Factors influencing participant enrolment in a diabetes prevention program in general practice: lessons from the Sydney diabetes prevention program

<b>Background:</b> The effectiveness of lifestyle interventions in reducing diabetes incidence has been well established. Little is known, however, about factors influencing the reach of diabetes prevention programs. This study examines the predictors of enrolment in the Sydney Diabetes Prevention Program (SDPP), a community-based diabetes prevention program conducted in general practice, New South Wales, Australia from 2008&ndash;2011.<br /><b><br />Methods:</b> SDPP was an effectiveness trial. Participating general practitioners (GPs) from three Divisions of General Practice invited individuals aged 50&ndash;65 years without known diabetes to complete the Australian Type 2 Diabetes Risk Assessment tool. Individuals at high risk of diabetes were invited to participate in a lifestyle modification program. A multivariate model using generalized estimating equations to control for clustering of enrolment outcomes by GPs was used to examine independent predictors of enrolment in the program. Predictors included age, gender, indigenous status, region of birth, socio-economic status, family history of diabetes, history of high glucose, use of anti-hypertensive medication, smoking status, fruit and vegetable intake, physical activity level and waist measurement.<br /><b><br />Results: </b>Of the 1821 eligible people identified as high risk, one third chose not to enrol in the lifestyle program. In multivariant analysis, physically inactive individuals (OR: 1.48, P = 0.004) and those with a family history of diabetes (OR: 1.67, P = 0.000) and history of high blood glucose levels (OR: 1.48, P = 0.001) were significantly more likely to enrol in the program. However, high risk individuals who smoked (OR: 0.52, P = 0.000), were born in a country with high diabetes risk (OR: 0.52, P = 0.000), were taking blood pressure lowering medications (OR: 0.80, P = 0.040) and consumed little fruit and vegetables (OR: 0.76, P = 0.047) were significantly less likely to take up the program.<br /><br /><b>Conclusions:</b> Targeted strategies are likely to be needed to engage groups such as smokers and high risk ethnic groups. Further research is required to better understand factors influencing enrolment in diabetes prevention programs in the primary health care setting, both at the GP and individual level.<br />

Moving towards a population health approach to the primary prevention of common mental disorders

There is a need for the development of effective universal preventive approaches to the common mental disorders, depression and anxiety, at a population level. Poor diet, physical inactivity and smoking have long been recognized as key contributors to the high prevalence noncommunicable diseases. However, there are now an increasing number of studies suggesting that the same modifiable lifestyle behaviors are also risk factors for common mental disorders. In this paper we point to the emerging data regarding lifestyle risk factors for common mental disorders, with a particular focus on and critique of the newest evidence regarding diet quality. On the basis of this most recent evidence, we consequently argue for the inclusion of depression and anxiety in the ranks of the high prevalence noncommunicable diseases influenced by habitual lifestyle practices. We believe that it is both feasible and timely to begin to develop effective, sustainable, population-level prevention initiatives for the common mental illnesses that build on the established and developing approaches to the noncommunicable somatic diseases.<br />

Ensuring implementation success : how should coach injury prevention education be improved if we want coaches to deliver safety programmes during training sessions?

Coaches play a major role in encouraging and ensuring that participants of their teams adopt appropriate safety practices. However, the extent to which the coaches undertake this role will depend upon their attitudes about injury prevention, their perceptions of what the other coaches usually do and their own beliefs about how much control they have in delivering such programmes. Fifty-one junior netball coaches were surveyed about incorporating the teaching of correct (safe) landing technique during their delivery of training sessions to junior players. Overall, &gt;94% of coaches had strongly positive attitudes towards teaching correct landing technique and &gt;80% had strongly positive perceptions of their own control over delivering such programmes. Coaches&rsquo; ratings of social norms relating to what others think about teaching safe landing were more positive (&gt;94%) than those relating to what others actually do (63&ndash;74%). In conclusion, the junior coaches were generally receptive towards delivering safe landing training programmes in the training sessions they led. Future coach education could include role modelling by prominent coaches so that more community-level coaches are aware that this is a behaviour that many coaches can, and do, engage in.

Promoting obesity prevention together with environmental sustainability

There is mounting evidence that current food production, transport, land use and urban design negatively impact both climate change and obesity outcomes. Recommendations to prevent climate change provide an opportunity to improve environmental outcomes and alter our food and physical activity environments in favour of a &lsquo;healthier&rsquo; energy balance. Hence, setting goals to achieve a more sustainable society offers a unique opportunity to reduce levels of obesity. In the case of children, this approach is supported with evidence that even from a young age they show emerging understandings of complex environmental issues and are capable of both internalizing positive environmental values and influencing their own environmental outcomes. Given young children's high levels of environmental awareness, it is easy to see how environmental sustainability messages may help educate and motivate children to make &lsquo;healthier&rsquo; choices. The purpose of this paper is to highlight a new approach to tackling childhood obesity by tapping into existing social movements, such as environmental sustainability, in order to increase children's motivation for healthy eating and physical activity behaviours and thus foster more wholesome communities. We contend that a social marketing framework may be a particularly useful tool to foster behaviour change beneficial to both personal and environmental health by increasing perceived benefits and reducing perceived costs of behaviour change. Consequently, we propose a new framework which highlights suggested pathways for helping children initiate and sustain &lsquo;healthier&rsquo; behaviours in order to inform future research and potentially childhood obesity intervention strategies.

Reconceptualizing autism : moving beyond the behavioral to address cause, cure and prevention

Since the publication of Leo Kanner's seminal paper in 1943, there has been essentially no definitive light shed on the cause, prevention or cure of autism. It is our contention that the reason lies, at least in part, with the original psychiatric conceptualization of the condition and the subsequent acceptance of this framework by health professionals ever since. We suggest an urgent revision of autism as a disease state such that its operationalization in major diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases recognizes the biological variables known to be associated with autism.

The possibility of regulating for obesity prevention - understanding regulation in the Commonwealth Government

A complex regulatory package is likely to be necessary to effectively reduce obesity prevalence in developed countries. This study investigated the barriers and facilitators to implementing regulatory interventions to prevent obesity within the executive arm of the Australian Commonwealth Government. Policy reviews were conducted on nine government departments to understand their roles and interests in obesity. From this process we identified regulatory review carried out by the Office of Best Practice Regulation as possibly posing a barrier to law reform for obesity prevention, along with the complexity of the food policymaking structures. The policy reviews informed subsequent in-depth semi-structured interviews with senior Commonwealth government officers (n = 13) focused on refining our understanding of the barriers to enacting obesity prevention policy. In addition to the two barriers already identified, interviewees identified a lack of evidence for interventions, which would reduce obesity prevalence, and the influence of politicians on executive decisions as posing obstacles. Most interviewees believed that the barriers to regulating to prevent obesity were strong and that intervention by elected politicians would be the most likely method of implementing obesity prevention policy.<br />

Implementation salvage experiences from the Melbourne diabetes prevention study

<b>Background </b>Many public health interventions based on apparently sound evidence from randomised controlled trials encounter difficulties when being scaled up within health systems. Even under the best of circumstances, implementation is exceedingly difficult. In this paper we will describe the implementation salvage experiences from the Melbourne Diabetes Prevention Study, which is a randomised controlled trial of the effectiveness and cost-effectiveness nested in the state-wide Life! Taking Action on Diabetes program in Victoria, Australia.<br /><br /><b>Discussion</b> The Melbourne Diabetes Prevention Study sits within an evolving larger scale implementation project, the Life! program. Changes that occurred during the roll-out of that program had a direct impact on the process of conducting this trial. The issues and methods of recovery the study team encountered were conceptualised using an implementation salvage strategies framework. The specific issues the study team came across included continuity of the state funding for Life! program and structural changes to the Life! program which consisted of adjustments to eligibility criteria, referral processes, structure and content, as well as alternative program delivery for different population groups. Staff turnover, recruitment problems, setting and venue concerns, availability of potential participants and participant characteristics were also identified as evaluation roadblocks. Each issue and corresponding salvage strategy is presented.<br /><br /><b>Summary </b>The experiences of conducting such a novel trial as the preliminary Melbourne Diabetes Prevention Study have been invaluable. The lessons learnt and knowledge gained will inform the future execution of this trial in the coming years. We anticipate that these results will also be beneficial to other researchers conducting similar trials in the public health field. We recommend that researchers openly share their experiences, barriers and challenges when conducting randomised controlled trials and implementation research. We encourage them to describe the factors that may have inhibited or enhanced the desired outcomes so that the academic community can learn and expand the research foundation of implementation salvage.<br />

EPODE approach for childhood obesity prevention : methods, progress and international development

Childhood obesity is a complex issue and needs multistakeholder involvement at all levels to foster healthier lifestyles in a sustainable way. &lsquo;Ensemble Pr&eacute;venons l'Ob&eacute;sit&eacute;Des Enfants&rsquo; (EPODE, Together Let's Prevent Childhood Obesity) is a large-scale, coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. This paper describes EPODE methodology and its objective of preventing childhood obesity.<br /><br />At a central level, a coordination team, using social marketing and organizational techniques, trains and coaches a local project manager nominated in each EPODE community by the local authorities. The local project manager is also provided with tools to mobilize local stakeholders through a local steering committee and local networks. The added value of the methodology is to mobilize stakeholders at all levels across the public and the private sectors. Its critical components include political commitment, sustainable resources, support services and a strong scientific input &ndash; drawing on the evidence-base &ndash; together with evaluation of the programme.<br /><br />Since 2004, EPODE methodology has been implemented in more than 500 communities in six countries. Community-based interventions are integral to childhood obesity prevention. EPODE provides a valuable model to address this challenge.<br />

Primary prevention of gestational diabetes for women who are overweight and obese : a randomised controlled trial

<b>Background: </b>Gestational Diabetes Mellitus (GDM) has well recognised adverse health implications for the &nbsp;mother and her newborn that are both short and long term. Obesity is a significant risk factor&nbsp;for developing GDM and the prevalence of obesity is increasing globally. It is a matter of&nbsp;public health importance that clinicians have evidence based strategies to inform practice and&nbsp;currently there is insufficient evidence regarding the impact of dietary and lifestyle&nbsp;interventions on improving maternal and newborn outcomes. The primary aim of this study is&nbsp;to measure the impact of a telephone based intervention that promotes positive lifestyle&nbsp;modifications on the incidence of GDM. Secondary aims include: the impact on gestational&nbsp;weight gain; large for gestational age babies; differences in blood glucose levels taken at the&nbsp;Oral Glucose Tolerance Test (OGTT) and selected factors relating to self-efficacy and&nbsp;psychological wellbeing.&nbsp;<div><b><br />Method/design:</b>&nbsp;A randomised controlled trial (RCT) will be conducted involving pregnant women who are &nbsp;overweight (BMI &gt;25 to 29.9 k/gm2) or obese (BMI &gt;30kgm/2), less than 14 weeks gestation&nbsp;and recruited from the Barwon South West region of Victoria, Australia. From recruitment&nbsp;until birth, women in theintervention group will receive a program informed by the Theory&nbsp;of Self-efficacy and employing Motivational Interviewing. Brief ( less than 5 minute) phone&nbsp;contact will alternate with a text message/email and will involve goal setting, behaviour&nbsp;change reinforcement with weekly weighing and charting, and the provision of health &nbsp;information. Those in the control group will receive usual care. Data for primary and&nbsp;secondary outcomes will be collected from medical record review and a questionnaire at 36&nbsp;weeks gestation.&nbsp;</div><div><b><br />Discussion:</b>&nbsp;Evidence based strategies that reduce the incidence of GDM are a priority for contemporary&nbsp;maternity care. Changing health behaviours is a complex undertaking and trialling a&nbsp;composite intervention that can be adopted in various primary health settings is required so&nbsp;women can be accessed as early in pregnancy as possible. Using a sound theoretical base to&nbsp;inform such an intervention will add depth to our understanding of this approach and to the&nbsp;interpretation of results, contributing to the evidence base for practice and policy.&nbsp;</div>

Prevention of diabetes in rural India with a telemedicine intervention

<b>Background :</b> Diabetes care is not presently available, accessible, or affordable to people living in rural areas in developing countries, such as India. The Chunampet Rural Diabetes Prevention Project (CRDPP) was conceived with the aim of implementing comprehensive diabetes screening, prevention, and treatment using a combination of telemedicine and personalized care in rural India.<br /><b><br />Methods : </b>This project was undertaken in a cluster of 42 villages in and around the Chunampet village in the state of Tamil Nadu in southern India. A telemedicine van was used to screen for diabetes and its complications using retinal photography, Doppler imaging, biothesiometry, and electrocardiography using standardized techniques. A rural diabetes center was set up to provide basic diabetes care.<br /><br /><b>Results :</b> Of the total 27,014 adult population living in 42 villages, 23,380 (86.5%) were screened for diabetes, of which 1138 (4.9%) had diabetes and 3410 (14.6%) had prediabetes. A total of 1001 diabetes subjects were screened for complications (response rate of 88.0%). Diabetic retinopathy was detected in 18.2%, neuropathy in 30.9%, microalbuminuria in 24.3%, peripheral vascular disease in 7.3%, and coronary artery disease in 10.8%. The mean hemoglobin A1c levels among the diabetes subjects in the whole community decreased from9.3 &plusmn; 2.6% to 8.5 &plusmn; 2.4% within 1 year. Less than 5% of patients needed referral for further management to the tertiary diabetes hospital in Chennai.