Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Balanced Living with Diabetes

VRHA Conference presentation

  • Login to see the comments

  • Be the first to like this

Balanced Living with Diabetes

  1. 1. Balanced Living with Diabetes: A Community-based Lifestyle Intervention Program for Improved Blood Glucose Control Eleanor Schlenker, PhD, RD Carlin Rafie, PhD, RD Melissa Chase, PhD Kathy Hosig, PhD, MPH, RD Associate Professor Director, Center for Public Health Practice and Research Population Health Sciences Virginia Tech
  2. 2. 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
  3. 3. 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
  4. 4.  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
  5. 5.  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
  6. 6. Burden of Diabetes 2013 Per-capita healthcare costs without diabetes = $4,305 Per-capita healthcare costs with diabetes = $14,000 Out-of-pocket costs 2.5x higher with diabetes
  7. 7. Source: American Association of Diabetes Educators
  8. 8.  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
  9. 9. Challenge: Lifestyle Behavior Change
  10. 10. Maslow’s Hierarchy of Needs Where does health behavior change fit in?
  11. 11. Socioecological Model
  12. 12. Challenge: Underserved  Services not available  Services not accessible  Target population may not take advantage of available services  Unique characteristics for each target population
  13. 13. Strategies  Health Behavior Theory  Community-based Participatory Research – CBPR
  14. 14. 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?
  15. 15. 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
  16. 16. 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
  17. 17. 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.
  18. 18. 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.
  19. 19. Balanced Living with Diabetes  Program Description  Program History  Program Tailoring and Outcomes in Virginia
  20. 20. Program Description
  21. 21. Balanced Living with Diabetes Adapted from Dining with Diabetes (CBPR) • Name developed through Project Advisory Board • Entire curriculum completely revised o Focus on interaction and application of basic concepts o 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 content o Aerobic, strength, stretching o Physical Activity Readiness Questionnaire o Goal setting and tracking o Step log for use with pedometers
  22. 22. Balanced Living with Diabetes 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
  23. 23. 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
  24. 24. Class Structure  Power Point interactive lecture by qualified local health professional (CDE/RD)  Physical Activity Discussion  Food demonstration/tasting by local Virginia Cooperative Extension Educator  Personal goal-setting, sharing, and practice
  25. 25. Sample BLD Slides
  26. 26. Balanced Living with Diabetes For People with Diabetes and their Families
  27. 27. High Blood Sugar Causes Complications
  28. 28. Complications of Diabetes DO NOT Have to Happen!!
  29. 29. How Can You Avoid Complications? • Good blood sugar control
  30. 30. Lifestyle to Control Type 2 Diabetes Choose healthy foods Be active Stay at a healthy weight
  31. 31. 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
  32. 32. Balanced Living with 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
  33. 33. The Plate Method Control portion size Control carbohydrates Focus on healthy foods
  34. 34. Which Food Has the Most Carbohydrate?
  35. 35. 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
  36. 36. Managing Type 2 Diabetes: Take Care of Yourself
  37. 37. Can I safely become more active? Physical Activity Readiness Questionnaire Fill it out now!
  38. 38. 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!
  39. 39. Tools for an Active Life • Pedometer • add 250 steps/day each week Use the PAR-Q and talk to your doctor before becoming much more active!
  40. 40. 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 Use the PAR-Q and talk to your doctor before becoming much more active!
  41. 41. Mastery Experiences
  42. 42. Practice • Use the blank plates in your handouts • Plan 2 meals –1 breakfast –1 lunch or dinner
  43. 43. Lunch or Dinner
  44. 44. 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
  45. 45. 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!
  46. 46. More Practice with Recipes • Look at the recipes in the handouts • Discuss with your group how to change these recipes to make them healthier
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. “Homework”
  51. 51. Bring for Next Time • Please bring some food labels from home.
  52. 52. Things To Do for Next Time • Please bring menus from your favorite restaurants.
  53. 53. Setting Goals Keeping Track
  54. 54. Setting Goals & Keeping Track • Set goals – foods to focus on – use Plate Method – wear step counter • Keep track – foods – Plate Method – Steps/Walks
  55. 55. 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!
  56. 56. Keep Track • write down goals • notice how you get enough steps on days you walk! Use the PAR-Q and talk to your doctor before becoming much more active!
  57. 57. Let’s Review! • Starting Point – Plate method? – Regular meals? – Counting steps? – Adding mins of walking? • Build slowly • Use your diary!
  58. 58. 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)
  59. 59. BLD Tailoring and Outcomes in Virginia
  60. 60. 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 region o 77% Caucasian o 7% African American o 3% Asian o < 1% Hispanic
  61. 61. Dining with Diabetes Pilot (2006-2009) 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)
  62. 62. Dining with Diabetes Pilot (2006-2009) • 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/week o 73% vs 82% (OR = 1.68; 95% CI=0.84¨C3.37; t=1.49, p=.07)
  63. 63. 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
  64. 64. 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
  65. 65. BLD with Medically Underserved African 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
  66. 66. BLD with Medically Underserved African Americans 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
  67. 67. BLD with Medically Underserved African Americans 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
  68. 68. BLD with Medically Underserved African Americans Preliminary Results
  69. 69. BLD with Medically Underserved African Americans • 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
  70. 70. 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
  71. 71. 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
  72. 72. 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”
  73. 73. 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
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. Sample HBLD Slides
  80. 80. Vida Balanceada con Diabetes Para personas con Diabetes y sus familias Sesión 1
  81. 81. Lo siguiente para hoy es: • Deguste comida deliciosa y saludable
  82. 82. 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
  83. 83. 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
  84. 84. 2-Group Randomized Control Trial
  85. 85. 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)
  86. 86. 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
  87. 87. Acknowledgments J 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)
  88. 88. 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
  89. 89. 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)
  90. 90. 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
  91. 91. US Cooperative Extension Service
  92. 92. 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
  93. 93. Target Counties and Cities Brunswick Orange Dickenson Page Emporia City Patrick Greensville Russell Lee Shenandoah Louisa Surry Madison Tazewell Nottoway Wise
  94. 94. Discussion

×