Addressing Social Determinants of Health to Improve Diabetes Prevention Program Outcomes Among Underserved African Americans

项目摘要 非裔美国人（AA）不成比例地负担糖尿病（DM），其发病率是非裔美国人的两倍。 白人（13% vs 7.5%），DM相关并发症和合并症（例如截肢， 心血管疾病）。一个关键的糖尿病前风险因素是超重/肥胖。近70%的AA超重或 肥胖，在低收入的AA中发病率更高。国家努力减少 不断增长的肥胖率和预防糖尿病是糖尿病预防计划（DPP），一种生活方式干预 在严格的临床试验中，证明通过改变饮食、锻炼和适度减肥（5-7%）可减少或延迟DM发作。 国家试验评估。民进党的一个团体版本已经广泛传播， 基于社区的试验支持其功效。尽管取得了这些成就，但在健康方面仍存在着巨大差距。 在DPP出席率和成果方面，AA的成功率有很大的提高空间，a 与白人相比，这一人群往往经历一半的DPP减肥量。我们的目标是建立 通过从健康透镜的社会决定因素（SD）角度定制DPP， 最佳DPP出勤率和具有临床意义的体重减轻（使用DM前AA）。这包括裁剪 与改善健康结果相关的文化和社会经济可持续发展机制， 主要是低收入和生活在低资源AA社区的AA之间的易感需求。 我们提出了一项随机对照试验，360例来自安全网医院（SNH）的糖尿病前AA患者， 标准DPP（S-DPP）与文化定制DPP（TC-DPP;例如，对语言、食物、价值观、 宗教信仰、规范、价值观），并加强针对文化的DPP，以解决与获得和支持有关的问题。 经济障碍（TCE-DPP;混合组/在线/文本DPP;社区卫生工作者支持，以改善 获得DPP课程，健康食品，锻炼和其他社区和健康资源;以及 奖励）12个月。我们将：1）检查TC-DPP和TCE-DDP对体重减轻百分比的影响， 出勤率（主要结局）和次要结局（体力活动，完成医生随访- 6个月和12个月时SNH AA的随访访视、HbA 1c和血压），2）评价潜在的介质/ 与AA SNH患者在6个月和12个月时的体重减轻和出勤率相关的调节因子， 可修改的促进因素和障碍，以及3）进行过程评估，以检查TCE-DPP的可接受性， 可行性和保真度，以及输送剂量、暴露、成本和结果之间的关系，以确定和 改进基本干预措施。民进党的多维干预是以我们的过去为指导的 试点，并基于组件，所有这些组件都被用来帮助推动临床上重要的结果， 最初的DPP试验-当然需要实现类似的结果与AA主要是低收入。到 据我们所知，这是第一项通过SD透镜测试多维剪裁以真正影响DPP的研究 出席率和结果，并有可能成为一个可行的，可扩展的模型，以减少DM之间的差距 有风险的AA。

PROJECT SUMMARY 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. We 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. We 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 financial incentives) over 12 months. We 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.