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

项目总结 非裔美国人(AA)患糖尿病(DM)的比例是美国人的两倍 白人(13%比7.5%)，糖尿病相关并发症和合并症(如截肢， 心血管疾病)。糖尿病前期的一个关键风险因素是超重/肥胖。近70%的美国人超重或 肥胖，在低收入的AA中发病率较高。国家减排努力的关键组成部分 增加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 事实证明，通过改变饮食、锻炼和适度减肥(5%-7%)，可以减少或延缓糖尿病的发病 经评估的国家试验。以团体为基础的民进党版本被广泛传播，数量众多 基于社区的试验支持其有效性。尽管取得了这些成就，但仍存在显著的健康差距。 在DPP出席率和结果方面，AAA中存在相当大的提高成功率的空间， 与白人相比，倾向于经历DPP体重减少量一半的人群。我们的目标是建立 关于我们有希望的先导研究，通过社会决定因素(SD)的健康镜头来裁剪DPP来实现 糖尿病前腹主动脉的最佳DPP出诊和临床有意义的体重减轻。这包括量身定做 与改善健康结果相关的文化和社会经济可持续发展机制 在主要是低收入和生活在低资源的戒酒协会社区的戒酒协会中的易感需求。 我们建议对360名来自安全网医院(SNH)的糖尿病前AA患者进行随机对照试验，以测试 标准民进党(S-民进党)与文化定制民进党(TC-民进党；例如，语言、食物、价值观、 宗教信仰、规范、价值观)和文化定制的民进党，以解决与访问和支持相关的问题 经济障碍(TCE-DPP；混合团体/在线/文本DPP；社区卫生工作者支持以改善 获得民进党课程、健康食品、锻炼和其他社区和卫生资源；以及财政 奖励)超过12个月。我们将：1)检测TC-DPP和TCE-DDP对体重损失百分比和 出诊(主要结果)和次要结果(体力活动、完成医生随访- 在6个月和12个月时对SNH AA进行向上访问、糖化血红蛋白和血压)，2)评估潜在的介质/ 与AA SNH患者在6个月和12个月时的体重减轻和就诊相关的主持人确定 可修改的促进者和障碍，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，以及传递剂量、暴露、成本和结果之间的关系，以确定和 改进必要的干预组件。我们的多维民进党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 最初的民进党试验--当然也是实现以低收入为主的AA的类似结果所必需的。至 据我们所知，这是第一项通过SD镜头测试多维剪裁真正影响DPP的研究 出勤率和结果，并有可能成为一个可行的，可扩展的模式，以减少DM的差距 处于危险中的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.