We gratefully acknowledge the sponsorship of the Oregon Health Sciences University Department of Family Medicine (John Saultz, Chair) for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:
Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio, Moderator: We’ll move to another aspect of the future of good healthcare and that is going to be community oriented primary care update, Dr. John Boltri, who’s professor and Vice Chair at Mercer University in Macon, Georgia. John has been in a National Institute of Health-funded collaborative project that promotes diabetes prevention and other outcome strategies for improved health outcome strategies.
John Boltri, MD, Mercer University, Macon, Georgia: A couple of the things I will talk about have been eluded to in various ways earlier this morning. The Department of Health and Human Services last month released six bullets in response to the PPACA, One of those included working with the community to develop new models of healthcare delivery that would be preventative in nature – that would improve lifestyles.
I think there is a common misconception amongst medical students, residents and many practicing physicians that we can change a patient’s behavior in a 15 minute visit, while we’re talking about their other seven problems – their diabetes, hypertension, dyslipedemia, cardiovascular disease, and the stroke after which they just got out of the hospital. I think the Department of Health and Human Services is forward-looking in wanting us to look at models of behavior change. What’s apparent is that it’s not easy to change behavior, which includes nybody in this room who’s ever smoked or tried to lose weight, or tried to change any other habitual behavior. That includes me too.
I’m going to talk about a project working with the community. I’ll give you a little bit of background on the project. Many of you have heard it before, but some of you haven’t. (See: Activities of the Fellows and Senior Fellows of the Coastal Research Group: Dr John Boltri and the Church-Based Diabetes Prevention and Translation Study Project. I will then give a brief review of the NIH funded project and then our progress to date.
Diabetes as a National Problem
There are roughly 26 million Americans with diabetes, seven million of whom undiagnosed. There are roughly 79 million that have pre-diabetes, a significant proportion of whom will go on to get diabetes.
This slide, from the Centers of Disease Control will show you the progression of obesity in this country:
In 1994 the vast majority of the country’s states had less than 18% obesity. Between 1994 and 2008, the percentage increases until a large majority of states had over 20%. By now, probably half the states have percentages over 26%.
The lower row of maps show the increases in the rates of diabetes through that timeline.In 1994 the diabetes rates was less than 6% for every state in the country country and less than 4.5% for most states. By 2008, the diabetes rate for the most every state in the country is over 9%. Thus, the diabetes rate increase follow the obesity increases.
Diabetes in the African-American Community
Our focus is on preventing diabetes in the African American community and we are focusing on preventing diabetes. I’m going to show you a slide about that in a moment. Now the life time risk is one-third for men and almost 40% for women, so look to your left and right, one of you will have diabetes in your lifetime, if you don’t already have it.
In the African-American community the risk of diagnosed diabetes is 77% higher compared to Non-Hispanic Whites. Glucose control, blood pressure and almost all other measures are less well controlled in the African-American community. Therefore, they have a higher complication rate as a result of their illness.
The Positive Impact of Specific Lifestyle Changes
There is excellent evidence from literature reviews that lifestyle changes, including diet, exercise, and, of course, “pushing the plate away”, can actually delay or prevent Type 2 diabetes.
There have been multiple randomized control trials with similar interventions in many countries throughout the world; including big studies in France, China and the United States. The incidence of diabetes can be reduced with just modest weight loss 5 to 7%, with a healthier diet and with moderate-intensity exercise, such as 30 minutes of brisk walking five days a week.
This one study is a good summation, this is the Finnish Diabetes Prevention Study, which had five recommendations: exercising; losing weight (5% of body weight); increasing fiber; decreasing soluble fat; and decreasing overall calories. In both the intervention and control group these recommmendations were made at the start of the study.
All patients in this study were overweight to obese and had pre-diabetes with a glucose level between 110 and 126. Looking at the whole population both intervention and control what this chart is showing you that those that did nothing, the zero column, whether they were in the intervention or control group, within a year they had progressed to diabetes, 30 or 37%. If they followed one of those five recommendations it dropped a little bit; if two of those five, it dropped a little bit more; and if three of the things, their incidence of diabetes was at 5% and 12%.
But of those that followed four or all five of the recommendations, zero percent got diabetes in that first year!
The problem is affecting behavior change in diverse groups. Every time I walk into a exam room it’s a “cultural meeting” between me and that person on the other side. Cultural context affects the experience of our patients – specifically the expectations of support. Following the traditions of one’s culture is very important. The customs of the patient affect the determinants of success.
It’s important that we develop culturally congruent programs. If we don’t, the effectiveness of attempting changes will not always be very successful.
A Culturally Congruent Program
That led us to create the Church-based Diabetes Prevention and Translation Study, for which we (Mercer University) received funding for in 2008. This is a five year study that works with African-American communities in two different states, which I will explain a little bit more.
Our method has been to recruit 42 churches (14 churches a year) over three years, randomized to a “control group”, which is not a true control group, because they get the church members receive our recommendations and they get some mailings every month about the diabetes prevention program.
We modified the National Institutes of Health Diabetes Prevention program, which was 16 sessions delivered one on one. Although NIH had a nutritionist expert sitting one on one with every participant that was in the lifestyle program, we modified that program, using community-based participatory research methods to a group faith-based program delivered in the churches, incorporating such elements as prayer and song. We do all the testing and implementation in the churches so that the participants don’t need to go outside of their community to participate.
The acronym that was chosen by members of the church community is STOP DIABETES, which stands for Skills Training On Preventing Diabetes with “t” making a cross.
We approached community leaders and invited them to be part of the research team, and then performed 12 focus groups over two year period. Based on these focus groups we developed a plan for creating the whole program. By this means the program is created by members of our research team which now included church pastors and congregation leaders. Of course, we learned a lot from the focus groups. I’m going to give you some of the more salient results.
The team of researchers and community participants developed tools for supporting behavior within the group. The church members agreed to support each other, and hold each other accountable to come to the meetings, to follow the program’s elements, and to share the results with each other. Every month the participants come in and they get their height, weight, blood pressure and their fasting glucose measured. As they walk away we hear one friend say to another “What’s your number today?” So there’s a high amount of accountability.
We also learn from the focus groups in this population that verbal messages from Scripture, and from themselves and others are very important motivators, as is the concept of the body as the temple of the Holy Spirit. Prayer can be a very strong source of strength. We have heard of “duet buddies” who now call each other at daybreak every morning to start off their day with a prayer.
As a result of these focus groups, we developed a faith-based format for the meetings. Each meeting starts with an opening prayer and or faith-based song. There’s a Scripture reading for the day – usually two or three short sentences. They have faith-linked exercises: they may walk while they’re praying or walk while they’re up singing hymns. There are also inspirational messages built into each program, and a closing prayer .
There’s a meditation sheet for the month, so that if they want additional readings from the Bible, they can seek those out during the month. After we had created the group materials, we brought pastors together in Macon, Georgia and in Hartford, Connecticut, who brought their Bibles and hymnals. We sat with them and they worked for many hours finding scriptural passages that related to the material.
I will present our first 18 months of data. We developed a relationship with pastors of churches. Members of our team are also pastors and they help us to recruit other pastors from other churches.
We then negotiate being able to make a presentation during the Sunday service. During the service we actually do a written diabetes screen for any adult that wants to participate. We collect those back and then after the service people are invited to get their hemoglobin, A1C checked that same day and or come back for a fasting glucose test during the week. We’re at the hospital for a whole day.
We’ve had 3380 people complete the diabetes risk assessment. Of those 1612 had a score that was considered sufficiently high by the American Diabetes Association to put them at risk for diabetes. Of those 1612, 1020 came back for a fasting glucose test.
I want to give you a perspective as to what that 1020 over 1612 means. We did a study about eight years ago in doctors’ offices where we used the same diabetes risk assessment and asked people to come back for a fasting glucose test, 18% came back for a fasting glucose test to doctors’ offices. So the 63% response from those 1612 identified is a really remarkable number. Of those 1020, 289 had prediabetes. We’ve had in the intensive program, which is a six week program followed by a monthly meeting. We’ve had over a 70% attendance rate at those meetings and also we’ve had also a very high follow-up percentage for both groups at 83%.
The churches’ entry into the program are staggered. Because we don’t start all the churches at once, I don’t have complete reporting data for all 18 months yet. But I do have full data for the first six months for all the churches.
For the two different groups we’ve had, these are our baseline characteristics. We had a fairly obese group in both groups 220 pounds in the control group, and 213 in the intervention group. All of them had elevated fasting glucose, and the blood pressures are also listed.
The change in parameters at six months showed the control group not losing very much weight, which was what we had originally expected. If you provide people with the information, but don’t provide a group support, not too much happens. On the other hand, the folks participating in the group support lost about 2.6 pounds, with their BMI’s dropping accordingly. Their fasting glucose dropped nine milligrams per deciliter, versus two in the control group and their blood pressure diastolic and systolic also dropped.
In conclusion this demonstrates that the academic-community partnerships can offer some important opportunities to improve the health of the community and begin to address some health disparities. Churches are an important venue for diabetes prevention in some African-American populations, and the community-based collaborative approach can be applied so as to translate proven health promotion methodology in hard to reach, high risk populations. Thank you.
Dr Clasen: Dr Zweifler, you have a question of Dr Boltri?
John Zweifler, MD: Yes, I do have a question. John, your project focus is on diabetes care. The interventions were educational, but the one that stood out to me was the faith-linked exercise component. I just wonder if we could achieve similar results if we weren’t focusing on diabetes, if we were just focusing on diet and exercise more generically would it have the same impact?
Dr Boltri: Sure. The factor, we think, that recruits participants to come is having some kind of disease. In this community the obesity and overweight rates approach 70%. So we’re now developing something called FAITH WORKS which stands for Families Actively Intervening in Improving Their Health. To participate, they need to have just one risk factor. It could be prediabetes, it could be hypertension and it could be hyperlipidemia. There are five such health factors, in addition to being overweight.
The program is going to include the whole family, so if one parent is overweight even if the children aren’t, the whole family then participates in the program. We will have three different programs – one for adults, one for young teens, and one for children that are in preschool or early school. The answer to your question is we’re not sure, but we hope so, we hope so.
Dr Clasen: Thank you, Dr Boltri. We had a question from David Sundwall as to why the IRB would give trouble to community participatory research. Our department Wright State University in Dayton paired with Dr. Boltri on some of the initial data, working with the-African American churches in Dayton. The program was published in the Bulletin, which the IRB felt was a compulsory kind of activity to get people to participate in the program, that they were not going to be freely accessing this.
When the pastor put his finger out to do a finger stick it, in the middle of the service, I think it surprised you, but a number of pieces of the research were given to the worship committee to redo, make more culturally competent, and make more relevant.
As a result, the university lost some of the control of the research entity and this bothered the IRB to a great extent. Therefore, they did not get that to have really a participatory community academic sort of activity. But the community side had to own part of the research. Even while this research was going on, the ADA (American Diabetes Association) van was across the street from this church, but no one was accessing it. The ADA personnel couldn’t figure out why. It’s because the activity in the church was owned and appreciated, but it almost took down our ability to publish the results.
As a matter of fact, we didn’t publish that data because the IRB raised so much fuss about it. There were some community board members that did get it that lived in the part of Dayton where the churches were located and certainly became advocates, but the pure academic researchers didn’t understand it.