balanced living with diabetes

Balanced Living with Diabetes:A Community-based Lifestyle Intervention

Program for Improved Blood Glucose Control

Eleanor Schlenker, PhD, RDCarlin Rafie, PhD, RDMelissa Chase, PhD

Kathy Hosig, PhD, MPH, RDAssociate Professor

Director, Center for Public Health Practice and ResearchPopulation Health Sciences

Virginia Tech

Outline Background

Challenges for health behavior change

Strategies for health behavior change

Balanced Living with Diabetes– Program description– Program history– Program tailoring and outcomes in Virginia

Elements of success

Next Steps– Expand VCE reach to Hispanic population (promotora)– BLD dissemination to rural Virginia

Diabetes Prevalence and Risk

US adults > 20 years (2010-2012)– Overall US population: 9.6%– Non-Hispanic blacks: 13.2%– Hispanics: 12.8%

Rural communities– 17% higher risk for diabetes– Higher prevalence of diabetes risk factors

poverty, obesity, tobacco use, low health literacy

– Less likely to engage in recommended diabetes self-care except quarterly A1c

– Less likely to have health insurance– Live farther from healthcare facilities

7th leading cause of death in US in 2010– Likely underreported

Health Complications– Heart disease and stroke

– Blindness

– Kidney failure

– Lower-limb amputation

Burden of Diabetes

Chronic disease and diabetes

– 1.7 times higher risk for cardiovascular disease

– 71% have hypertension

– 65% have high LDL cholesterol

– 29% have diabetic retinopathy

– 60% of non-traumatic lower-limb amputations occur in people with diagnosed diabetes

– Diabetes listed as primary cause for 44% of new kidney failure cases

Burden of Diabetes

Burden of Diabetes

2013

Per-capita healthcare costs without diabetes = $4,305Per-capita healthcare costs with diabetes = $14,000Out-of-pocket costs 2.5x higher with diabetes

Source: American Association of Diabetes Educators

American Diabetes Association recommendation:– A1c < 7.0%

Prevent complications

Reduce medical costs

For each 1% decrease in mean A1c:

– 21% decrease in risk of death related to diabetes

– 14% decrease in risk for myocardial infarction

– 37% decrease in risk for microvascular complications

Preventing Diabetes Complications

Challenge:

Lifestyle Behavior Change

Maslow’s Hierarchy of Needs

Where does health behavior change fit in?

Socioecological Model

Challenge: Underserved

Services not available

Services not accessible

Target population may not take advantage of available services

Unique characteristics for each target population

Strategies

Health Behavior Theory

Community-based Participatory Research– CBPR

Health Behavior Theory

Is basic information (knowledge) important for health behavior change?– Is it enough?

Why do interventions that focus on providing information (i.e. “education”) often fail to produce change in behavior?

Rationale for Theory-based Interventions

Health behavior interventions that are fully grounded in theory appear to be more effective in producing change in health behavior – why?

– Fidelity to theory components

– Processes involved in maintaining fidelity to theory

Social Cognitive Theory Constructs

– Individual characteristics Self-efficacy Behavioral Capability Expectations Expectancies Self-control Emotional coping responses

– Environmental factors Vicarious (observational) learning Environment (social and physical) Situation (perception of environment) Reinforcement Reciprocal determinism

Community-based Participatory Research (CBPR)

Involvement of communities in designing, implementing and evaluating community interventions, with an emphasis on sustainability

Community members and researchers partner to combine knowledge and action for social change to improve community health and often reduce health disparities.

Community-based Participatory Research (CBPR)

Academic/research and community partners join to develop models and approaches to building communication, trust and capacity

CBPR equitably involves all partners in the research process and recognizes the unique strengths that each brings.

Balanced Living with Diabetes

Program Description

Program History

Program Tailoring and Outcomes in Virginia

Program Description

Balanced Living with DiabetesAdapted from Dining with Diabetes (CBPR)

• Name developed through Project Advisory Board

• Entire curriculum completely revisedo Focus on interaction and application of basic conceptso Tested and revised 2 times

• Stronger fidelity to Social Cognitive Theory (SCT)

• Refined assessments to include SCT variables

• Recipes tested by Virginia residents and Extension Agents for taste, ease of preparation

• Additional physical activity contento Aerobic, strength, stretchingo Physical Activity Readiness Questionnaireo Goal setting and trackingo Step log for use with pedometers


Social Cognitive Theory

• Curriculum content to address expectations

• Mastery experiences to increase self-efficacy

• In-class interaction for social support

• Emphasis on self-regulation

– Goal-setting

– Tracking

Program Operation*

• Weekly 2-hour classes for four weeks

• Reunion class three months after last class

• Assessments at first and 3-month reunion classes:– A1c, height/weight– Diabetes self-management, SCT variables

• Encourage diabetes support group for class members and family

*Considered a research study; protocol approved by VT Institutional Review Board

Class Structure

Power Point interactive lecture by qualified localhealth professional (CDE/RD)

Physical Activity Discussion

Food demonstration/tasting by local Virginia Cooperative Extension Educator

Personal goal-setting, sharing, and practice

Sample BLD Slides


For People with Diabetes and their Families

High Blood Sugar Causes Complications

Complications of DiabetesDO NOT Have to Happen!!

How Can You Avoid Complications?

• Good blood sugar control

Lifestyle to Control Type 2 Diabetes

Choose healthy foods

Be active

Stay at a healthy weight

How Can Balanced Living with Diabetes Help You?

• Manage your diabetes

• Choose healthy foods

• Be more active

• Lower your blood sugar

• Prevent complications from diabetes


• Making Food Choices– Using the Plate Method– Learn foods to focus on

• Being Active– Walking or other moderate physical activity– Strength and stretching exercises

• Practicing What you Learn– Setting goals– Making plans– Keeping track

The Plate MethodControl portion size

Control carbohydratesFocus on healthy foods

Which Food Has the MostCarbohydrate?

Finding Carbohydrate with Food Labels

• Compare carbohydrate in foods using the Nutrition Facts panel

Total carbohydrate = 13 g Dietary fiber = 3 g Sugars = 3g

Carbohydrate = fiber + sugar + starch

Managing Type 2 Diabetes:Take Care of Yourself

Can I safely become more active?

Physical Activity Readiness Questionnaire

Fill it out now!

Balanced Living with Diabetes Fitness

• Ways to be more active.• Tools to help you stick to it.• PAR-Q and your doctor

Use the PAR-Q and talk to your doctor before becoming much more active!

Tools for an Active Life

• Pedometer

• add 250 steps/day each weekUse the PAR-Q and talk to your doctor before becoming much more active!

Staying More Active

• 150 minutes a week• exercise like walking• slow enough to talk, but not sing!• build to 30 minutes at least 5 days a week


Mastery Experiences

Practice

• Use the blank plates in your handouts

• Plan 2 meals– 1 breakfast– 1 lunch or dinner

Lunch or Dinner

Practice:Finding Carbohydrate with Food Labels

• Use labels at your table or handouts• Find: Serving size Carbohydrate Dietary fiber Sugar

• Compare labels for the same types of food Yogurt Oat cereal Vegetables Wheat cereal

Do You Have Some Tips for Us?

• Do you have ideas that you have used at home to make your recipes healthier?

• Please share with us!

More Practice with Recipes

• Look at the recipes in the handouts

• Discuss with your group how to change these recipes to make them healthier

Practice!

• Use the food labels at your table– Oils– Shortening, Butter and Margarine– Spreads– Milk– Ranch Dressing

• Talk to the people at your table about healthy choices using these labels

Practice!• Use the food labels at your table

– Vegetable Soup– Chicken Noodle Soup

• Talk to the people at your table about healthy choices using these labels

Practice!• Use the menus in your handouts or that

you brought

• Talk to the people at your table about healthy choices using these menus

• Use the Plate Method!– Write your choices on the blank

plate

“Homework”

Bring for Next Time

• Please bring somefood labels from home.

Things To Do for Next Time

• Please bring menus from your favorite restaurants.

Setting Goals

Keeping Track

Setting Goals & Keeping Track

• Set goals– foods to focus on– use Plate Method – wear step counter

• Keep track– foods– Plate Method– Steps/Walks

Let’s Set Goals for this Week!

• Where are you now?– Plate method?– Regular meals?

• Where do you want to go this week?– Build slowly

• Use your diary!

Keep Track

• write down goals

• notice how you get enough steps on days you walk!


Let’s Review!

• Starting Point– Plate method?– Regular meals?– Counting steps?– Adding mins of

walking?• Build slowly• Use your diary!

Program History Virginia Department of Health (Diabetes Prevention and

Control Program) funding:– Dining with Diabetes by Virginia Cooperative Extension (VCE) with

local healthcare professionals, local health departments 13 counties in Southwest and Central Virginia (2006-2009)

Obici Healthcare Foundation grant:– VCE partnered with Virginia Diabetes Council

6 counties in Obici service area (2011)

National Institutes of Health grant:– Program adapted to Balanced Living with Diabetes– Partnering with Baptist General Convention of Virginia

27 churches in 9 Virginia locations (2010-2015)

Hispanic Balanced Living with Diabetes (unfunded)– VCE partnered with Catholic churches

5 churches in Southwest/Southside Virginia (2014-2015)

BLD Tailoring and Outcomesin Virginia

Dining with Diabetes Pilot (2006-2009)

N = 146 participants (8 locations analyzed)o 80% female

o 66% > 60 years old (mean age = 66.4 ± 10.3 years)

o 53% reported income of lower than $30,000

o Race/ethnicity representative of geographic regiono 77% Caucasiano 7% African Americano 3% Asiano < 1% Hispanic


A1c baseline to 3-month follow up:

Overall

o 7.36 ± 1.60 vs 7.27 ± 1.47 (paired t-test, p = 0.310)

> 7% A1c at baseline (n = 45)

o 8.50 ± 1.58 to 8.00 ± 1.54 (paired t-test, p < 0.001)


• Self-reported behaviors baseline to 3-month follow up:

• 5 times more likely to use a plan to control carbohydrate at least 3 days/week

o 38% vs. 74% (OR = 4.64, 95% CI = 2.50 – 8.61; t = 5.36, p < .01)

• ↑ 30 minutes physical activity at least 3 days/weeko 73% vs 82% (OR = 1.68; 95% CI=0.84¨C3.37; t=1.49, p=.07)

Obici Foundation Project (2011)(used revised BLD)

39% lowered A1c

51% maintained appropriate A1c levels

65% increased days/week using a meal planning method

73% increased days/week with 30 minutes of walking or similar activity

RCT with BLD Targeting Medically Underserved African Americans

5-year project funded by National Institutes of Health (National Institute for Nursing Research)

3 churches in each of 10 Virginia communities(n=30)– Churches randomly assigned to treatment condition BLD BLD plus technical assistance for monthly support

group meetings 12-month delayed intervention

BLD with Medically UnderservedAfrican Americans

Location• African American Baptist Churches• Medically underserved areas of Virginia

Partners

• Baptist General Convention• Statewide association of black churches• Health ministry infrastructure

• Virginia Cooperative Extension• Virginia Department of Health


Formative work (CBPR)

• Director of church health ministry involved from beginning (proposal stage)

• Recipe testing at member churches

• Pilot/feasibility programs at 2 member churches


Community Advisory Board

• Key stakeholders• Members of target population• Members of partner agencies

• Administrative and staff• Designed consent documents/process• Chose recipes for testing• Designed/approved marketing/recruiting

materials• Continued involvement and formative evaluation

• Dissemination• Sustainability


Preliminary Results


• 264 participants completed 12-month assessments• 5 locations, 14 churches

• Demographics• 77% female; 23% male• 96% African American

• Retention rate• 82% at 3 months• 80% at 6 months• 77% at 12 months

BLD with Medically Underserved African Americans

Change in A1c by Treatment Condition for Participants with Baseline A1c ≥ 7.0(n = 106)

Treatment Condition

Baseline A1c

(mean ± sd)

3-month A1c

(mean ± sd)

6-month A1c

(mean ± sd)

12-month A1c

(mean ± sd)

Control waiting 8.5 ± 1.5 8.1 ± 1.4 8.0 ± 1.0 7.8 ± 1.6

Standard program

8.8 ± 1.7 8.3 ± 1.3 8.1 ± 1.4 8.3 ± 1.8

Program + support groups

8.7 ± 1.7 8.2 ± 1.1 8.3 ± 1.2 8.2 ± 1.3

Identifying and Exploring Capacity & Readiness of Faith-Based Organizations Implementing

Lifestyle-Related Chronic Disease Health Programs

Preliminary Research– Explore capacity and readiness factors that influence

partner experience implementing a collaborative lifestyle-related faith-based health program (BLD)

Formative and Culminating Research– Develop and pilot a tool to assess organizational

capacity and readiness of faith-based organizations to implement lifestyle-related health programs

Results

50% did not have policies to promote physical activity

68% did not have policies related to healthy food/beverage options at church functions

Most common policy = “No Smoking”

Results

57% had health and wellness mission statement

55% had health and wellness budget

57% had health ministry

– Larger churches more likely to have health ministry

– Churches with health ministry more likely to have at least one health-related policy that was enforced

Results

Most churches had not partnered with colleges/universities for health programming

Only ~50% had partnered with local/state agencies

Assessment tool is promising– Self-assessment tool for churches– Research tool

Hispanic BLD

Background• Growing minority population in US

• Increased risk for type 2 diabetes

• Disproportionate suffering from complications from diabetes

• ↓ access to care• Potential for undocumented participants• Unique influences on access to care

• Majority of Hispanic population is Catholic

Hispanic BLD

Location• Catholic Churches with services in Spanish• Identified via communication with Richmond diocese

Partners

• Richmond Diocese and 4 regional Catholic churches• St. Mary’s Catholic Church in Blacksburg (support)• Virginia Cooperative Extension• Virginia Department of Health• VT Center for Public Health Practice and Research

Hispanic BLD

Formative work• Doctoral student from El Salvador worked

with BLD for MPH practicum and then……

• Interpreted BLD materials into Spanish

• Obtained permission from state Catholic diocese to work with local churches

• Established relationship with local Catholic churches for formative work

• Identified importance of promotora-navigator

Hispanic BLD

Formative work

• Recipe testing at two local churches• Another local Catholic church helped prepare foods

and provided resources for pilot/feasibility programs

• Health fair/ A1c screening at same churches

• Pilot feasibility programs at the same churches• Prefer Sundays after mass

Sample HBLD Slides

Vida Balanceada con Diabetes

Para personas con Diabetes y sus familiasSesión 1

Lo siguiente para hoy es:• Deguste comida deliciosa y saludable

Formative A1c Screening Results(2 Catholic Churches)

Of 60 participants screened:

• 100% self-identified as Hispanic

• 68% were female

• 64% were 40 years old or younger

• 64% did not have a high school degree or higher

• 75% did not have medical insurance

Formative A1c Screening Results(2 Catholic Churches)

• 54% had A1c > 5.7%

• Of these, 72% had never been told that they had pre-diabetes, diabetes or high blood sugar

2-Group Randomized Control Trial

HBLD Pilot RCT Results

A1c-Baseline A1c- 3 months

HBLD (n=11)

6.4 ± 0.9 6.4 ± 0.9

HBLDd(n=10)

6.0 ± 0.5 6.2 ± 0.7

Baseline and 3-month Follow Up A1c for Intervention and Delayed Control Churches*

* No differences for change from baseline to 3-month follow up between churches (Kruskal Wallis, p > 0.05)

Considerations and Lessons Learned

High enthusiasm from churches Documented need Opportunity to reach severely underserved

Church dissemination infrastructure weaker Work more closely with individual churches Must have approval from State Diocese

Greater flexibility from Extension needed for timing of classes (Sundays)

Bilingual educator required

Promotora navigator to improve access to care

AcknowledgmentsJ Elisha Burke, DMin (Director, Health Ministry - BGCVA)Eleanor Schlenker, PhD, RD (Extension Nutrition Specialist - VT)Eileen Anderson Bill (Research Assistant Professor, Psychology – VT)Ann Forburger, MEd, CHES (Project Coordinator - VT)Monica Motley, MPH (almost PhD)Ivette Valenzuela, MPH (almost PhD)Deborah Jones, MPH (Extension Specialist, Virginia State University)Carlin Rafie, PhD, RD (Extension Nutrition Specialist - VT)Melissa Chase, PhD (Consumer Food Safety Program Manager - VT)

Common Elements

Know your target population

CBPR– Builds trust, empathy, capacity

Go where the people already come together

Work with people who are connected to the target population

Honor and embrace differences in perspective

Next Steps

Explore promotora model for Virginia Cooperative Extension programs– MPH practicum/capstone (Karina Chavez)

Impacting Rural Community Health Through Evidence-based Program Implementation in the Cooperative Extension Network– USDA: National Institute of Food and Agriculture (2 yrs)

USDA-NIFA Rural BLD Dissemination

Expand BLD to all qualifying rural counties/cities in Virginia with a Family and Consumer Sciences Extension Agent.

Conduct process evaluation to facilitate program sustainabilty

US Cooperative Extension Service

USDA-NIFA Rural BLD Dissemination

Goal 1: Create capacity to use Master Food Volunteers to assist with BLD implementation

Goal 2: Create sustained capacity for implementation of BLD in rural Virginia counties

Goal 3: Produce a BLD curriculum kit to be made available to other state and local Extension programs

Target Counties and Cities

Brunswick OrangeDickenson PageEmporia City PatrickGreensville RussellLee ShenandoahLouisa SurryMadison TazewellNottoway Wise

Discussion