Presentations:

338-OR: Communicating Cardiovascular Risk to Latinos with Type 2 Diabetes Using a Spanish Language-Based Multimedia Program
Monday, Jun 11, 2012, 4:30 PM - 4:45 PM
PARIS ROACH, CHANDAN SAHA, DAVID G. MARRERO, Indianapolis, IN.

Abstract:

Cardiovascular disease (CVD) is the leading cause of mortality in Latinos with type 2 diabetes (T2DM), yet CVD risk factors (RF) are under-treated in this population. This may result from low awareness of CVD and low literacy among patients and from linguistic barriers, limited encounter time, and “clinical inertia” among providers. To address these barriers, we developed a Spanish-language, tablet computer-based multimedia CVD risk communication intervention consisting of a series of video presentations that patients viewed just prior to outpatient encounters. Each presentation uniquely incorporated individual CVDRF data and 10-year CVD risk based on UKPDS Risk Engine estimates. The program also generated color graphic 1-page printouts showing updated CVDRF status for use during the encounter. The hypothesis that this intervention would stimulate therapeutic intervention (TI), i.e. the discussion of CVD risk during the visit (determined via exit interviews) or a change in medication directed toward CVDRFs (determined via chart audit) was tested in a randomized controlled comparison of the intervention vs usual care in four urban primary care clinics providing care to the local Spanish-speaking Latino population. Participants (n=144) had a mean age of 47 years, 69% had less than a high school education, and 87% had annual income less than $40K. Patients in the intervention group (n=86) were exposed to the intervention one to three times during the 12-month follow-up period, and compared to control patients (n=58), had an overall TI rate that was 87% higher, based on a Poisson regression model: 19.6 vs. 10.5 TI per patient per 12 months, p=0.023. 94-100% of intervention group patients felt that it facilitated interactions with their providers. This multimedia CVD risk communication intervention resulted in a significant increase in TI aimed at reducing CVDRFs in a Spanish-speaking population with T2DM and was used successfully within the primary care environment.

COMMENT: The intervention was simple and resulted in improved patient/provider communication and increased prescriptions for blood pressure and lipid control in a low literacy and income cohort.

339-OR: Impact of Communicating Genetic and Phenotypic Risk of Type 2 Diabetes (T2D) on Objectively-Measured Physical Activity (PA): The Diabetes Risk Communication Trial
Monday, Jun 11, 2012, 4:45 PM - 5:00 PM
JOB G. GODINO, ESTHER VAN SLUIJS, THERESA M. MARTEAU, STEPHEN SUTTON, STEPHEN J. SHARP, SIMON J. GRIFFIN, Cambridge, United Kingdom

Abstract

Information about risk of T2D is widely available, yet effects are uncertain and regulation of providers has been proposed. We aimed to assess effects of providing such information on risk reducing health behaviors, anxiety, and cognitive and emotional antecedents of behavior change.
We recruited 569 adults aged 39 to 61 years from a population-based observational study in Cambridgeshire, UK. Participants underwent clinical, anthropometric, and psychosocial measurements, were genotyped for 23 SNPs associated with T2D, and wore a combined heart rate and movement sensor (Actiheart) continuously for 6 days and nights to assess PA. They were randomized to receive either standard lifestyle advice alone (control group, n=190), or in combination with a genetic (n=189) or phenotypic (n=190) risk estimate for T2D. PA (energy expenditure in kJ/kg/day), fruit and vegetable (FV) consumption (g/day), self-reported weight (kg), intention to increase PA and FV consumption (5-point scale), anxiety (State-Trait Anxiety Inventory), and diabetes related worry (24-point scale) were remeasured 8 weeks after randomization. We assessed intervention effects by regression analysis, adjusted for baseline values.
557 (98%) participants completed the trial. Comparing the combined intervention groups with the control group, no effect was observed on PA (β=1.15, 95% CI:-1.34 to 3.65, p=0.37), FV consumption (β=-4.08, 95% CI:-37.3 to 29.1), self-reported weight (β=-0.06, 95% CI:-0.63 to 0.51), intentions (PA: β=0.01, 95% CI: -0.09 to 0.11; FV consumption: β=0.02, 95% CI:-0.07 to 0.11), anxiety (β=-0.29, 95% CI:-1.77 to 1.19), and diabetes related worry (β=0.16, 95% CI:-0.12 to 0.45). There was no difference in outcomes between intervention groups.
Information about genetic or phenotypic risk of T2D is not associated with changes in behavior or anxiety in the short term, and it is unlikely to enhance T2D prevention strategies.

COMMENT: While providing genetic or phenotype risk improved patient knowledge without increasing worry or anxiety, it was ineffective in changing behavior.

340-OR: The Effect of Community-Based Peer Support in Achieving and Maintaining Weight Loss Following Lifestyle Intervention
Monday, Jun 11, 2012, 5:00 PM - 5:15 PM
GRETCHEN A. PIATT, MIM C. SEIDEL, ROBERT POWELL, JANICE C. ZGIBOR, Ann Arbor, MI, Pittsburgh, PA.

Abstract

341-OR: Weight Loss for Metabolic Syndrome in Primary Care: Results from the SHINE Telephone Translation of the Diabetes Prevention Program (DPP)
Monday, Jun 11, 2012, 5:15 PM - 5:30 PM
RUTH S. WEINSTOCK, PAULA M. TRIEF, DONALD CIBULA, LINDA DELAHANTY, PHILIP MORIN, Syracuse, NY, Boston,MA.

Abstract

SHINE (Support, Health Information, Nutrition and Exercise) is a randomized weight loss trial (n=257) of 2 telephone interventions, based on the DPP, delivered through 5 primary care sites. Telephone delivery was used to increase reach. Participants were randomized to receive the DPP lifestyle change program, participating individually by phone (solo; n=129; 114 received intervention) or in a group by conference call (n=128; 123 received intervention). The 16 session DPP curriculum was delivered over 1 year by trained primary care staff, with continued contact in year 2. Six and 12 month data are presented. Participants' data were: mean age 51.8 yrs, 74.3% female, 85.6% white, 12.8% African American, 1.2% Hispanic, 44.1% employed, 22.4% retired, 53.2% married, 46.3% high school graduates, 36.9% annual income <$30,000. At baseline, participants had metabolic syndrome (without diabetes) with mean weight 107.5 kg, BMI 39.3 kg/m², waist circumference 118.4 cm, fasting glucose 99.6 mg/dl, blood pressure 128.8/75.6 mm Hg, triglycerides 145.3 mg/dl, HDL-chol 42.4 mg/dl, LDL-chol 108.1 mg/dl. Intention-to-treat mixed linear model regression using repeated measures was performed. At 6 and 12 months solo treatment participants adjusted mean weight (waist circumference) decreased by 4.1 kg (3.4cm) and 4.6 kg (5.1 cm), and in group treatment decreased by 4.8 kg (2.7 cm) and 6.0 kg (6.0 cm); all adj p<.01. At 1 year, mean % weight loss from baseline was 4.6% in both treatments; 40.3%/46.6% lost at least 5% weight; 26.9%/37.7% lost at least 7% weight and 17.9%/26% lost at least 10% weight in the solo/group treatments respectively. There were no significant differences in weight loss between treatment groups. Glucose, lipid and blood pressure levels did not significantly improve. In conclusion, primary care staff can be trained to deliver a DPP translation by telephone that is effective for achieving significant weight loss in both individual and group formats.

COMMENT: This is a significant addition to our search for “DPP LITE”.  A low cost telephone intervention was quite successful in this low income and SDS cohort.

342-OR: Reducing Diabetes Distress: First Results From The REDEEM Trial
Monday, Jun 11, 2012, 5:30 PM - 5:45 PM
LAWRENCE FISHER, DANIELLE M. HESSLER, JOSEPH T. MULLAN, RUSSELL GLASGOW, PATRICIA AREAN, UMESH MASHARANI, San Francisco, CA, Bethesda, MD.

Abstract

Diabetes distress (DD) refers to the emotional burdens that are part of the spectrum of patient diabetes experience. DD is common, is distinct from depression and has been associated with a variety of glycemic and behavioral markers. Reducing Distress and Enhancing Effective Management (REDEEM) was a 3-arm clinical trial to reduce DD among patients with type 2 diabetes.
Following baseline assessment, patients were randomized to one of three interventions: a Computer Automated Self-Management program (CASM) that helps establish behavioral goals, address barriers and monitor progress; CASM plus problem-solving therapy (CAPS), a CBT program to address DD directly; and Leap Ahead (LA), an attention control health risk screening. Patients then received 4 live support calls at 2, 4, 6 and 8 weeks, followed by a 4-month assessment, a booster at 5 months, 4 more live support calls at weeks 24, 28, 36, 44, and final assessment at 12 months.
Inclusion criteria were T2DM >12 months, moderate DD (>1.5 DDS score), age >21, read and speak English, screen out for clinical depression (PHQ8 <15). Using MLM, ITT analyses analyzed changes in DD at 0-4, and 4-12 months on the Regimen Distress (RD) and Emotional Burden (EB) subscales of the Diabetes Distress Scale.
With 0-12 month attrition at 8.4% and controlling for demographics, significant decreases in both RD and EB occurred for the entire sample at 0-4 and 4-12 months (p< .002), but no significant between-group differences in reductions in RD or EB occurred for either time period. However, a significant Group By Baseline RD interaction at 0-4 months (p=.009) indicated that those with high DD at baseline achieved greater reductions in RD in CAPS than in CASM (p = .01) or LA (p=.007). These reductions were uniformly maintained between 4-12 months. There was no significant Group By Baseline EB interaction.
Findings indicate that management support alone does not decrease DD, but that a combination of management support and focused DD problem solving significantly reduces DD, with maintenance over time.

COMMENT: The emotional burdens of diabetes are significant and are frequently overlooked in a busy clinical setting.  The interventions described were effective in reducing these burdens.  The interventions were more effective in the higher distress patients and those with longer duration diabetes.

343-OR: Diabetes Nurse Case Management and Motivational Interviewing for Change (DYNAMIC Study): Results of a 2-Year RCT
Monday, Jun 11, 2012, 5:45 PM - 6:00 PM
RAQUEL M. ANEL-TIANGCO, ALAN ADELMAN, CHERYL DELLASEGA, ROBERT A. GABBAY, Hershey, PA.

Abstract

Nurse case management (NCM) and motivational interviewing (MI) are two approaches that have been used in the management of chronic medical conditions like diabetes. NCM is a collaborative process that provides and coordinates health care to decrease fragmentation. MI is a teachable method to counsel patients on behavior change by enhancing the intrinsic motivation to change. The data thus far on their effects on clinical outcomes have been inconclusive.
The aim of this study was to determine if the addition of nurse case management and motivational interviewing to usual primary care would result in improved outcomes over two years in high risk patients with type 2 diabetes.
A 2-year randomized controlled trial was conducted in diabetes patients from 12 primary care clinics. Patients were randomized to usual care control (n=313) or the intervention (n= 232) who received additional NCM care, including self-management education, MI-guided behavior change counseling and prompting PCPs to implement diabetes guidelines. All nurse case managers received intensive training in MI with an ongoing assessment of fidelity.
At the end of 2 years, systolic BP was better in the intervention group than the control group (131±15.9 vs. 135±18.2, p < 0.05). HbA1c, LDL, and diastolic BP improved in both groups: HbA1c (control group 9.1% to 8.0%, intervention group 8.8% to 7.8%), LDL (control group 127 to 100 mg/dL, intervention group 128 to 102 mg/dL), diastolic BP (control group 78 to 74 mm Hg, intervention group 80 to 74 mm Hg). Screening for complications improved significantly in the intervention group compared to the control group: foot exam, ophthalmologic exam, and nephropathy screening.NCM and MI improved systolic BP and complications screening. The large decrease in HbA1C and LDL in the control group may have obscured any further intervention effect. Although nurses prompted providers for medication titration, strategies to reduce provider clinical inertia might also be needed.

COMMENT:  I was not impressed with the effectiveness of the intervention.  Both groups did improve in the outcomes measured.  Perhaps the improvement in preventative care were worth the effort, but without a cost/benefit analysis one can not be sure that the suggested approach is worthwhile.

344-OR: Internet Programs for Youth with Type 1 Diabetes (T1D) Improve Outcomes
Monday, Jun 11, 2012, 6:00 PM - 6:15 PM
MARGARET GREY, ROBIN WHITTEMORE, SANGCHOON JEON, SARAH JASER, KATHRYN M. MURPHY, MELISSA FAULKNER, ALAN DELAMATER, New Haven, CT, Philadelphia, PA, Tucson, AZ, Miami, FL.

Abstract

The purpose of this trial was to compare the effectiveness of TEENCOPE™ (internet coping skills training) with MANAGING DIABETES (internet education program) for youth with T1D on A1C, self-management, self-efficacy, stress, coping, quality of life (QOL), & family conflict over 12 month follow-up. Mediators of improved outcomes were also explored.
Teens with T1D (n=320, 11-14 years) from 4 sites were randomly assigned to one of the programs & completed baseline, 3, 6, and 12 month data via the internet. A1C was obtained from clinic records. Teens were 12.3 +1.1 yrs old, with T1D duration 6.1 + 3.5 yrs, A1C 8.3 +1.5%, 60% on pump therapy, 55% female & 62% non-Hispanic White. Groups were comparable at baseline. Participation (78% completed 4 of 5 sessions) & satisfaction were high. Data were analyzed with mixed models.
Teens in both groups reported a significant increase in diabetes problem-solving (p<.01), goal setting (p<.01), self-efficacy (p<.001), and QOL (p<.001) along with a decrease in collaboration with parents (p<.001) and stress (p<.01) after controlling for race, income, gender, age, duration, therapy type, and site. Teens participating in MANAGING DIABETES reported a significant improvement in social acceptance over time (p<.001) and less family conflict (p<.05) than those in TEENCOPE. Teens participating in TEENCOPE reported better communication (p<.05) and coping (p<.01) over time. A1C did not deteriorate in either group. Improvements in self-management, self-efficacy, perceived stress, and coping mediated the effect of TEENCOPE on QOL. Improvements in self-efficacy, social competence, and family conflict mediated the effect of MANAGING DIABETES on QOL.
Participation in both internet programs was excellent & led to improved psychosocial outcomes after 12 months in ethnically diverse youth with T1D. Thus, young teens may benefit from both diabetes-specific coping and educational internet programs. Results of the mediation analysis begin to identify the mechanisms by which programs improve QOL.

COMMENT: The two programs had different objectives.  TEENCOPE was focused on developing coping and problem solving skills while MANAGING DIABETES was focused on education.  Nevertheless both programs were equally engaging and resulted in significant improvements In quality of life.  Neither program improved A1C.

345-OR: Can You Hear (and See) Me Now? Skype-Based Intervention for Teens with Poorly Controlled Diabetes
Monday, Jun 11, 2012, 6:15 PM - 6:30 PM
MICHAEL A. HARRIS, KURT A. FREEMAN, DANNY C. DUKE, BETH HIRSCHFIELD, BRUCE BOSTON, Portland, OR.

Abstract

This study examined the relative effectiveness of a behavioral-based family therapy intervention for diabetes (BFST-D) delivered via tele-health (SKYPE) or face-to-face (CLINIC) for youth with poorly controlled diabetes (< 9.0%) and their families.
Seventy three youth (M age 15.1 years, SD=1.8) and their parents participated. Of youth in the study, 85% of were Caucasian, 44% were female, and 36% resided in single-parent homes. They had mean duration of DM of 6.8 years (SD=3.7) and a mean baseline HbA1c of 11.2% (SD=1.7%).
At baseline and post-treatment, youth and parents completed the Diabetes Self Management Profile (DSMP), an assessment of diabetes treatment adherence, and HbA1c values were collected.
Results showed no difference in the number of BFST-D treatment sessions completed across SKYPE (9.9) vs CLINIC (6.9). Three separate ANCOVAs were performed with treatment condition serving as the independent variable and baseline HbA1c value and youth and parent-reported DSMP total scores serving as the covariates. From baseline to post-treatment, HbA1c declined by an average of 0.76% for the CLINIC group and an average of 0.40% for the SKYPE group. ANCOVA yielded no significant between-group differences. From baseline to end of treatment, youth-reported DSMP scores increased by an average of 5.8 points for the CLINIC group and by an average of 2.9 points for the SKYPE group. ANCOVA identified no significant between-group difference. From baseline to end of treatment, parent-reported DSMP scores increased by an average of 28 points for the CLINIC group and by an average of 21 points for the SKYPE group. ANCOVA identified no significant between-group differences for parent or youth-reported DSMP scores.
Findings suggest no statistically significant differences between SKYPE and CLINIC based delivery of BFST-D for youths with poorly controlled T1DM, supporting either delivery method as effective.

COMMENT:  this is an important study demonstrating that family-based behavioral therapy can be effectively delivered by video teleconferencing.  This is a cost-saving and time saving strategy.  I wish that the author had presented the no show rates for both treatment delivery strategies and patient/family satisfaction scores.