Effectiveness of an Adapted Diabetes Prevention Program Lifestyle Intervention in Older and Younger Adults Sarah M. Brokaw, MPH, Dorota Carpenedo, MPH, Paul Campbell, MS, NASM-CPT, Marcene K. Butcher, RD, CDE, Ginny Furshong, BS, Steven D. Helgerson, MD, MPH, Todd S. Harwell, MPH, and the Montana Cardiovascular Disease and Diabetes Prevention Workgroup*
OBJECTIVES: To compare participation, self-monitoring behaviors, and weight loss outcomes in older and younger participants in an adapted Diabetes Prevention Program (DPP) lifestyle intervention. DESIGN: Pre- and postevaluation of outcomes in participants enrolled in the Montana Cardiovascular Disease (CVD) and DPP lifestyle intervention from 2008 through 2012. SETTING: Community. PARTICIPANTS: Adults at high risk for CVD and type 2 diabetes mellitus (N = 3,804). MEASUREMENTS: Number of core (16 weekly sessions) and postcore (6 monthly sessions) intervention sessions attended, weekly self-monitoring of fat intake and minutes of physical activity, weight loss outcomes and achievement of the weight loss goal, and improvements in CVD-related risk factors. RESULTS: Participants aged 65 and older were significantly more likely to attend more intervention sessions, self-monitor their fat intake, and achieve the physical activity and weight loss goals than those younger than 65. Older and younger participants experienced significant improvements in CVD-related risk factors. CONCLUSION: Older adults at high risk of CVD and diabetes mellitus participating in an adapted DPP lifestyle intervention had higher participation and self-monitoring rates than younger participants, were more likely to achieve physical activity and weight loss goals, and achieved similar CVD risk reduction. J Am Geriatr Soc 63:1067–1074, 2015.
Key words: type 2 diabetes mellitus; prevention; lifestyle intervention; age; Montana From the Montana Department of Public Health and Human Services, Helena, Montana. *Members of the Montana Cardiovascular Disease and Diabetes Prevention Workgroup are identified in Appendix 1. Address correspondence to Sarah M. Brokaw, Montana Department of Public Health and Human Services, Cogswell Building, C-314, PO Box 202951, Helena, MT 59620. E-mail: [email protected] DOI: 10.1111/jgs.13428
JAGS 63:1067–1074, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
T
he prevalence of type 2 diabetes mellitus continues to increase in the United States. From 1980 through 2011, the number of U.S. adults with diagnosed diabetes mellitus rose from 5.5 million to 19.6 million, and an additional 7 million adults had undiagnosed disease in 2011. In 2011, the percentage of diagnosed diabetes mellitus in people aged 65 to 74 was 21.8%, which was more than 13 times that of people younger than 45 (1.6%).1 Landmark randomized controlled clinical trials, including the Da Qing Diabetes Prevention Study, the Finnish Diabetes Prevention Study (DPS), and the National Institutes of Health (NIH) Diabetes Prevention Program (DPP), have demonstrated that the incidence of type 2 diabetes mellitus in adults at high risk can be significantly reduced through an intensive lifestyle intervention.2–4 The lifestyle interventions in these studies were delivered one on one to participants.3,4 In the DPP, participants in the lifestyle intervention group had a 58% lower risk of developing type 2 diabetes mellitus than the placebo group at approximately 3 years and a 34% lower risk at 10 years.4,5 Participants in the lifestyle group aged 60 and older had a 71% lower risk than those in the placebo group.4 In the NIH DPP and DPS trials, older participants in the lifestyle interventions were significantly more likely to achieve the study weight loss goals than younger participants.3,6 Since the publication of these landmark studies, a number of translation studies have shown that it is feasible to deliver the lifestyle intervention in a group setting and achieve similar weight loss outcomes.7–16 One limitation of the majority of these translation studies is the small number of participants enrolled, particularly participants aged 65 and older. Additionally, none of these translation studies have assessed adherence to the lifestyle intervention or the effectiveness of the intervention related to weight loss outcomes in older and younger participants. In 2008, the Montana Department of Public Health and Human Services (DPHHS) implemented an adapted group-based CVD and DPP, demonstrating the feasibility of enrolling high-risk adults and achieving weight loss outcomes
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similar to those in the NIH DPP.8,9 The objective of this study was to evaluate adherence, self-monitoring behaviors, and weight loss outcomes in older and younger participants in this adapted DPP lifestyle intervention.
activity, and calories and submitted weekly self-monitoring booklets for the lifestyle coaches to review. Self-reported grams of fat and calorie intake were reported as a daily average and physical activity minutes as a weekly total.
METHODS
Data Analysis
Intervention Sites and Intervention Design A description of this intervention has been published previously.8,9 Briefly, the Montana DPHHS began implementing an adapted DPP in a group setting in 2008. The lifestyle intervention is delivered at 15 intervention sites in urban and rural communities within Montana: 10 diabetes selfmanagement education (DSME) programs, two DSME programs in collaboration with their local YMCA, one cardiac rehabilitation program, one rural health clinic, and one local health department. Sites use trained health professionals (registered dietitians and registered nurses) as lifestyle coaches to provide 16 core sessions, followed by six monthly postcore sessions. These sessions were initially delivered using the original DPP’s 10-month Lifestyle Balance curriculum, and in 2012, the sites began implementing an updated version, the Centers for Disease Control and Prevention (CDC) national DPP curriculum.17,18 The participant lifestyle change goals for this intervention are the same as those in the original DPP:17 daily selfmonitoring of dietary fat intake and achieving a dietary fat intake goal customized to their baseline weight, achieving 150 minutes or more per week of moderately vigorous physical activity, and achieving weight loss of 7% or more of baseline weight at completion of the 4-month core period and maintaining that weight loss during the 6-month postcore period.
Data were analyzed using SAS 9.3 (SAS Institute, Inc., Cary, NC). Participants were categorized into two age groups (150 mg/dL, low-density lipoprotein-cholesterol >130 mg/ dL or treatment, or high-density lipoprotein cholesterol (HDL-C)
OBJECTIVES: To compare participation, self-monitoring behaviors, and weight loss outcomes in older and younger participants in an adapted Diabetes Prevention Program (DPP) lifestyle intervention. DESIGN: Pre- and postevaluation of outcomes in participants enrolled in the Montana Cardiovascular Disease (CVD) and DPP lifestyle intervention from 2008 through 2012. SETTING: Community. PARTICIPANTS: Adults at high risk for CVD and type 2 diabetes mellitus (N = 3,804). MEASUREMENTS: Number of core (16 weekly sessions) and postcore (6 monthly sessions) intervention sessions attended, weekly self-monitoring of fat intake and minutes of physical activity, weight loss outcomes and achievement of the weight loss goal, and improvements in CVD-related risk factors. RESULTS: Participants aged 65 and older were significantly more likely to attend more intervention sessions, self-monitor their fat intake, and achieve the physical activity and weight loss goals than those younger than 65. Older and younger participants experienced significant improvements in CVD-related risk factors. CONCLUSION: Older adults at high risk of CVD and diabetes mellitus participating in an adapted DPP lifestyle intervention had higher participation and self-monitoring rates than younger participants, were more likely to achieve physical activity and weight loss goals, and achieved similar CVD risk reduction. J Am Geriatr Soc 63:1067–1074, 2015.
Key words: type 2 diabetes mellitus; prevention; lifestyle intervention; age; Montana From the Montana Department of Public Health and Human Services, Helena, Montana. *Members of the Montana Cardiovascular Disease and Diabetes Prevention Workgroup are identified in Appendix 1. Address correspondence to Sarah M. Brokaw, Montana Department of Public Health and Human Services, Cogswell Building, C-314, PO Box 202951, Helena, MT 59620. E-mail: [email protected] DOI: 10.1111/jgs.13428
JAGS 63:1067–1074, 2015 © 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society
T
he prevalence of type 2 diabetes mellitus continues to increase in the United States. From 1980 through 2011, the number of U.S. adults with diagnosed diabetes mellitus rose from 5.5 million to 19.6 million, and an additional 7 million adults had undiagnosed disease in 2011. In 2011, the percentage of diagnosed diabetes mellitus in people aged 65 to 74 was 21.8%, which was more than 13 times that of people younger than 45 (1.6%).1 Landmark randomized controlled clinical trials, including the Da Qing Diabetes Prevention Study, the Finnish Diabetes Prevention Study (DPS), and the National Institutes of Health (NIH) Diabetes Prevention Program (DPP), have demonstrated that the incidence of type 2 diabetes mellitus in adults at high risk can be significantly reduced through an intensive lifestyle intervention.2–4 The lifestyle interventions in these studies were delivered one on one to participants.3,4 In the DPP, participants in the lifestyle intervention group had a 58% lower risk of developing type 2 diabetes mellitus than the placebo group at approximately 3 years and a 34% lower risk at 10 years.4,5 Participants in the lifestyle group aged 60 and older had a 71% lower risk than those in the placebo group.4 In the NIH DPP and DPS trials, older participants in the lifestyle interventions were significantly more likely to achieve the study weight loss goals than younger participants.3,6 Since the publication of these landmark studies, a number of translation studies have shown that it is feasible to deliver the lifestyle intervention in a group setting and achieve similar weight loss outcomes.7–16 One limitation of the majority of these translation studies is the small number of participants enrolled, particularly participants aged 65 and older. Additionally, none of these translation studies have assessed adherence to the lifestyle intervention or the effectiveness of the intervention related to weight loss outcomes in older and younger participants. In 2008, the Montana Department of Public Health and Human Services (DPHHS) implemented an adapted group-based CVD and DPP, demonstrating the feasibility of enrolling high-risk adults and achieving weight loss outcomes
0002-8614/15/$15.00
1068
BROKAW ET AL.
JUNE 2015–VOL. 63, NO. 6
JAGS
similar to those in the NIH DPP.8,9 The objective of this study was to evaluate adherence, self-monitoring behaviors, and weight loss outcomes in older and younger participants in this adapted DPP lifestyle intervention.
activity, and calories and submitted weekly self-monitoring booklets for the lifestyle coaches to review. Self-reported grams of fat and calorie intake were reported as a daily average and physical activity minutes as a weekly total.
METHODS
Data Analysis
Intervention Sites and Intervention Design A description of this intervention has been published previously.8,9 Briefly, the Montana DPHHS began implementing an adapted DPP in a group setting in 2008. The lifestyle intervention is delivered at 15 intervention sites in urban and rural communities within Montana: 10 diabetes selfmanagement education (DSME) programs, two DSME programs in collaboration with their local YMCA, one cardiac rehabilitation program, one rural health clinic, and one local health department. Sites use trained health professionals (registered dietitians and registered nurses) as lifestyle coaches to provide 16 core sessions, followed by six monthly postcore sessions. These sessions were initially delivered using the original DPP’s 10-month Lifestyle Balance curriculum, and in 2012, the sites began implementing an updated version, the Centers for Disease Control and Prevention (CDC) national DPP curriculum.17,18 The participant lifestyle change goals for this intervention are the same as those in the original DPP:17 daily selfmonitoring of dietary fat intake and achieving a dietary fat intake goal customized to their baseline weight, achieving 150 minutes or more per week of moderately vigorous physical activity, and achieving weight loss of 7% or more of baseline weight at completion of the 4-month core period and maintaining that weight loss during the 6-month postcore period.
Data were analyzed using SAS 9.3 (SAS Institute, Inc., Cary, NC). Participants were categorized into two age groups (150 mg/dL, low-density lipoprotein-cholesterol >130 mg/ dL or treatment, or high-density lipoprotein cholesterol (HDL-C)
