Combined Diet and PA Prevention Programs to Prevent Type 2 DM – Healthy Eating and Active Living Fall 2016

Part 1: Needs Assessment

Describe in detail the population and setting with which you will work. Identify the public health problem. Use surveillance data to support the needs of the community. As appropriate, discuss the health disparities of your target community. (20 points)
What stakeholders may be needed along the way? Describe the role of each stakeholder, and the questions they may want answered about the intervention. Also briefly describe how a successful intervention would impact that stakeholder, and how an unsuccessful program might impact that stakeholder. Stakeholders may be individuals, groups, or organizations. (20 points)

As of 2010, diabetes remains the seventh leading cause of death in the United States (American Diabetes Association, 2016). Between 2010 and 2012, the population of Americans suffering from diabetes increased from 25.8 million to 29.1 million, encompassing just over 9% of the United States’ population (ADA, 2016). Although diabetes, particularly type II, affects adults far more often than children, still over 500,000 youth under the age of 20 years old are diagnosed with type II diabetes annually (ADA, 2016). However, type II diabetes is typically diagnosed in middle age and older adults, and the risks increase as an individual ages (ADA, 2016). Several risk factors have been strongly associated with type II diabetes, including a family history of diabetes, poor dietary habits, high cholesterol and low-density lipoprotein levels, sedentary lifestyle, overweight and obesity, and an impaired glucose tolerance (International Diabetes Federation, 2015). In particular, overweight and obesity, unhealthy diet, and physical inactivity are three important risk factors for which an individual typically has the capacity to minimize.

Obesity is defined as a body mass index (BMI) of over 30kg/m². As of 2010, over 1 in 3 adults is considered to be obese (NIDDK, 2012). This number encompasses just over 35% of adults over the age of twenty in the United States. Additionally, another 33% of adults over twenty years of age are considered to be overweight, possessing a BMI of 25kg/m² or higher (NIDDK, 2012). Although there are several factors leading to weight gain and eventual obesity that an individual may not be able to change, such as genes, family history, and socioeconomic status, there also exist several modifiable factors, such as dietary habits, attitude, and lifestyle habits, that contribute to one’s risk for diseases like diabetes. This leads to an important link between two high risk factors associated with type I diabetes, namely, overweight and obesity and poor dietary habits. High cholesterol and low-density lipoprotein (LDL) levels in addition to high blood pressure, all of which can result from an unhealthy diet, have shown to increase one’s risk of developing diabetes (American Heart Association, 2015). From 2009 to 2012, over 75% of adults diagnosed with diabetes also had a blood pressure greater than 140/90mmHg and over 65% presented with an LDL cholesterol level of greater than 100mg/dL (ADA, 2016). These are considered modifiable risk factors, as altering one’s diet and physical activity lifestyle can help to significantly lower these risk factors.

The Center for Disease Control’s national physical activity guidelines recommend that adults perform at least 150 minutes of moderate physical activity and at least 75 minutes of vigorous physical activity every week to see health benefits (Center for Disease Control, 2008). Additionally, the CDC recommends two or more days per week of muscle strengthening for major muscle groups. These guidelines are proven to decrease one’s risk for several life-threatening diseases including cardiovascular disease, hypertension and type II diabetes. Unfortunately, as several studies have shown via accelerometer measurements, Troiana et al. found that less than 5% of adults in the United States adhere to this recommended thirty minutes per day of physical activity (Troiana, 2008). This statistic strongly contributes to the almost 30 million Americans suffering from diabetes and other chronic illnesses.

Furthermore, along with the detrimental health costs and comorbidities associated with diabetes, such as diabetic retinopathy, kidney disease, and lower limb amputations, diabetes produces substantial economic health costs (ADA, 2016). In 2012, the overall medical costs of diabetes in the United States totaled $245 billion, creating over two times higher average medical costs for individuals diagnosed with diabetes than those without (ADA, 2016). In an economic review of over 25 studies involving combined diet and physical activity programs’ effects on the prevention of type II diabetes in individuals at high risk, the Community Preventive Services Task Force found that such programs are cost-effective. All implemented programs reviewed cost a median of $653 per study participant (Diabetes Prevention and Control, 2015). Relative to the cost per quality adjusted life year – which is defined as “a health outcome that combines the years of life with the quality of life experienced during those years, relative to quality associated with perfect health” (Glossary, 2014) – a median of $13,761 for all programs reviewed shows a financial benefit that would reduce the burden of diabetes on the United States economy.

For this intervention, adults over the age of 18 years old with a BMI of 24.9kg/m², a classification of overweight, will be included. The population will be recruited through primary healthcare clinics throughout Maryland. In 2012, 10.24% of Marylanders were diagnosed with diabetes, and the state as a whole retained a diabetes mortality rate of 20.5 per 100,000 residents (Baltimore City, 2014). Thus, Maryland could certainly benefit from a successful Diabetes Prevention Program implemented via diet and physical activity alterations.

Setting

Intervention level

Eligibility criteria

Exclusion criteria

Ethnicity

Gender

Intervention

Maryland, United States

Primary healthcare clinics/centers

>18 years old

BMI > 24.9kg/m²

<18 years old

BMI <25kg/m²

Diagnosis of Diabetes Mellitus; Cardiovascular Disease or Incident; Serious medical conditions contraindicating adherence to the PA program

All

Combined Diet and Physical Activity Promotion Programs

Stakeholder	Role in Intervention	Questions from Stakeholder	Effect on Stakeholder of a Successful Program	Effect on Stakeholder of an Unsuccessful Program
Overweight/Obese Adults (>18y.o.)	Participants	What is the cost of participating in the program? What is the time commitment for participating in the program? What potential benefits will the program have for my health? What potential risks does the program pose to me?	Decreased risk for Type II Diabetes Decreased risk for cardiovascular disease Potentially decreased body mass index Weight loss Increased quality of life	Risks for type II diabetes are maintained Risks for cardiovascular disease are maintained Possible negative attitude towards the benefits of PA and healthy eating on weight loss and health status Continued cost of medical care for diabetes risk factors (i.e. hypertension, high cholesterol, high blood glucose, etc.)
Parents & Family	Support system, encouraging adherence to the program	How will this prevention program benefit my child/family member? What risks does this prevention program pose to my child/family member? What are the anticipated long-term effects of this prevention program? How can I help my child/family member better adhere to the prevention program?	Better health status for a child or family member Lowered anxiety for the health risks of a child or family member	Possible negative attitude towards the benefits of PA and healthy eating on weight loss and health status Continued anxiety for the health risks of a child or family member Continued cost of medical care for the risk factors of the child or family member (i.e. hypertension, high cholesterol, high blood glucose, etc.)
Primary Care Clinic Healthcare Providers	Promotion of Diabetes Prevention Programs	What materials or time commitment are necessary for our dissemination of information regarding a diabetes prevention program? How will this prevention program benefit our patients? Can this prevention program pose any risk to our patients? What are the costs associated with implementation of this prevention program?	Decreased need to provide medical care to treat the “high risk” aspects of the participants (i.e. hypertension, high cholesterol, high blood glucose, etc.) Improved health status of patients	Increased need to provide medical care to treat the “high risk” aspects of the participants Maintenance of poor health status of at risk patients
Nutritionists	Healthy diet promotion and counseling to participants	What dietary risk factors is this prevention program designed to focus on? What types of promotional materials are being used to circulate information about healthy dietary habits?	Achievement of adequate counseling and promotion of healthy dietary habits Weight loss of clients/ participants Improved health status of clients/ participants	No change in health status of clients/ participants Clients/ participants continue to be at risk for diabetes and associated diseases
Physical Activity Counselors	Regular PA promotion and counseling to participants	Will this prevention program focus on attaining the minimum recommended amount of physical activity for adults? What specific types of physical activity are being implemented in this program? What types of promotional materials are being used to circulate information about regular physical activity benefits?	Achievement of adequate counseling and promotion of regular physical activity Weight loss of clients/ participants Improved health status of clients/ participants	No change in health status of clients/ participants Clients/ participants continue to be at risk for diabetes and associated diseases
Local Hospitals	N/A	What effect will this prevention program have on the healthcare needs of the community?	Decreased costs of inpatient medical care for incidents associated with diabetes (such as a cardiovascular incident)	None

Part 2: Intervention Identification

State and define the intervention strategy – what does it mean? What populations has this strategy been used with? What settings has it been used in? How are your community characteristics similar or different to those of the communities in which the strategy has been effective? (20 points)
Is the strategy recommended by the Task Force? Why or why not? (10 points)
Provide at least 3 examples from existing articles (peer-reviewed preferably, but could come from other places). These should be different than the research-tested intervention programs(RTIP) listed already. You can include or link to this information, but you should provide different examples. (45 points total)
1. Describe the intervention – what did the authors do? What was the procedure? How long was the intervention? Please describe individual components as well as the broader intervention plan.
2. What were the outcomes measured?
3. What amount of change did they find?

My selected intervention strategy is Combined Diet and Physical Activity Promotion Programs to Prevent Type II Diabetes Among People at Increased Risk. Promotion of an improved diet and a higher rate of physical activity are encouraged via trained practitioners – such as dieticians, physiotherapists, nurses and others – who work directly with the participants in a community level setting. In my intervention, similar to the settings in the majority of studies reviewed by the Community Preventive Services Task Force, the setting utilized is at the community level in primary healthcare clinics throughout Maryland.

In the Community Preventive Services Task Force Review of 53 studies related to this intervention, the average age of participants ranged from 35-65, with one study involving 12-16 year olds. These 53 reviewed studies also included populations of varying ethnicities and socioeconomic statuses. The large majority of the studies reviewed utilized an intervention at the community setting in primary care or specialty care clinics throughout the United States and Europe, with five studies employing online- or television-based interventions rather than in person. My community characteristics are very similar to those typically employed. The population I am targeting includes adults at a higher risk for Type 2 Diabetes (over the age of 18 and with a BMI of greater than 24.9kg/m²) and of all ethnicities and socioeconomic statuses. These individuals will be recruited via primary care clinics in Maryland, much like those in the studies reviewed by the Task Force.

The Task Force findings resulted in sufficient evidence to recommend this intervention in July of 2014. This positive recommendation was based “on strong evidence of effectiveness in reducing new-onset diabetes.” Additionally, the studies reviewed strongly demonstrated a return to normal blood sugar levels and a decrease in several cardiovascular and diabetic risk factors for the participants. These included factors such as decreasing high blood pressure, lowering LDL levels and increasing HDL levels, decreasing cholesterol, and reducing weight.

The following chart describes three different studies utilizing strategies based on a combined diet and physical activity promotion program to prevent Type II Diabetes among people at an increased risk.

Article 1: Sanchez A, Silvestre C, Sauto R, Martínez C, Grandes G; PreDE research group. Feasibility and effectiveness of the implementation of a primary prevention programme for type 2 diabetes in routine primary care practice: a phase IV cluster randomised clinical trial. BMC Fam Pract. 2012 Nov 16;13:109. doi: 10.1186/1471-2296-13-109.
Describe the intervention.	This study involved evaluating the feasibility of implementing a diabetes prevention program into 14 Osakidetza primary care clinics throughout the Basque Country in northern Spain. The targeted population included males and females aged 45-70 years who were at high-risk for type 2 diabetes (i.e. score >14 on the Findrisc Diabetes Risk scale). Participants were excluded if they had a cardiovascular disorder, mental health disorder, renal failure, severe COPD, pregnancy complications, severe infection, or had received or were awaiting an organ transplant.
What did the authors do?	A total of 1,089 participants, non-diabetic but at high risk, were recruited and followed for a two-year span. Healthcare nurses were the primary channels of dissemination for the program.
What was the procedure?	Both the control and intervention groups underwent baseline assessments involving a clinical examination, blood lipid profile, and an oral glucose tolerance test (OGTT). In the control group, the usual care for diabetes prevention and treatment was utilized. In the intervention group, The Diabetes in Europe-Prevention using Lifestyle, Physical Activity and Nutritional Intervention (DE-PLAN), a combined diet and physical activity educational intervention program designed to reduce the risk of developing Type 2 Diabetes, was implemented. This program was implemented in two phases. The first involved four intensive group educational sessions lasting an hour and a half each. In the second phase, once every 6 weeks the participants would receive a motivational reinforcement in the form of educational intervention.
How long was the intervention?	This intervention lasted a total of 24 consecutive months and percentages of individuals diagnosed with diabetes after inclusion in the study were measured at 12 and 24 months.
What were the outcomes measured?	The primary outcome measurement included the relative risk of patients developing Type 2 Diabetes (measured via an OGTT in the intervention and control groups after 2 years). The secondary outcome measurements involved observed healthy lifestyle behavior changes. The 7-Day Physical Activity Recall Questionnaire was used to determine the number of participants in both groups who met the recommended daily PA levels. The Mediterranean Diet Adherence Screener was used to determine the number of participants who consumed 5 or more servings or fruits and vegetables per day.
What amount of change did they find?	This study is a recently implemented program and thus still ongoing. The authors hope to determine the effectiveness of a program implemented to promote healthy lifestyle changes for the prevention of type 2 diabetes upon completion of the study.
Article 2: Brokaw, S. M., Carpenedo, D., Campbell, P., Butcher, M. K., Furshong, G., Helgerson, S. D., & Harwell, T. S. (2015). Effectiveness of an Adapted Diabetes Prevention Program Lifestyle Intervention in Older and Younger Adults. Journal Of The American Geriatrics Society, 63(6), 1067-1074.
Describe the intervention.	This intervention utilized an adapted version of the CDC’s Diabetes Prevention Program. They employed trained health professionals to deliver educational lifestyle behavior change sessions through core and postcore time periods. This intervention involved targeting behavior changes related to nutrition/healthy diet and physical activity. Participants in this study included young (18-65 years old) and older (>65 years old) adults who possessed a higher risk (at least one or more risk factors) for cardiovascular disease or type 2 diabetes and who possessed a BMI >25kg/m² (overweight).
What did the authors do?	The authors did not utilize a randomized study design nor did they implement a control group for comparison. They recruited trained healthcare professionals from a variety of fields (such as registered nurses and dieticians) to act as Lifestyle Coaches for the behavior change sessions and weight monitoring. The authors set the goals for this intervention as the same as those used in the original 10-month Lifestyle Balance Diabetes Prevention Program. These goals included daily self-monitoring of dietary fat intake, achieving an individualized (per body weight) dietary fat intake goal each day, achieving greater than 150 minutes of MVPA each week, and a weight loss of 7% from baseline measurements after the four month core period. An additional goal was to maintain this 7% weight loss throughout the six-month postcore period.
What was the procedure?	Upon enrollment in the study, researched collected height, weight, blood pressure, fasting blood glucose, and lipid level measurements for all participants. Lifestyle coaches also collected a weight measurement at each session. Based on these measurements, participants were given an individualized daily calorie intake and fat intake goal. Participants also had the opportunity for two supervised physical activity sessions per week. Participants were required to submit weekly booklets to their lifestyle coach, in which they self-recorded daily calorie intakes, fat intakes, and physical activity. Lifestyle coaches provided weekly educational sessions for four months (core period), followed by monthly sessions for the next six months (postcore period).
How long was the intervention?	The entire research intervention lasted from 2008 to 2012 (4 years), during which 3,804 total participants enrolled and 2,867 (75%) completed the program in its entirety. Individually, an intervention for a single participant lasted for ten months.
What were the outcomes measured?	Outcome measurements included attendance of the core and postcore sessions, self-monitoring of daily fat intake, self-monitoring of weekly minutes of MVPA, weight loss from baseline after four and ten months, and improvements in cardiovascular disease risk factors (lipid profile, blood pressures, and fasting blood glucose levels).
What amount of change did they find?	The researchers found that older participants were significantly more likely than younger participants to attend a larger majority of the core and postcore sessions, to regularly self-monitor dietary intake and PA levels, and to achieve a 5-7% weight loss. Mean weight loss in the younger participants (18-65 years old) was 3.0kg and mean weight loss in the older participants (65 years and up) was 2.5kg during the postcore period. However, both older and younger participants showed significant improvements in cardiovascular risk factors.
Article 3: Vita, P., Cardona-Morrell, M., Bauman, A., Singh, M. F., Moore, M., Pennock, R., & Colagiuri, S. (2016). Type 2 diabetes prevention in the community: 12-month outcomes from the Sydney Diabetes Prevention Program. Diabetes Research And Clinical Practice, 11213-19.
Describe the intervention.	This study was a community-based translational intervention that utilized the Sydney Diabetes Prevention Program (SDPP) within the primary healthcare setting. The SDPP is a 12-month lifestyle modification program aimed to reduce type 2 diabetes risk factors in those individuals at high risk for developing the disease. The targeted population included males and females aged 50-65 years in the greater Sydney, Australia area. These participants were recruited via 222 PCP’s within 83 primary healthcare clinics who utilized The Australian Diabetes Risk Assessment Tool (AUSDRISK) to evaluate the initial risk of patients (high risk was noted as a score of 15 or greater).
What did the authors do?	The authors utilized Primary Care Physicians to screen a total of 4,055 participants. Of these, after eliminating those who had previously undiagnosed diabetes and those who did not fit the eligibility criteria, the recruited population totaled 1,238 individuals (37.5% male and 62.5% female). The authors also recruited Lifestyle Officers, trained health professionals that ranged from dieticians to psychologists to nurses, to implement a health coaching approach in group and individual sessions. The specific goals set for the SDPP included increasing MVPA to at least 30 minutes per day, reducing total daily fat intake and daily saturated fat intake, increasing daily fiber intake, and reducing weight by 5%.
What was the procedure?	After high-risk patients were identified and recruited via the AUSDRISK, initial height, weight, and waist circumference measurements were taken. The intervention was delivered via one individual and three 2-hour in-person group sessions on healthy behavioral changes. If a participant declined the group session, he or she had the option of an individual session of three health coaching telephone calls instead. All participants received follow-up telephone calls from Lifestyle Officers at 3, 6 and 12 months. At 12 months, a face-to-face visit and intervention review was conducted with the Lifestyle Officer and the PCP. Height, weight and waist circumference measurements were repeated at the 12-month mark.
How long was the intervention?	The entire intervention lasted a total of twelve months. Individual and group health coaching sessions from the Lifestyle Officer each lasted two hours. There was no long-term follow-up conducted.
What were the outcomes measured?	The primary outcomes measured were total and saturated fat intake, minutes per week of moderate to vigorous physical activity, and kilograms of weight change from baseline to completion of the intervention. Additionally, fasting lipid profile and fasting blood glucose measurements were sent to a lab for calculation. A secondary outcome involved change in waist circumference from the baseline measurement to the post-intervention 12-month measurement.
What amount of change did they find?	At 12 months, the average weight loss was 4.3kg overall and the average decrease in waist circumference was 4.7cm. With a significance level of p<0.001, there was a significant change noted in reduced energy intake, reduced total fat intake, reduced saturated fat intake, and increased total fiber intake. Additionally, there were significant reductions in fasting lipid profile measurements. Over 20% of participants achieved a greater than 5% weight loss and a significant proportion of participants reported achieving the nutritional goals after 12 months. Overall, participants reporting having better success achieving diet modification rather than an increase in MVPA. However, compared with other community-based programs, the average 2kg weight loss is thought to equate to about a 30% decrease in Diabetes risk factors (if the weight loss is maintained for at least two years).

Part 3: Intervention Fit

Provide a logic model and SMART Objectives for your intervention. You should have a SMART objective for each behavior you anticipate changing. (35 points; 10 points for SMART objectives, 25 points for the logic model)

Explain the logic of why this intervention may work. For example, why would teaching children about healthy eating change their actual eating behaviors? Or why would adding sidewalks increase physical activity for transportation or recreation? (15 points)
1. Think about the “Field of Dreams” problem – if you offer the intervention, will it actually change behavior?
Discuss limitations of the selected strategy, and things to look out for/be mindful of along the way. Examples may be limitations of resources, community capacity, or anticipated effect of the intervention. (15 points)
What data would you collect to know if you are implementing the strategy the way it was intended (process evaluation/implementation monitoring)? Refer back to your logic model and the Logic Model module as needed. Be sure to cover dose, reach, fidelity, and implementation. (40 points)

Logic Model: Combined Diet and Physical Activity Promotion Programs to Prevent Type II Diabetes Among People at Increased Risk

Input/Resources	Activities	Outputs
• Funding: National Diabetes Prevention Program (NDPP) and American Medical Association (AMA) • Personnel: Primary Care Physicians (PCP’s), Nutritionists/Dieticians, Physical Activity Counselors • Materials: pamphlets and presentations on MVPA goals per week and daily dietary goals • Equipment: diet and physical activity log books • Space: large open space at YMCA’s for PA classes held by physical activity counselors • Relationships: – Coordination between PCP’s, nutritionists/dieticians, and physical activity counselors – Agreement with local YMCA’s to allow physical activity counselors use of facilities for exercise sessions twice a week for one year	• Initial evaluation by PCP to determine eligibility for intervention • After initial evaluation, quarterly visits to PCP (every three months) will include vital signs, BMI measurements, lipid profiles, and fasting blood glucose measurements. • Participants will attend 30 minutes per week of one-on-one nutritional counseling for the first 2 months (8 sessions), followed by monthly 30 minute sessions for the remaining 10 months, in which they will receive individually tailored diet goals • Participants will have 15 minutes of physical activity counseling and discussion of PA goals following each PCP visit • Participants will be offered two physical activity sessions at local YMCA’s per week, conducted by the study’s participating physical activity counselors • Participants will be given a diet and physical activity log book to track their nutritional habits and PA minutes per week and discuss with their nutritionist and physical activity counselor	• PCP’s will review the diet and PA logs at each visit • Nutritionists will review with the participants the diet log and any necessary adjustments at each session • Physical activity counselors will review the PA log at each visit and discuss necessary changes • At each quarterly visit, PCP’s will take the participants’ vital signs (heart rate, respiratory rate and blood pressure), height, weight, lipid levels, and fasting blood glucose
Short-Term Outcomes	Intermediate Outcomes	Long-Term Outcomes
• Increased recognition of average (healthy) dietary intake levels for individualized weight • Increased awareness of fat and sugar intakes • Increased knowledge of weekly physical activity goals • Improved awareness of the importance of diet and PA in preventing diabetes	• Decreased dietary fat intakes • Decreased dietary sugar intakes • Increased minutes of MVPA per week	• Decreased BMI from baseline as a result of dietary and physical activity behavior changes • Decreased LDL and increased HDL levels from baseline • Decreased fasting blood glucose levels from baseline • Decreased blood pressure measurements from baseline • Decreased risk of type II diabetes as evidenced by reduced prevalence of obesity • Reduced number of health complications due to diabetes risk factors (i.e. cardiovascular incidents) • Decreased prevalence of diabetes

SMART Objectives:

Behavior Change: Decrease dietary fat intakes
SMART Objective: 80% of participants in this combined diet and physical activity intervention will intake <30% of daily energy from fat by the end of the one-year program (December 31, 2017).
Behavior Change: Decrease dietary sugar intakes
SMART Objective: 80% of participants in this combined diet and physical activity intervention will intake <5% of daily energy from sugar by the end of the one-year program (December 31, 2017).
Behavior Change: Decrease the BW of Combined Diet and PA Maryland DPP participants
SMART Objective: 80% of participants in this combined diet and physical activity intervention will lose 5% or more of body weight from baseline by the end of the one year program (December 31, 2017).
Behavior Change: Increase MVPA minutes per week of Combined Diet and PA Maryland DPP participants
SMART Objective: By June 30, 2017 (halfway mark), 75% of participants in this combined diet and physical activity intervention will report completing greater than 150 minutes of MVPA per week.
Behavior Change: Increase awareness of and adherence to recommended daily dietary intakes
SMART Objective: 90% of participants in this combined diet and physical activity intervention will decrease their LDL levels to 100mg/dL or less and increase their HDL levels to 60mg/dL or greater by the end of the one year program (December 31, 2017).

This intervention focuses largely on individualized plans with one-on-one sessions to discuss progress and promote accountability. The participants have multiple resources – the PCP, nutritionist/dietician, and physical activity counselor – from whom they can learn healthy diet and physical activity habits. This is a logical intervention, as it measures progress along the way via quarterly visits with the PCP, during which objective measurements are taken (i.e. vital signs, BMI measurements, lipid profiles, and fasting blood glucose measurements); via individual sessions with the nutritionist/dietician once a week for eight weeks and then once a month for ten months; and via individual sessions with a physical activity counselor following each PCP visit. Additionally, this intervention targets a population in need of these lifestyle changes. After discussion with the PCP of the risks that high blood pressure, poor lipid profiles and high fasting blood glucose levels can pose to developing type II diabetes, participants should have a clear view of the advantages a healthy diet and regular physical activity can supply. Also, as the targeted population is individuals with a BMI of > 24.9kg/m², a reduced body weight from this program can aid in an improved cardiovascular risk profile as well.

A major limitation of this study is the self-reported measures of dietary intakes and weekly physical activity. All participants may not be accurate, truthful or consistent in his or her log of individual daily dietary intakes and physical activity. Additionally, participants are not required to attend the physical activity sessions at the YMCA. They are simply offered as opportunities to engage in a portion of the recommended 150 minutes of MVPA per week that help to hold individuals accountable if they prefer not to do the exercise on their own. Another limitation is the ability of the participants to afford healthy foods and the access participants have to a safe environment in which to exercise. Many areas of Maryland, such as Baltimore City, are very urbanized and may not have large open spaces such as parks or athletic fields at which participants can engage in physical activity.

Additionally, this intervention provides a large amount of access to educational information via the participants’ personal nutritionist/dietician, physical activity counselor and primary care provider, all of which may not be accessible following the intervention. However, the hope is to establish healthy dietary and physical activity habits that will be sustained for a long period of time. Finally, this intervention would be difficult to implement long-term due to the amount of resources it requires. Three different health professionals are utilized in the intervention and each, due to the individual sessions provided for each participant, devotes a large amount of time to the intervention. There is no long-term follow-up included to determine the sustainability of the behavior changes initiated during this intervention.

As this program is initially being implemented via primary care providers, the targeted audience (obese individuals older than 18 years) is within reach of the program only if they in fact visit their primary healthcare clinic. Thus, the reach of this intervention is missing any individuals who are either to stubborn to seek medical care at their primary care clinic or who do not have the financial means or insurance coverage to visit a primary care clinic. Furthermore, no promotional advertising is utilized in this intervention. If some of the targeted population were aware of the potential to participate in a combine diet and physical activity prevention program via their primary care clinic, they may be more inclined to seek medical care. When evaluating the coverage of this intervention, it is also important to consideration participation of the intended target population. Not every eligible individual may choose to participant in the intervention, and not every participant may complete the entire program or even consistently complete all components of the program. Participation can be partially monitored by taking attendance at the biweekly offered physical activity sessions at the YMCA. Coverage and reach can be estimated by comparing the number of individuals who enroll in the study with the overall number of the targeted population in Maryland (i.e. Maryland’s estimated number of obese individuals). Particularly, survey the geographic and socioeconomic subgroups from which the enrolled participants come and compare this number to the average number of obese individuals expected in these subgroups overall throughout Maryland.

This intervention provides a significant dosage, as it includes eighteen potential nutritional consultations and four physical activity consultations, with an additional 104 optional exercise sessions offered at local YMCA’s. However, there is no way to guarantee all of the participants attend all of these provided sessions. Reasons for nonparticipation or missed attendances could include lack of transportation, injury or illness, lack of childcare, poor weather conditions, or simply forgetfulness. To estimate dosage, a log can be maintained to keep track of how many participants attend what percentage of the PCP visits, nutritional counseling appointments, PA counseling appointments, and optional PA sessions provided during the intervention.

Another important consideration to the overall success of the intervention is the extent to which program activities are delivered and implemented as intended. In this case, the success of the program also depends a large part on how well the PCP’s, nutritionists, and physical activity counselors deliver the educational information and how well they individually tailor the diet and physical activity programs for the participants. Their success in the delivery can largely affect the adherence of the participants to the set goals. As professional nutritionists, dieticians and physical activity counselors are used in this intervention, training in their respective fields in unnecessary. However, they should be instructed in the goals of the intervention and potentially in communication methods regarding working relationships with other healthcare professionals. Each specialist’s role, as a PCP, a nutritionist, and a physical activity counselor, is just as important individually as the entire team’s role as a unit in achieving the best health outcomes for the participants. To determine the successful fidelity and delivery of the intervention, participants could be offered a satisfaction survey at the end of the program. Additionally, those administering the intervention can be interviewed on how well they believe they implemented the program as it was intended. In particular, questioning the different specialists on how well they believe the interaction, coordination and communication between each other functioned and how important this communication was to the success of the program is an important factor affecting fidelity.

In this particular program, accuracy may be the most at risk. As a large part of the program depends on self-reported measures of dietary intake and physical activity, there is no way to definitively ensure the participants are accurately recording this data. Accuracy can simply be promoted at the nutritionists’ and physical activity counselors’ insistence during the individual meetings, by encouraging precise logging of diets and minutes of MVPA will lead to better health outcomes.

Part 4: Reflection

Oftentimes when working with communities, the initial plan is not what ultimately happens. What would your second choice strategy be for your identified behavior and community? Why would you choose this strategy? In other words, in what ways would this strategy also address the needs of the community based on your assessment for Part 1? (25 points)

My initially chosen strategy for diabetes prevention involved a combined diet and physical activity promotion program for individuals at increased risk of Type 2 Diabetes, implemented via primary care providers in healthcare clinics. However, this strategy, although logical, also has several limitations. My second choice strategy for diabetes prevention involves a self-management education intervention in community settings for adults with Type 2 Diabetes. This would still involve cooperation and coordination with primary care providers. However, the implementation settings would include community centers, support groups for Type 2 Diabetes (NIDDM), faith-based institutions, and NIDDM community treatment centers. Although this does not eliminate the need for PCP education in the primary healthcare setting, it does expand the reach of diabetes prevention education by including participants who may not have the financial means to see a doctor or who feel intimidated by a medical setting. It also utilizes a group-based setting rather than one-on-one counseling and thus adds a larger aspect of social support to the intervention.

The short-term and intermediate outcomes of this intervention strategy remain the same and include increasing knowledge of diabetes risk factors and methods for prevention, increasing awareness of the importance of diet and physical activity, improving attitudes and beliefs regarding Type 2 Diabetes, and increasing the behaviors of a healthy diet and adequate physical activity. I think this is an equally as important strategy because education and awareness are important foundations to changing any health behavior. These along with motivation to change those behaviors, which should hopefully result from the participants’ increased education, are key to improving diet and physical activity among those at an increased risk or currently suffering from Type 2 Diabetes. However, this strategy of self-management education for prevention of Type 2 Diabetes would be most effective when combined with treatment by a primary care provider in a clinic setting.

Reflect on how you may use the Community Guide, Nutrition Education Library, and other resources in the future. What did you like about these resources? What didn’t you like? Provide suggestions on how you would make the sites easier for practitioners to use. (20 points)

The Community Guide website provides easily accessible information on a wide variety of mental and physical health and well-being related subjects. I found it incredibly useful in the in which all of this information was organized into one section, making it easy to browse among the different topics. The Community Guide also gives a very clearly laid out summary of its findings as well as access to the publications reviewed and the information in each strategy in detail. This provided an excellent resource from which to determine the components of potential community health strategies.

A suggestion that could be considered for future implementation may be a section listing clinical applicability for different fields. For example, which strategies are thought to be most appropriate for utilization by a sports medicine clinician versus a geriatric nutritionist versus a pediatric physician. Additionally, perhaps for strategies found to have insufficient evidence for recommendation, information could be suggested on future research needed or alterations that could be made to increase the amount of evidence and help achieve task force recommendation.

References:

American Diabetes Association. (2016, April 1). Statistics About Diabetes. Retrieved September 03, 2016, from http://www.diabetes.org/diabetes-basics/statistics/.

American Heart Association. (2015, August). Understand Your Risk for Diabetes. Retrieved September 03, 2016, from http://www.heart.org/HEARTORG/Conditions/Diabetes/UnderstandYourRiskforDiabetes/Understand-Your-Risk-for-Diabetes_UCM_002034_Article.jsp#.V8r9LWXrKSU.

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