African Americans (AAs) are disproportionately burdened by diabetes mellitus (DM) with
rates twice as high as Whites (13% vs 7.5%), and increased rates of DM-related
complications and comorbidities (e.g. amputations, cardiovascular disease). A key pre-DM
risk factor is overweight/obesity. Nearly 70% of AAs are overweight or obese, with higher
rates among AAs with low-income. A critical component of national efforts to reduce
growing obesity rates and prevent DM is the Diabetes Prevention Program (DPP), a
lifestyle intervention proven to reduce or delay DM onset with diet change, exercise, and
modest weight loss (5-7%) in a rigorously evaluated national trial. A group-based version
of the DPP has been widely disseminated and numerous community-based trials support its
efficacy. In spite of these successes, there are significant health disparities in DPP
attendance and outcomes and considerable room exists for improving success rates among
AAs, a population that tends to experience half the amount of DPP weight loss compared to
Whites. The investigators aim to build on our promising pilot studies by tailoring the
DPP via a social determinants (SD) of health lens to achieve optimal DPP attendance and
clinically meaningful weight loss with pre-DM AAs. This includes tailoring on cultural
and socioeconomic SD mechanisms that are associated with improving health outcomes and
align with predisposing needs among AAs who are primarily of low-income and live in
low-resource AA communities.
The investigators propose a randomized controlled trial of 360 pre-DM AA patients from a
safety net hospital (SNH) to test a standard DPP (S-DPP) against a culturally tailored
DPP (TC-DPP; e.g., tailoring of language, foods, values, religiosity, norms, values)
alone and a culturally tailored DPP enhanced to address access and support related
economic barriers (TCE-DPP; hybrid group/online/text DPP; community health worker support
to improve access to DPP classes, healthy food, exercise, and other community and health
resources; and class promotions) over 12 months. The investigators will: 1) examine
effects of TC-DPP and TCE-DDP on percent weight loss and attendance (primary outcomes)
and on secondary outcomes (physical activity, completion of physician follow-up visit,
hbA1c, and blood pressure) at 6 and 12 months with SNH AAs, 2) evaluate potential
mediators/ moderators related to weight loss and attendance among AA SNH patients at 6
and 12 months to determine modifiable facilitators and barriers, and 3) conduct a process
evaluation to examine TCE-DPP acceptability, feasibility, and fidelity, and relationships
between delivery dose, exposure, costs, and outcomes to identify and improve essential
intervention components. Our multidimensional DPP interventions are guided by our past
pilots, and based on components that, all together, were used to help drive clinically
important outcomes in the original DPP trial - and are certainly needed to achieve
similar outcomes with AA primarily of low-income. To our knowledge this is the first
study to test multidimensional tailoring via an SD lens to truly impact DPP attendance
and outcomes, and has potential to be a feasible, scalable model to reduce DM disparities
among at-risk AA.
