending four or more of the six workshop sessions). Data were analyzed from 12,208 Hispanic adults collected during a national dissemination of the Stanford suite of Chronic Disease Self-Management Education (CDSME) programs spanning 45 states, the District of Columbia, and Puerto Rico. Two logistic regression analyses were performed. Over 65% of participants attended Spanish-language workshops, and 78.3% of participants successfully completed workshops. Relative to participants in English-language workshops, participants who attended Spanish-language CDSME workshops were more likely to successfully complete workshops, as were those aged 80 years and older, females, and those who lived alone. Participants who were aged 50–79 years and female were significantly more likely to attend Spanish-language workshops than their counterparts under age 50. Conversely, those with more chronic conditions were less likely to attend Spanish-language workshops. Those who attended workshops with more participants and where the Hispanic population was less affluent were more likely to attend Spanish-language workshops. This study provides insight into Spanish-language CDSME program recruitment and utilization with implications for program adoption in underserved Hispanic community settings.
PMCID: PMC4410508  PMID: 25964900
chronic disease self-management; evidence-based program; Hispanic adults; intervention dose; Spanish language
23.  Long-Term Outcomes of a Web-Based Diabetes Prevention Program: 2-Year Results of a Single-Arm Longitudinal Study 
Digital therapeutics are evidence-based behavioral treatments delivered online that can increase accessibility and effectiveness of health care. However, few studies have examined long-term clinical outcomes of digital therapeutics.
The objective of this study was to conduct a 2-year follow-up on participants in the Internet-based Prevent diabetes prevention program pilot study, specifically examining the effects on body weight and A1c, which are risk factors for diabetes development.
A quasi-experimental research design was used, including a single-arm pre- and post-intervention assessment of outcomes. Participants underwent a 16-week weight loss intervention and an ongoing weight maintenance intervention. As part of the program, participants received a wireless scale, which was used to collect body weight data on an ongoing basis. Participants also received A1c test kits at baseline, 0.5 year, 1 year, and 2-year time points.
Participants previously diagnosed with prediabetes (n=220) were originally enrolled in the pilot study. A subset of participants (n=187) met Centers for Disease Control and Prevention (CDC) criteria for starting the program (starters), and a further subset (n=155) met CDC criteria for completing the program (completers) and were both included in analyses. Program starters lost an average of 4.7% (SD 0.4) of baseline body weight after 1 year and 4.2% (SD 0.8) after 2 years, and reduced A1c by mean 0.38% (SD 0.07) after 1 year and 0.43% (SD 0.08) after 2 years. Program completers lost mean 4.9% (SD 0.5) of baseline body weight after 1 year and 4.3% (SD 0.8) after 2 years, and reduced A1c by 0.40% (SD 0.07) after 1 year and 0.46% (SD 0.08) after 2 years. For both groups, neither 2-year weight loss nor A1c results were significantly different from 1-year results.
Users of the Prevent program experienced significant reductions in body weight and A1c that are maintained after 2 years. Contrary to the expected progression from prediabetes to diabetes over time, average A1c levels continued to show an average regression from within the prediabetic range (5.7%-6.4%) initially to the normal range (<5.7%) after 2 years. Further investigation is warranted to test digital therapeutics as a scalable solution to address national diabetes and cardiovascular disease prevention efforts.
PMCID: PMC4409647  PMID: 25863515
prediabetes; type 2 diabetes; obesity; diabetes prevention program; internet; online; mobile apps; mhealth; digital health; intervention
24.  Changes in Food Choices of Participants in the Special Diabetes Program for Indians–Diabetes Prevention Demonstration Project, 2006–2010 
American Indians/Alaska Natives (AI/ANs) have a disproportionately high rate of type 2 diabetes. Changing food choices plays a key role in preventing diabetes. This study documented changes in the food choices of AI/ANs with diagnosed prediabetes who participated in a diabetes prevention program.
The Special Diabetes Program for Indians–Diabetes Prevention Demonstration Project implemented the evidence-based Diabetes Prevention Program (DPP) lifestyle intervention in 36 health care programs nationwide, engaging 80 AI/AN communities. At baseline, at 30 days post-curriculum, and at the first annual assessment, participants completed a sociodemographic survey and 27-item food frequency questionnaire and underwent a medical examination assessing fasting blood glucose (FBG), blood pressure, body mass index (BMI), low-density lipoprotein [LDL], high-density lipoprotein [HDL], and triglycerides. Multiple linear regressions were used to assess the relationship between temporal changes in food choice and other diabetes risk factors.
From January 2006 to July 2010, baseline, post-curriculum, and first annual assessments were completed by 3,135 (100%), 2,046 (65%), and 1,480 (47%) participants, respectively. An increase in healthy food choices was associated initially with reduced bodyweight, BMI, FBG, and LDL and increased physical activity. At first annual assessment, the associations persisted between healthy food choices and bodyweight, BMI, and physical activity.
AI/AN adults from various tribal and urban communities participating in this preventive intervention made sustained changes in food choices and had reductions in diabetes risk factors. The outcomes demonstrate the feasibility and effectiveness of translating the DPP lifestyle intervention to community-based settings.
PMCID: PMC4651117  PMID: 26564009
25.  Translating the Diabetes Prevention Program Into American Indian and Alaska Native Communities 
Diabetes Care  2013;36(7):2027-2034.
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.
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.
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.
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.
PMCID: PMC3687272  PMID: 23275375

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