Reducing Diabetes Risk in American Indian Women
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Slide 1 :
Reducing Diabetes Risk in American Indian WomenJanice L. Thompson, Peg Allen, Deborah L. Helitzer, Clifford Qualls, Ayn N. Whyte, Venita K. Wolfe, Carla J. Herman Funded by the National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health (grant # R01 DK 047096) and supported by DHHS/NIH/NCRR-GCRC Grant # M01 RR00977
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Acknowledgments This study is dedicated to Dr. Janette Carter, who passionately devoted her life work to the prevention and management of diabetes among Native Americans.
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Acknowledgments All authors report no conflicts of interest relevant to the subject manner discussed in this manuscript. We heartily thank the women who participated in this study. We also acknowledge the GCRC nursing and dietetic outpatient staff for assistance with data collection, and Novaline Wilson, MPH, Georgia Perez, and Brenda Broussard, MPH, RD for their contributions to intervention design and implementation and participant recruitment and retention in this study. All of these individuals were financially compensated for their time and contributions to this study.
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Background Depending on the Native American tribes, prevalence rates for type 2 diabetes 2-5 times higher than in non-Hispanic whites 56.3% of Native American women aged 18 and over are overweight or obese (compared to 50.6% of U.S. women overall) 45.5% of Native American women aged =18 reported no leisure-time physical activity (compared to 39.8% of U.S. women overall) Over 60% of Native Americans now live in urban areas Diabetes in American Indians and Alaska Natives. NIH Pub. No 02-4467, May 2002. National Health Interview Surveys 2002-2004: Adams PF, Schoenborn CA. Health behaviors of adults: United States, 2002-04. National Center for Health Statistics. Vital Health Stat 10(230). September 2006. U.S. Census Bureau, 2000 Census, www.census.gov/.
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Background Intensive individual interventions with high risk adults show decreased risk of type 2 diabetes (e.g. Diabetes Prevention Program) Can lower-intensity, more easily replicable group interventions also reduce risk of type 2 diabetes? Knowler, W, Barret-Connor E, Fowler S, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM. 2002; 346(6): 393-403. Schulze MB, Hu FB. Primary prevention of diabetes: What can be done and how much can be prevented? Annual Reviews of Public Health 2005;26:445-67. Steyn NP et al. Diet, nutrition and the prevention of type 2 diabetes. Public Health Nutrition. 2004;7(1A):147-165.
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Purpose Determine the effects of a culturally influenced intervention on behavioral risk factors for type 2 diabetes among asymptomatic American Indian women recruited from the general urban community.
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Main Research Hypothesis Intervention participants would improve one or more of the following primary outcomes in the intervention group compared to the control group over 18 months of follow-up: decreased dietary fat, total energy intake, increased vegetable consumption, self-reported leisure-time physical activity or percentage of participants who meet physical activity recommendations.
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Secondary Research Hypothesis Intervention participants would improve on fruit and sweetened beverage intake, body composition, insulin sensitivity, fasting blood glucose (FBG), resting blood pressure or lipid profiles in the intervention group compared to the control group over the 18-month follow-up period.
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Intervention Development Based on the earlier Strong in Body and Spirit group educational sessions with rural Pueblo adults (Gilliland et al., 2002; Diabetes Care, 25:78-83). 32 Native American women participated in three focus groups to discuss the health information needs of NA women and content for diabetes prevention program Feedback incorporated Five pilot group sessions developed by multicultural team
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Pilot Testing of Curriculum The Sharing Wisdom curriculum was then pilot tested with 7 urban Native American women. The 7 women attended the 5 group sessions. Women assessed the cultural relevance, content, organization, and format of the curriculum. Women gave feedback after each session and in a structured interview with the evaluation team.
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Outcomes of Pilot Testing Wanted more thorough explanation of how healthful eating and physical activity reduce risks for diabetes Came from various tribal communities and diverse backgrounds, and indicated there is no ONE appropriate cultural message for all Native women. Wanted program to include friends and family Wanted information on how tribes around the country are reducing diabetes risks Appreciated opportunity to help design a program
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Sharing Wisdom Curriculum Session One: Be Strong in Body and Spirit - Wellness, diabetes, stress, physical activity Session Two: Veggie Tales - Increasing veggies & fruits, decreasing fats - Food labels, handling eating out Session Three: Sugar and Spice Aren’t Necessarily Nice - Added sugars, sugared beverages, snacks Session Four: Planting Seeds of Wisdom - Social support Session Five: Growing Your Garden of the Future
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Group Sessions Women attended one session per month Sessions lasted about 2.5 hours Each session was offered 3 times and when participants selected (evenings, weekends) Facilitated discussion format, led by Native American women as peer role models Each session included goal setting & action steps & review of how it went the previous month
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Recruitment Women recruited through word of mouth, flyers, key informants, radio and print media: Local community college and university Community Centers Health Clinics at Albuquerque Area Indian Health Services and First Nations Health Source Local businesses, stores, laundromats Word of mouth was most effective
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Participant Eligibility Female Age 18-40 years Native American (self-identified) No diabetes Not pregnant or breastfeeding and not planning to get pregnant for 2 years Plan to live in local urban area for 2 years
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Study Design Randomized controlled trial that was community-based. 100 women randomized into intervention group 100 women into control group Intervention women did group sessions between baseline and 6 month clinic visit Clinical measures taken at baseline, 6-, 12-, and 18-months Control group women received intervention after 18-month clinic measures Women recruited in four waves, clinical measures conducted June 2002 – February 2006 Delayed intervention classes finished June 2006
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Dietary Measures Dietary patterns self-reported on standardized Block food frequency questionnaire (Block 1986) -Includes Southwestern foods -Past 12-month or 6-month intake 24-hour dietary recall by research dietitians -Sweet beverage intake -Frequency of eating out Block et al. (1986). Am J Epidemiol 124:453-469.
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Other Clinical Measures Fasting glucose, insulin, and blood lipids Resting systolic and diastolic blood pressures Height (stadiometer), weight (beam scale), waist circumference (measuring tape) Body mass index (BMI) calculated from height and weight (kg/m2)
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Other Clinical Measures % Body Fat – bioelectrical impedance analysis, using an equation validated with Native American women (Stolarczyk 1994) Self-reported physical activity using questionnaire validated with Native Americans (Kriska 1993) Sub-maximal bicycle fitness test (YMCA protocol) Stolarczyk et al., (1994). Am J Clin Nutr 59:964-970. Kriska et al. (1993). Diabetelogia 36:863-869. Block et al. (1986). Am J Epidemiol 124:453-469.
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Statistical Analyses All data analyzed in 2006 and 2007 by Clifford Qualls, PhD Used an intent-to-treat analysis (carried forward last values for each measure from point of dropout). Remaining missing values interpolated by averaging adjacent values.
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Statistical Analyses (continued) 2X4 (group by visit) repeated measures ANOVA using PROC MIXED used to determine effects of intervention over follow-up. For nonsignificant group by visit interactions, higher order interactions were excluded and results reported for reduced models. For categoric variables, Fisher’s exact test was used to determine between-group differences.
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At baseline (n=200): Average age 29.3 years old (range 18-40) Most were Navajo (66%) or Pueblo (19%), others from 18 different tribal nations in U.S. 74% with family history of type 2 diabetes 72% had at least some college education 63.5% worked outside the home 56.5% were mothers children at home Participant Characteristics
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At baseline (n=200): 21% with impaired fasting glucose (100-125 mg/dL) 40% obese (BMI = 30 kg/m2) 33% overweight (25.0 = BMI < 30 kg/m2) Mean %body fat = 41.2 ± 6.4 percent Mean total energy intake = 2211± 972 kcal Mean percent fat in the diet = 39.0 ± 5.5% Baseline characteristics statistically similar across intervention and control groups (p>.10) Participant Characteristics
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Intervention Group Attendance Among the 100 intervention group women: 53% attended 3 or more group sessions 27% attended 1 or 2 classes Attendees appreciated sharing and discussing behavior change challenges & problem solving Evaluation team did 25 exit interviews with women who attended = 3 classes
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Clinic Visit Retention Among all 200 women: 82% at 6-months (n=164) 77% at 12-months (n=154) 68% at 18-months (n=135) Reasons for dropout included moving out of state, becoming pregnant or being too busy Dropout was statistically random and similar across the intervention and control groups
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Figure 1. Flow of study participants showing new dropouts at each follow-up
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Impact of Intervention on Primary Outcomes Significant group by visit interaction for vegetable intake. No other significant group by visit interactions for primary outcomes. Significant effect of visit for both groups – decreased energy intake, total fat intake, saturated fat intake. No change in leisure time physical activity.
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Changes in Dietary Intake Servings per Day Note: RM ANOVA group by visit interaction p=.02
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Impact of Intervention on Secondary Outcomes Significant group by time interaction for fruit intake. Group by visit interactions for BMI and diastolic blood pressure (DBP) approached significance. Indicated trend toward decrease in BMI in intervention group and increased in BMI in control group over time (p=0.08). Also indicated trend toward decrease in DBP for the intervention group and increase in the control group at 6 months post-intervention (p=0.06). Significant effect of visit for both groups indicating decreases in dietary intake of total sugar, sweetened beverages, TV viewing, waist circumference, total cholesterol, and LDL and increases in HDL.
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Changes in Dietary Intake Servings per Day Note: RM ANOVA group by visit interaction p=.006
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Physiological Changes Note: Changes not significant by group over time.
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Body Composition Changes Note: No significant differences by group.
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Body Composition Changes Note: No significant differences by group.
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Results among Women with Impaired Fasting Glucose (n=42) Regardless of group: 62% of the women converted to normal FBG by 18-months Average decrease in FBG at 18-months: 12% among those who maintained any amount of weight loss at 18-months 1% among those who did not Mean percent of baseline body weight lost at 18-months among those who lost weight was 6.2%
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Conclusions Native recruiters were effective Word of mouth most effective form of recruitment Mobile population so high drop-out should be planned for in future studies Most women had cell phones only & frequent # changes Getting permission to contact 2 friends or relatives at the beginning made follow-up possible
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Conclusions Structured physical activity intervention may have helped women improve fitness Results indicate that a culturally influenced, less intensive lifestyle intervention can result in improvements in self-reported intakes of vegetables and fruit over an 18-month period. Both intervention and control groups experienced positive changes in metabolic health parameters and in TV viewing, fat and sugar intake, and consumption of sweetened beverages. Results suggest less-intensive interventions may be effective in reducing risk for type 2 diabetes in young, urban American Indian women.
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