Diabetes Prevention Program Translation in the Veterans Health Administration

doi:10.1016/j.amepre.2016.11.009

American Journal of Preventive Medicine

Volume 53, Issue 1, July 2017, Pages 70-77

https://doi.org/10.1016/j.amepre.2016.11.009 Get rights and content

Introduction

This clinical demonstration trial compared the effectiveness of the Veterans Affairs Diabetes Prevention Program (VA-DPP) with an evidence-based usual care weight management program (MOVE!^®) in the Veterans Health Administration health system.

Design

Prospective, pragmatic, non-randomized comparative effectiveness study of two behavioral weight management interventions.

Setting/participants

Obese/overweight Veterans with prediabetes were recruited from three geographically diverse VA sites between 2012 and 2014.

Intervention

VA-DPP included 22 group-based intensive lifestyle change sessions.

Main outcome measures

Weight change at 6 and 12 months, hemoglobin A1c (HbA1c) at 12 months, and VA health expenditure changes at 15 months were assessed using VA electronic health record and claims data. Between- and within-group comparisons for weight and HbA1c were done using linear mixed-effects models controlling for age, gender, race/ethnicity, baseline outcome values, and site. Analyses were conducted in 2015–2016.

Results

A total of 387 participants enrolled (273 VA-DPP, 114 MOVE!). More VA-DPP participants completed at least one (73.3% VA-DPP vs 57.5% MOVE! p=0.002); four (57.5% VA-DPP vs 42.5% MOVE!, p=0.007); and eight or more sessions (42.5% VA-DPP vs 31% MOVE!, p=0.035). Weight loss from baseline was significant at both 6 (p<0.001) and 12 months (p<0.001) for VA-DPP participants, but only significant at 6 months for MOVE! participants (p=0.004). Between groups, there were significant differences in 6-month weight loss (–4.1 kg VA-DPP vs –1.9 kg MOVE!, p<0.001), but not 12-month weight loss (–3.4 kg VA-DPP vs –2.0 kg MOVE!, p=0.16). There were no significant differences in HbA1c change or outpatient, inpatient, and total VA expenditures.

Conclusions

VA-DPP participants had higher participation rates and weight loss at 6 months, but similar weight, HbA1c, and health expenditures at 12 months compared to MOVE! participants. Features of VA-DPP may help enhance the capability of MOVE! to reach a larger proportion of the served population and promote individual-level weight maintenance.

Introduction

Prediabetes, or abnormally elevated blood sugar levels that do not yet meet the threshold for Type 2 diabetes, is prevalent and associated with significant risk of progression to Type 2 diabetes.1, 2, 3, 4 However, evidence from RCTs, including the Diabetes Prevention Program (DPP) Study, shows progression to diabetes can be prevented with intensive lifestyle interventions involving dietary change, physical activity, and weight loss.1, 2, 5, 6, 7 Thus, numerous studies have evaluated translations of DPP-based lifestyle interventions into real-world settings.8, 9, 10, 11 However, important evidence gaps remain in real-world DPP effectiveness as most studies have used uncontrolled pre–post, single-site study designs and very few have examined diabetes-related outcomes or expenditures.8, 9, 10, 11

To address these important gaps, the authors conducted a multisite clinical demonstration trial in the Veterans Affairs (VA) that assessed change in weight; hemoglobin A1c (HbA1c); and health expenditures. This was a pragmatic comparative effectiveness trial of two group-based lifestyle interventions that varied in content, intensity, and delivery (Appendix Table 1, available online): the VA-DPP and the usual care MOVE!^® weight management program (MOVE!). VA-DPP included more sessions (i.e., higher intensity); had closed groups led by a single instructor; and standardized goals for all participants, which might increase group cohesion. Therefore, it was hypothesized that VA-DPP would lead to greater weight loss and improved HbA1c over 12 months among overweight/obese participants with prediabetes versus MOVE!.¹²

Section snippets

Study Sample

This was a prospective, pragmatic, non-randomized comparative effectiveness trial conducted from 2012 to 2015. This non-randomized design reflects the challenge of implementing VA-DPP with high fidelity balanced against the pragmatic need to adapt to local clinical context.13, 14 A Transparent Reporting of Evaluations with Nonrandomized Designs statement is provided in Appendix Table 2 (available online).¹⁵ The degree to which pragmatic considerations drove study design decisions was assessed

Results

Between August 2012 and January 2014, a total of 1,830 patients were assessed for eligibility (Figure 1).25, 26 An additional 20 patients were contacted but excluded from analyses because of incomplete screening information. A total of 387 eligible individuals were systematically assigned to VA-DPP (n=273) or MOVE! (n=114). The number of participants assigned to VA-DPP was higher than that assigned to MOVE! because the number of candidate participants often failed to reach 40 within the 2-month

Discussion

This study found that VA-DPP resulted in significantly more 6-month weight loss than MOVE!, but these differences were not significant at 12 months, nor were differences in HbA1c or VA expenditures. Based on a recent systematic review of DPP translation studies, the VA-DPP compares favorably with the minority (41%) of studies included in the review that succeeded in achieving moderate or high weight loss (>2.4 kg).¹⁰ However, this was a comparative effectiveness trial, which included an active

Conclusions

A pragmatic trial of VA-DPP resulted in higher participation rates with significantly greater 6-month weight loss and a non-significant trend toward greater 12-month weight loss compared with MOVE!. Thus, MOVE! may be enhanced by aligning more closely to VA-DPP to augment the reach (for at-risk individuals) and individual-level effectiveness (of individual weight loss). This is one of the first studies to include a predominantly male cohort and highlights the continued difficulty in recruiting

Acknowledgments

All authors made substantial contributions to conception and design or analysis and interpretation of data and drafting of the article or critical revision for important intellectual content. CRR, LJD, MLM, and SKD designed the study. TM wrote the first draft of the manuscript. RGH, HMK, JAB, CRR, LJD, TM, and MAY analyzed the data. TM, LJD, MAY, MLM, SKD, JEW, NIS, CB, MH, FM, RGH, HMK, LSK, and CRR reviewed and edited the manuscript. TM is the guarantor of this article. Portions of this

References (40)

G. Li et al.
The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study
Lancet
(2008)
A.G. Tabak et al.
Prediabetes: a high-risk state for diabetes development
Lancet
(2012)
J. Lindstrom et al.
Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study
Lancet
(2006)
D.J. Cohen et al.
Fidelity versus flexibility: translating evidence-based research into practice
Am J Prev Med
(2008)
K.E. Thorpe et al.
A pragmatic-explanatory continuum indicator summary (PRECIS): a tool to help trial designers
J Clin Epidemiol
(2009)
M.K. Kramer et al.
Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery
Am J Prev Med
(2009)
M.A. McVay et al.
Obesity-related health status changes and weight-loss treatment utilization
Am J Prev Med
(2014)
L.J. Damschroder et al.
Small-changes obesity treatment among veterans: 12-month outcomes
Am J Prev Med
(2014)
B. Gough
“Real men don’t diet”: an analysis of contemporary newspaper representations of men, food and health
Soc Sci Med
(2007)
K.D. Hoerster et al.
Health and health behavior differences: U.S. Military, veteran, and civilian men
Am J Prev Med
(2012)

W.C. Knowler et al.

Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

N Engl J Med

(2002)

G.A. Nichols et al.

Progression from newly acquired impaired fasting glusose to type 2 diabetes

Diabetes Care

(2007)

W.C. Knowler et al.

10-Year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study

Lancet

(2009)

T.J. Orchard et al.

Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study

Diabet Med

(2013)

M.K. Ali et al.

How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program?

Health Aff (Millwood)

(2012)

R. Kahn et al.

The reality of type 2 diabetes prevention

Diabetes Care

(2014)

Z. Aziz et al.

A systematic review of real-world diabetes prevention programs: learnings from the last 15 years

Implement Sci

(2015)

W. Cefalu et al.

Update and next steps for real-world translation of interventions for Type 2 diabetes prevention: reflections from a Diabetes Care Editors’ Expert Forum

Diabetes Care

(2016)

L.C. Kahwati et al.

RE-AIM evaluation of the Veterans Health Administration’s MOVE! Weight Management Program

Transl Behav Med

(2011)

T. Moin et al.

Implementing Diabetes Prevention in the VA: Results from a Clinical Demonstration Project

(2015)

Cited by (32)

Physical health of Post-9/11 U.S. Military veterans in the context of Healthy People 2020 targeted topic areas: Results from the Comparative Health Assessment Interview Research Study
2023, Preventive Medicine Reports
Large-scale epidemiological studies suggest that veterans may have poorer physical health than nonveterans, but this has been largely unexamined in post-9/11 veterans despite research indicating their high levels of disability and healthcare utilization. Additionally, little investigation has been conducted on sex-based differences and interactions by veteran status. Notably, few studies have explored veteran physical health in relation to national health guidelines. Self-reported, weighted data were analyzed on post-9/11 U.S. veterans and nonveterans (n = 19,693; 6,992 women, 12,701 men; 15,160 veterans, 4,533 nonveterans). Prevalence was estimated for 24 physical health conditions classified by Healthy People 2020 targeted topic areas. Associations between physical health outcomes and veteran status were evaluated using bivariable and multivariable analyses. Back/neck pain was most reported by veterans (49.3 %), twice that of nonveterans (22.8 %)(p < 0.001). Adjusted odds ratios (AORs) for musculoskeletal and hearing disorders, traumatic brain injury, and chronic fatigue syndrome (CFS) were 3–6 times higher in veterans versus nonveterans (p < 0.001). Women versus men had the greatest adjusted odds for bladder infections (males:females, AOR = 0.08, 95 % CI:0.04–0.18)(p < 0.001), and greater odds than men for multiple sclerosis, CFS, cancer, irritable bowel syndrome/colitis, respiratory disease, some musculoskeletal disorders, and vision loss (p < 0.05). Cardiovascular-related conditions were most prominent for men (p < 0.001). Veteran status by sex interactions were found for obesity (p < 0.03; greater for male veterans) and migraine (p < 0.01; greater for females). Healthy People 2020 targeted topic areas exclude some important physical health conditions that are associated with being a veteran. National health guidelines for Americans should provide greater consideration of veterans in their design.
Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change)
2023, Contemporary Clinical Trials
The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions.
In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use.
If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.
Effect of primary care-level chronic disease management policy on self-management of patients with hypertension and diabetes in Korea
2022, Primary Care Diabetes
Citation Excerpt :
Primary care-level chronic disease management programs have shown positive effects. In the United States, advanced DPP has been associated with a reduced risk of diabetes [10]; additionally, it is more effective for short-term weight loss than other programs [11]. From a healthcare provider’s perspective, incentives have increased physician participation in education [12] and optimism for better patient outcomes [13].
This study aimed to evaluate the effect of introducing a regional chronic disease management project on the self-management of patients with hypertension and diabetes.
This study included 174,546 patients. The relationship between introducing chronic disease management in a region and the self-awareness of disease status was analyzed using a generalized estimating equation model. Poisson regression analysis was used to evaluate the effect of policy adoption on medication adherence and risk-reduction behavior in patients with hypertension and diabetes. Finally, we used a difference-in-differences model to assess the net effectiveness of policies.
Overall, regions with policies implemented showed more condition awareness and drug adherence than those without; however, this was only significant in regions where patients and physicians were incentivized. Risk-reduction behavior for patients with diabetes was higher in regions with policies implemented than in those without. The policy had a net effect of significantly and non-significantly increasing disease awareness and medication adherence, respectively.
Chronic disease management policies at the primary care level that incentivized both patients and physicians improved patient self-management. However, the effects on patients with diabetes and hypertension differed. Future studies should account for additional patient outcomes, including long-term impact assessments and clinical outcomes.
Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial
2021, Contemporary Clinical Trials
Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care—MOVE!—among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.
A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention
2020, Diabetes Research and Clinical Practice
Citation Excerpt :
Out of the 23 papers in which it was specified, duration of group sessions ranged from 45 min [50], to 8 h [30], with a mean of 2 h. All papers stated the number of group sessions in their intervention, which varied from 1 (or 2 half days) [26,30,34] to 74 sessions [46], with a mean of 19 sessions. All DPPs had a baseline measure and most had assessments immediately after the programme to monitor changes in outcomes (n = 23) [16,25,40,42,44,45,47–52,27,53–55,29–33,37,39]. Time of follow-up varied from 2 weeks (n = 1) [35], to 7 years (n = 1) [46], with follow-up after 1 year of the intervention being most common (n = 8) [6,26,28,34,38,39,41,45].
Many countries worldwide have developed diabetes prevention programmes (DPPs) that involve lifestyle modification. Research has shown that uptake and retention of DPPs are important and by exploring recruitment strategies and behaviour change techniques (BCTs) used, factors that are most effective in promoting uptake and retention can be identified. Objectives: This review aims to identify recruitment strategies of group-based DPPs that are associated with high uptake and common BCTs associated with high retention. Methods: Papers were identified with a systematic literature search. Programmes that were predominantly group-based and involved lifestyle modification and in which uptake and/or retention could be determined, were included. Intervention details were extracted, recruitment strategies and BCTs identified, and response, uptake and retention rates were calculated. Results: A range of recruitment strategies were used making it difficult to discern associations with uptake rates. For BCTs, all programmes used a credible source, 81% used instruction on how to perform a behaviour and 71% used goal setting (behaviour). BCTs more commonly found in high retention programmes included problem-solving, demonstrating the behaviour, using behavioural practice and reducing negative emotions. Conclusions: Recommendations include that DPPs incorporate BCTs like problem-solving and demonstrating the behaviour to maximise retention.
Results From a Trial of an Online Diabetes Prevention Program Intervention
2018, American Journal of Preventive Medicine
Citation Excerpt :
Among 1,830 patients assessed for eligibility, 387 eligible individuals were systematically assigned to in-person DPP (n = 273) or MOVE! ( n = 114, details available elsewhere15). Among these, 262 participants (n = 198 VA-DPP, n = 64 MOVE!)
Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions.
A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!).
Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial.
Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions.
Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017.
From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was –4.7kg at 6 months and –4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP.
An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

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Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Research ArticleDiabetes Prevention Program Translation in the Veterans Health Administration

Introduction

Design

Setting/participants

Intervention

Main outcome measures

Results

Conclusions

Introduction

Section snippets

Study Sample

Results

Discussion

Conclusions

Acknowledgments

Lancet

Lancet

Lancet

Am J Prev Med

J Clin Epidemiol

Am J Prev Med

Am J Prev Med

Am J Prev Med

Soc Sci Med

Am J Prev Med

Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

N Engl J Med

Progression from newly acquired impaired fasting glusose to type 2 diabetes

Diabetes Care

10-Year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study

Lancet

Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study

Diabet Med

How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program?

Health Aff (Millwood)

The reality of type 2 diabetes prevention

Diabetes Care

A systematic review of real-world diabetes prevention programs: learnings from the last 15 years

Implement Sci

Update and next steps for real-world translation of interventions for Type 2 diabetes prevention: reflections from a Diabetes Care Editors’ Expert Forum

Diabetes Care

RE-AIM evaluation of the Veterans Health Administration’s MOVE! Weight Management Program

Transl Behav Med

Implementing Diabetes Prevention in the VA: Results from a Clinical Demonstration Project

Research Article
Diabetes Prevention Program Translation in the Veterans Health Administration