COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS FINDING SLIDES FOR TODAY’S WEBINAR March 6, 2019 Behavior Change to Prevent Chronic Disease: www.villanova.edu/COPE Psychology in Action Click on Elizabeth Venditti webinar Moderator: Lisa Diewald MS, RD, LDN description page Program Manager MacDonald Center for Obesity Prevention and Education Villanova University M.Louise Fitzpatrick College of Nursing Nursing Education Continuing Education Programming Research OBJECTIVES DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? Discuss key components of evidence-based lifestyle If you are calling in today rather than interventions using your computer to log on, and need CE credit, please email Describe the efficacy trials and translational research contributing cope@villanova.edu and provide your to current public health science (specifically related to obesity name so we can send your certificate. management/diabetes prevention) in high risk groups Identify challenges that remain in the field to improve translational and public health CE CREDITS CE DETAILS • This webinar awards 1 contact hour for nurses and 1 CPEU • Villanova University College of Nursing is accredited as a for dietitians provider of continuing nursing education by the American Nurses Credentialing Center Commission on • Suggested CDR Learning Need Codes: 5370, 6010, 6020 Accreditation and 5190 • Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education • Level 2 (CPE) Accredited Provider with the Commission on Dietetic Registration • CDR Performance Indicators: 9.6.1, 9.6.6, 6.2.5 Page 1
Behavior Change to Prevent Chronic Disease: DISCLOSURE Psychology in Action Neither the planners or presenter have any conflicts of interest to disclose. Elizabeth Venditti, Ph.D. Accredited status does not imply endorsement by Villanova University, COPE or the American Associate Professor of Psychiatry and Epidemiology Nurses Credentialing Center of any commercial University of Pittsburg School of Medicine products or medical/nutrition advice displayed in conjunction with an activity. Outline for Today’s Presentation Behavior Change to Prevent Chronic Disease: Psychology in Action Rationale for behavior change interventions in obesity/diabetes prevention for adults (why) Fundamental intervention components (what) Elizabeth M. Venditti, Ph.D. Associate Professor of Psychiatry and Epidemiology Evidence base from some major randomized University of Pittsburgh School of Medicine trials and translational effectiveness studies Implications for integrated clinical practice MacDonald Center for Obesity Prevention and Education Villanova University College of Nursing March 6, 2019 Diabetes is Costly Type 2 Diabetes in the US • > 30 million with diagnosed diabetes • Driving force is Type 2 diabetes (~ 10 % of US population) (accounts for 90-95% of all diabetes • ~ 84 million with “pre-diabetes” (most cases) don’t know) • Estimated that $1 out of $7 total health care dollars is spent treating diabetes • 1 out of 3 people will develop diabetes and its complications in their lifetime • Total costs--$327 billion and rising • Prevalent in Blacks, Hispanics, American Indian, Alaska Native, Source: American Diabetes Association 2018 Native Hawaiian/Pacific Islanders Source: American Diabetes Association 2018 Page 2
Lifestyle Self-Management Rationale: Why Bother With is Good Medicine Lifestyle Behavior Change? •We know genetic, physiologic, • Person, environment and cognition interact to psychosocial factors are complex and we shape healthy behavior and counter unhealthy need to address individual vulnerabilities behavior •Yet…food/activity environment is potent in • Primary focus is on building capacity to self- shaping habits in animals and people (“a regulate in changing (sometimes toxic) final common pathway”) environments • Emphasis is on social learning (thinking/behavior), •The bargain: lifestyle interventions impact social norms, social support and social ecology energy balance behavior change and (“taking charge of what’s around you”) influence broad spectrum physical outcomes, health related quality of life and Bandura, A. Health promotion by social cognitive means (2004) well-being, depression Health Education and Behavior: 31, 143-164. Multicomponent lifestyle interventions If lifestyle intervention is good medicine, what is a minimally effective dose? • 1-8: Self-management of diet/nutrition, physical activity, weight, environment (specifies weight, activity, calorie/fat goals, self monitoring for induction of weight loss, core behavioral skills) • 9-16 and beyond: Psychological and behavioral skills; trial and error problem solving and application re: personal barriers for healthy eating and activity Diabetes Prevention Program (DPP) DPP Maintenance Intervention Intensive Lifestyle Intervention as an exemplar (not sustainable/reimburseable) (many came before…innovations since) Goal based (7% weight loss; 150 minutes per Required in-person contact at least week moderately vigorous physical activity) every two months Individual case managers or “lifestyle coaches” Interim phone/mail contact or group leaders to facilitate basic self- DPP delivered 50.3 ( ± 21.8) total management/problem solving skills sessions over 2.8 years Structured “core curriculum” sequence; Supplemental group classes flexibility to adapt within standardized format (gold-standard is 16 sessions over 6 months) Motivational “campaigns”, “boosters”, “restarts” Less frequent, but regular contact following core program delivery (e.g. monthly contacts) Page 3
Long history of obesity outcomes research shows weight loss is feasible, achievable Lifestyle Intervention Randomized-controlled behavioral treatment studies (since 1970’s)* show it’s possible to Evidence achieve (on average) 10% loss at ~ 6 months (e.g. ~ 10 kg in 200 lb (Adults) individual) Longer duration contact = better weight loss Regain is the norm; maintenance contacts and moderate- high levels of physical activity slow rate of regain Many multi-site RCT’s show 4-8% average weight loss at ~ 1-3 years (~ 5 kg) Wadden TA (multiple reviews listed in PubMed) Science of Behavior Change But what about non-responders? (SOBC) • Psychological/behavioral interventions • More of the same is not better. There are being studied (how to build capacity) will “late bloomers” but not as likely. increasingly focus on: • The first two months of behavioral lifestyle – What is common intervention often predicts long term – What needs to be individualized response • Unick et. al (2014) showed achieving ≥ 2% • Examples loss at 8 weeks predicts likelihood of 10% – “Target engagement” mechanisms weight loss at one year – Neurobehavioral functions • Only 15% of those who don’t show this – Stepped care, augmentation, adaptive marker of weight loss response go on to intervention approaches succeed at that level. Diabetes Prevention Program Clinical Trial (began 1998) DPP Primary Intervention Goal . . .. . To prevent or delay the development . . . . . . of type 2 diabetes in persons with . . .. . impaired glucose tolerance (IGT) . . . . . . . . . . Page 4
Modifiable Risk Factors for Feasibility of Preventing Type 2 Diabetes Type 2 Diabetes • Obesity • Long period of glucose intolerance that precedes the development of diabetes • Body fat distribution • Screening tests identify persons at higher risk • Safe, potentially effective interventions can address • Physical inactivity modifiable risk factors • Rising fasting and 2 hr glucose levels DPP Eligibility DPP Study Design • Age > 25 years • 3-group RCT (lifestyle, metformin, • Elevated plasma glucose placebo) – 2 hour glucose 140-199 mg/dl • 27 clinical sites and/or • Standardized across clinics: – Fasting glucose 95-125 mg/dl – Common protocol and procedures • BMI > 24 kg/m 2 (Asian-American/22 kg/m 2 ) manual – Expert staff training • Goal: recruit at least 50% of sample from – Data quality control program high risk race/ethnic groups Study Population Screening and Recruitment Age, Race, Ethnicity Asian/Pacific Islander Number of participants 4% (n=142) American Indian Hispanic Step 1 screening ≥ 60 yrs 158,177 5% (n=171) 16% 20% (n=508) Step 2 OGTT (n=648) African 30,985 25-44 yrs American Step 3 start run-in 31% 20% (n=645) 4,719 (n=1000) Step 3 end run-in 4,080 45-59 yrs Caucasian 49% (n=1586) 55% (n=1768) Step 4 randomization 3,819* * 3,234 in 3 arm study (585 in troglitazone arm) The DPP Research Group, Diabetes Care 23:1619-29, 2000 DPP Research Group, Controlled Clin Trials (2002) Page 5
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