Presessions to the National Diabetes Prevention Program May be a Promising Strategy to Improve Attendance and Weight Loss Outcomes

Abstract

Purpose:

The National Diabetes Prevention Program (NDPP) is a widely disseminated lifestyle intervention. Attendance is problematic, leading to suboptimal weight loss, especially among racial/ethnic minority participants. We conducted a novel “presession” protocol to improve engagement of diverse NDPP candidates, comparing NDPP participants who attended a presession to those who did not on attendance and weight loss outcomes.

Design:

Longitudinal cohort study.

Setting:

A safety net health-care system.

Participants:

A total of 1140 patients with diabetes risks (58.9% Hispanic, 19.8% non-Hispanic black, 61.8% low income).

Intervention:

The NDPP has been delivered in a Denver, Colorado health-care system since 2013. The program included 22 to 25 sessions over 1 year. Beginning September 2016, individuals were required to attend a presession before enrollment that focused on (1) increasing risk awareness, (2) motivational interviewing to participate in the NDPP, and (3) problem-solving around engagement barriers.

Measures:

Duration and intensity of NDPP attendance and weight loss.

Analysis:

Outcomes of 75 presession participants who enrolled in the NDPP were compared to 1065 prior participants using analysis of covariance and multivariable logistic regression.

Results:

Presession participants stayed in the NDPP 99.8 days longer (P < .001) and attended 14.3% more sessions (P < .001) on average than those without a presession. Presession participants lost 2.0% more weight (P < .001) and were 3.5 times more likely to achieve the 5% weight loss target (P < .001).

Conclusion:

Presessions may improve NDPP outcomes for individuals from diverse backgrounds. A full-scale trial is needed to determine whether presessions reliably improve NDPP effectiveness.

Keywords

type 2 diabetes prevention retention weight loss disparities

Purpose

Type 2 diabetes affects 12.2% of US adults with higher rates among racial/ethnic minorities.¹ The Diabetes Prevention Program was a successful clinical trial showing intensive lifestyle support for weight loss reduced diabetes incidence by 58%.² The intervention was since translated into the National Diabetes Prevention Program (NDPP) and disseminated by the Centers for Disease Control and Prevention (CDC).³ A 2017 report found that attendance of NDPP participants is problematic and leads to suboptimal weight loss.⁴ Attendance and weight loss are especially low among Hispanic and African American participants.^4,5 Improved strategies to engage and support weight loss among NDPP participants are needed for diverse populations. Implementing a “presession” during the NDPP enrollment process may be a pragmatic strategy for delivering a motivational intervention to bolster program effectiveness. Presessions have previously been recommended⁶ but with no known outcomes to date. We report results of a novel presession protocol for diverse participants with elevated diabetes risks. This study compares NDPP participants who attended a presession to those who did not on attendance and weight loss after controlling for sociodemographic characteristics.

Methods

Setting

Denver Health is a safety net health-care system providing the NDPP since March 2013 following CDC-established guidelines.⁷ The yearlong program includes 22 to 25 weekly to monthly group sessions and promotes ≥5% weight loss through diet and physical activity. Trained lay health educators serving as NDPP coaches led sessions in English or Spanish. New NDPP classes began every 3 to 6 months.

Presession Protocol

The NDPP classes that launched in September 2016 and January 2017 were preceded by “presessions.” These group-based meetings led by NDPP coaches were held 1 to 3 weeks prior to new NDPP classes, lasted approximately 1 hour, and focused on (1) education on diabetes risks, (2) motivational interviewing to participate in the NDPP, and (3) problem-solving around barriers to engagement.

The protocol was developed based on Health Belief Model⁸ and Transtheoretical Model principles,⁹ along with feedback from coaches and past participants. Educational topics included an overview of diabetes and associated risk factors; rates of diabetes onset; guidance that modest weight loss can reduce risk; and evidence-based resources, including the NDPP. Coaches used motivational interviewing to help participants identify their preferred plan to reduce risk and encourage NDPP participation. Problem solving to increase readiness, address barriers, and make a commitment was guided by developing a SMART strategy (Specific, Measurable, Achievable, Realistic, and Time-bound). Coaches helped participants identify barriers to attendance and possible solutions. Participants were informed that more attendance is associated with greater weight loss, but benefits can still be achieved despite missing some sessions (each session is associated with 0.31% weight loss⁴ such that attending ≥15 sessions may result in ≥5% weight loss, on average). Scaling questions were used to help participants identify an appropriate initial goal, such as feeling confident to attend at least 1 session. Finally, participants completed an action plan including their SMART goal and anticipated problem-solving strategies.

Participants

We used CDC-established NDPP eligibility criteria (eg, A1c 5.7-6.4).⁷ Recruitment methods were described previously.¹⁰ From March 2013 through January 2017, a total of 1140 participants began the NDPP. Of these, 75 completed a presession prior to enrollment. An additional 15 individuals attended a presession but did not enroll, and no further data were collected.

Measures

Participants were weighed at each NDPP session. Outcome measures were duration (days) and intensity (percentage of sessions attended) of NDPP attendance, percentage weight change (based on first/last weights collected), and achievement of ≥5% (vs <5%) weight loss at any point in the program (per Centers for Medicare and Medicaid Services performance standards¹¹).

Analysis

The primary analysis for this longitudinal cohort study compared outcomes of 75 participants who received a presession prior to the NDPP to 1065 participants who did not. We also conducted a sensitivity analysis comparing outcomes of presession participants to 42 individuals who began the NDPP during the immediately preceding June 2016 cycle but were not offered a presession. This group was selected for the sensitivity analysis to reduce potential influences of differences over time in coaching staff, other modifications in NDPP implementation (eg, incorporating the revised 2016 NDPP curriculum³), and general time trends. Differences in characteristics between intervention groups were assessed using χ² and t tests. Differences in NDPP outcomes were analyzed with analysis of covariance and multivariable logistic regression. Covariates included age, gender, race/ethnicity, and income (above or below 133% of federal poverty level). Analyses were completed using SPSS version 22. The Colorado Multiple Institutional Review Board approved this program evaluation project.

Results

The majority of participants were female (77.5%), low income (61.8%), and Hispanic (58.9%). An additional 21.5% of participants were non-Hispanic white and 19.8% were non-Hispanic black. Mean age was 48.4 (standard deviation = 12.7). There were no significant differences in characteristics between participants who received a presession and those who did not.

Table 1 shows unadjusted group differences in NDPP outcomes. In adjusted models, presession participants attended more sessions (49.3% vs 35.0%; P < .001) and stayed in the program longer (196.3 vs 96.5 days; P < .001) on average than participants who were not offered a presession. Presession participants also achieved more weight loss (3.4% vs 1.5%; P < .001) and were over 3 times more likely to achieve ≥5% weight loss (odds ratio 3.5, P < .001, 95% confidence interval [2.1-6.1]). Sensitivity analysis results were consistent (Table 1).

Table 1.

National Diabetes Prevention Program (NDPP) Outcomes by Completion of Presessions, N = 1140.^a

Outcomes	No Presession Offered Prior to NDPP (n = 1065)	No Presession Offered Prior to NDPP—June 2016 Cohort Only (n = 42)	Presession Completed Prior to NDPP (n = 75)	P Value
Outcomes	No Presession Offered Prior to NDPP (n = 1065)		Presession Completed Prior to NDPP (n = 75)	Primary Analysis^b	Sensitivity analysis^b
Percent of NDPP sessions attended	34.8 ± 0.0	27.6 ± 0.0	48.7 ± 0.0	<.001	<.001
Number of days in NDPP	96.4 ± 3.6	94.3 ± 19.4	190.6 ± 14.8	<.001	<.001
Percent weight loss	1.6 ± 0.1	1.8 ± 0.6	3.5 ± 0.6	<.001	.039
Achieved ≥5% weight loss	195 (18.3)	9 (21.4)	30 (40.0)	.003	.044

^a Data are presented as unadjusted mean ± standard error of the mean with t test P values for continuous variables and frequency (%) with χ² P values for categorical variables. Boldface indicates statistical significance (P < .05).

^b Primary analysis compares outcomes of 75 participants who received a presession prior to the NDPP as of September 2016 to 1065 prior participants who did not. Sensitivity analysis compares outcomes of presession participants to 42 individuals who began the NDPP during the immediately preceding June 2016 cycle only.

Conclusions

Summary

Our study of a presession enhancement to the NDPP showed successful attendance and weight loss results upon initial dissemination in a diverse, predominately low-income population. Thus, presessions may be a strategy to address previous concerns of suboptimal NDPP outcomes.^4,5

Limitations

Results are not fully generalizable. Presessions were not designed to address specific cultural needs of racial/ethnic minority groups, nor was this study designed to evaluate racial/ethnic group differences, which is an important area of future investigation. A randomized trial is necessary to determine whether presessions reliably improve NDPP effectiveness.

Significance

Presessions may contribute to improved NDPP outcomes by increasing perceived risk, enhancing readiness for change and self-efficacy, and helping to cope with potential barriers. Alternatively, presessions may serve as a screening mechanism to identify highly motivated individuals, thereby improving program efficiency. If effective upon further study, presessions have potential for nationwide dissemination across more than 1700 NDPP sites.¹²

So What?

What is already known on this topic?

The NDPP is an evidence-based intervention to prevent diabetes, but attendance is problematic and leads to suboptimal weight loss, especially among racial/ethnic minority participants.

What does this article add?

We report results of implementing a novel “pre-session” protocol to improve engagement of diverse NDPP candidates.

What are the implications for health promotion or research?

Presessions may be an effective strategy to improve NDPP outcomes.

Footnotes

Authors’ Note

Authors report no financial conflicts of interest. The contents of this publication are the sole responsibility of the authors and do not represent official views of any organization. N.D.R. is principally responsible for the presented study, including study design, data access, and the decision to submit and publish the manuscript. N.D.R., P.G.K., R.M.G., K.A.S., and J.S.H. conceived the research and participated in writing and interpretation. N.D.R. conducted the data analysis and wrote the manuscript. All authors critically reviewed the manuscript, as well as read and approved the final submitted version.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: The National Diabetes Prevention Program at Denver Health was funded by the Amendment 35 Cancer, Cardiovascular Disease and Pulmonary Disease Grant Program administered by the Colorado Department of Public Health and Environment, as well as an award from America’s Health Insurance Plans in partnership with the Centers for Disease Control and Prevention. Additional support was provided by Denver Health.

ORCID iD

Natalie D. Ritchie, PhD

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