Eat Right, Live Right for a Healthier You

Background

Over the past few decades, Diabetes Mellitus type 2 has become a prevalent condition within western society (Abate & Chandalia, 2003). In America, the disease affects minority populations such as African-Americans disproportionately (Thackeray et al. 2004). African-Americans have a far greater likelihood to suffer type 2 diabetes and the many forms of comorbid conditions that result from it as compared to non-Hispanic Caucasians (Thackeray, Merrill et al. 2004). Diabetes mellitus type 2 involves the human body’s inability to digest excess glucose found in the blood. The inability to carry out the essential function of sugar breakdown tends to affect the functions of other vital organs in the body. According to the Centers for Disease Control (CDC), approximately 30% of diabetes patients who are over the age of 40 years are living with some form of nervous system condition (Centers for Disease Control 2011). For this reason it is important to tackle the problem of diabetes type 2 considering the impact it otherwise would have (Department of Health and Human Services).

According to Thackeray et al. (2004), African-Americans are more likely to suffer the devastating consequences of diabetes mellitus type 2 than non-Hispanic whites. This calls for a program to alleviate the problem in the group that is most at risk, namely – African-American population within Indianapolis over the age of 40. Studies have shown that among minority populations over the age of 40, low income tends to play a role in type 2 diabetes prevalence. This finding was the basis for selecting the target population of the current program (Robbins et al 2001).

The name of the program is “Eat Right, Live Right for a Better You.” It is aimed at low-income African-Americans living in the city of Indianapolis; studies show that among African-American women the level of income is strongly associated with type 2 diabetes diagnosis (Robbins et al 2001). The current program seeks to educate the participants about how to manage the disease through tertiary prevention techniques such as blood glucose monitoring in order to maintain healthy levels. In addition to that, the program seeks to create awareness of the importance of physical activity in controlling the effects of type 2 diabetes.

Program Design

Table 1.

Logic Model. Summary of Relevant Resources, Activities Planned, Short and Long Term Outcomes and The Ultimate Goals of the Eat Right, Live Right Program.

Resources	Activities	Outputs	Short & Long term Outcomes	Impact
· Community Healthcare System ·accelerometers ·       Nutritionists ·       Telephones ·       Skills specialists ·       Nurses ·       Researchers ·       Self-report surveys ·       IRB approval ·       A1c home test kit	·       Classes ·       Home visits ·       Mailing out literature on health ·       Distribution of self-report surveys	·       12 classes to be conducted ·       350 people to be recruited ·       400 surveys to be sent out ·       90% projected response rate ·       90% projected class attendance rate	·       Improved awareness about diabetes self-management ·       increased knowledge about importance of physical activity ·       increased knowledge about medication and diabetes self-management	·       engagement in more moderate intensity physical activity ·       reduced blood glucose levels close to or at normal levels ·       consumption of more fruits and vegetables ·       consumption of more lean meat

The Eat Right, Live Right program is based on two evidence-based programs called Racial and Ethnic Approaches to Community Health (REACH) Detroit Partnership (Two et al, 2005) and the New Leaf program (Keyserling, Samuel-Hodge et al. 2002). These programs were successfully implemented in Detroit and central North Carolina respectively with participants that are comparable to the target audience for the current program. The Eat Right, Live Right program is a hybrid of the two programs and adapted to suit the needs of the target population in Indianapolis – African-American men and women over the age of 40 years (Two et al, 2005). The hybrid is used because even though the REACH Detroit Partnership included African-American participants, as detailed in Table 2, the sample size comprised a substantial number of adults under the age of 40. The New Leaf program was also made up entirely of African-American women (Keyserling, Samuel-Hodge et al. 2002). The all-female sample size only satisfies one aspect of the desired target population for the current Eat Right, Live Right program as outlined in Table 2.

	REACH Detroit Partnership	New Leaf Program
Target Population	·       151 Adult African-American and Latino Adults	·       200 African-American women
Variables measured	·       blood glucose level ·       knowledge about role of diet in managing diabetes type 2	·       Physical activity, diabetes knowledge
Key Results	·       Through the implementation of the diabetes self-care knowledge and dietary behaviors, the study reported a 0.8% decrease in blood glucose levels as compared to a control group that received no intervention within that same 5-month period. ·       There was an increase in fruit and vegetable consumption which was assessed by a post-intervention survey. ·       Participants who reported draining fat off meats after cooking also showed statistically significant results with a p-value of less than 0.001. ·       In addition to that there was an increase in knowledge about the positive impact healthy dietary habits has on diabetes type 2 outcomes (Dadzie, 2015).	·       In terms of physical activity, there was an increase in the burning of calories which was measured by an accelerometer participants were to wear when they were awake. ·       Between the first group who received counseling and physical activity advice, there was 15% more activity level as compared to the group which received just educational material in the mail (Dadzie, 2015).

The Eat Right, Live Right program will comprise two groups – an experimental group, which will be referred to as group A, and a control group called group B. There will be ten (10) well-trained instructors drawn from the initial pool of participants to teach classes. Pre- and post-test data will be collected on hemoglobin A1c and physical activity levels, as well as healthy nutrition knowledge. The measurements at the beginning and end of the intervention will be the main means by which to determine the effectiveness of the program.

Implementation

Experimental Group

The target population will be drawn from the central Indianapolis-based Community Health Network and will total about three hundred and fifty (350) African-American adults over the age of 40 years. The group will be randomly assigned to two groups for purposes of comparison. The focus of the program will be the intrapersonal level of the socioecological model. In addition to that the theoretical foundation will be based on the Social Cognitive Theory.

Surveys will be sent out to potential participants, and based on their responses a determination will be made as to whether or not each one is a good fit for the program. From the responses received, ten (10) will be chosen to be Peer Educators. Training of Peer Educators will be conducted by nurses, physicians, and nutritionists so that they in turn can instruct the participants in scheduled class sessions. Training the Peer Educators will be useful for the overall success of the program since they will be drawn from the same population as the target group. It will be easier for them to empathize with the difficulties of the group and also increase the chances of the participants taking the lessons more seriously. The classes will be conducted for group A, and they will occur twice a month with each session lasting about 45 minutes to an hour for 4 months. The time commitment is a reasonable one considering the fact that it is not overly demanding. The purpose of the classes will be to educate participants about the importance of nutrition in managing diabetes. There will also be home visits by nutritionists to answer any questions participants may have and to suggest options to better manage the condition. A diet high in fiber for instance has been shown to be successful in controlling blood glucose levels and reducing hyperinsulinemia and concentration of lipid in the plasma (Chandalia et al, 2000). In addition to proper dietary habits pertaining to diabetes, participants will be taught stress management techniques. Stress management techniques will help in dealing with the frustration and excessive stress that comes about as a result of having little energy and dealing with diabetes type 2 in general.

The intervention will also include physical activity monitoring. As part of improving the overall physical health and well-being of the participants, accelerometers will be distributed to all participants. The accelerometers will be worn during the time of day when they are most active. The purpose of this is to track the amount of moderate-intensity physical activity engaged in by participants. The activity will be gauged by calories burned each week. Empirical evidence supports the notion that long-lasting and comparatively less strenuous physical activity tends to be the most effective in dealing with type 2 diabetes management (Polikandrioti & Dokoutsidou 2009).

Survey items will be taken from the Behavioral Risk Factor Surveillance System (BRFSS) and will be modified as necessary to collect the information relevant to the goals of the study. The survey will collect such baseline information as physical activity level, stress, and dietary habits. The measurements will be done at the beginning of the study before the intervention is applied. After the intervention is carried out data on the same variables, namely blood glucose levels, physical activity level, and dietary habit, will be collected and analyzed for the experimental group. A comparison of pre- and post-intervention data will be performed in order to determine the success or otherwise of the program.

Control Group

For group B, which will be the control group, surveys will be taken as well. The purpose of this is to determine the baseline data for their physical activity, hemoglobin A1c levels, and knowledge about the role of healthy diet in managing diabetes. Health literature will be mailed out to each participant in the control group. None of the treatments received by the experimental group will be applied to the control group. Not applying any of the experimental group’s treatments to the control group will allow for a better comparison and more valid conclusions to be made about the effectiveness of the intervention applied.

SMART Objectives

Short-term Outcomes (6 months – 1 year)

In terms of short-term outcomes, participants who receive the intervention are expected to increase their knowledge of diabetes self-management techniques. Among them are regular blood glucose monitoring, healthier dietary choices, and increased moderate physical activity. Within six months of the intervention, participants are expected to both know the importance of and engage in regular moderate intensity physical activities, and this will be measured by the amount of calories burned as recorded by an accelerometer. The classes will be the main source of knowledge of the role of diet in managing diabetes. Knowledge gained will be measured by survey responses to be distributed. After between 6 months to 1 year, the participants will be expected to know how to test for blood glucose levels and also be taking steps to reduce it. The result will be validated by a registered nurse conducting in-clinic tests to determine how much lower blood glucose levels have fallen from the baseline. To further reinforce the knowledge gained, monthly visits and/or phone calls will be made to the homes of the participants during the course of the intervention.

Long term Outcomes (1 – 2 years)

In the long-term, participants in the experimental group will be expected to have reduced hemoglobin A1c levels through regular monitoring and opt for more fruits and vegetables as part of their regular diet instead of foods high in saturated fat, sugar content, and sodium. Participants will also be expected to engage in more moderate intensity physical activity to enable them to expend energy and not engage in a sedentary lifestyle.

The control group is expected to have a negligible amount of change in hemoglobin A1c levels, healthy dietary habits, and physical activity from baseline. If there is ever any change it will likely be attributable to the health literature mailed out. It is expected to be comparatively less of a change to what will result in the intervention group. Outcomes will be measured by using the BRFSS survey items modified to suit the needs of the current program.

Contextual Factors

Social Cognitive Theory (SCT) is the main theoretical foundation of the Eat Right, Live Right program. SCT was derived from the Social Learning Theory. The theory, propounded by Albert Bandura, posits that people learn from the observation of others engaging in a specific activity and the positive results that come about (Rimer & Glanz, 2005). The relevant constructs of the theory to the current intervention under consideration are as follows: behavioral capability, self-efficacy, expectations, and reinforcements.

Behavioral capability according to Rimer and Glanz (2005) is the requisite knowledge and expertise needed to carry out a specific target behavior. For the purposes of the current intervention, classes conducted will be the main source of skill and knowledge acquisition for the experimental group. The classes will expose the participants to best practices in the field that have been tried and tested and proven to be effective in achieving the target behavior – successful diabetes self-management. For instance, Peer Educators demonstrating how to effectively use a hemoglobin A1c home test kit to test blood glucose levels will teach participants who have little to no experience how to perform the test. Also nutritionists who will suggest different ingredients that are healthy for type 2 diabetes management will train them on how to make healthier food choices.

Self-efficacy refers to a participant’s capacity to perform a specific behavior. The participants’ belief in their potential and capability, in other words, determines whether or not there will be successful behavior change as desired (Rimer & Glanz, 2005). The key to the successful implementation of the self-efficacy construct is to have objectives that are Specific, Measurable, Achievable, Relevant, and Time bound (SMART). The SMART objectives are in direct reference to the short- and long-term outcomes that are forecasted. That is, between 6 months to 1 year, the intervention is expected to teach the participants the importance of blood glucose monitoring, healthy food choices, moderate intensity physical activity, and stress management techniques. Between year 1 and 2, participants are expected to have these behaviors become a normal and regular aspect of their daily routine in order to attain maximum results. The objectives mentioned will be assessed by sending out evaluation surveys especially for the healthy food choice data. Regarding the hemoglobin A1c and physical activity levels, evaluation will be done in the clinic with an A1c test kit and accelerometer readings respectively. During the short-term phase a useful tool to keep motivation high is to keep a record of progress.

The positive outcomes expected will serve as motivation for the participants. Peer Educators will show video clips of past participants who have had positive experiences. By so doing, the positive experiences will serve as a model for the current participants and they will be encouraged to fully participate. In addition, their own success will go a long way in reinforcing the likelihood of them sustaining the newly learned behaviors.

Social Cognitive Theory was chosen for a number of reasons. One of the reasons is that it is a hybrid of behaviorist and cognitive psychology approaches. It basically focuses on conscientizing individuals about the health condition they face – diabetes type 2 in this case – and how to effectively change the status quo just by making minimal behavioral adjustments over time. It therefore represents a two-pronged approach to health behavior change and that makes it a suitable choice for the Eat Right, Live Right Program.

Positive Contributing Factors

Access to good quality health care is crucial to achieving optimal health especially for the target population under consideration. Thankfully, the Healthy Indiana Plan (HIP 2.0) is available for low-income individuals. The program seeks to identify such individuals who use the HIP 2.0 to pay for medical needs related to type 2 diabetes within the Community Health Network in the city of Indianapolis. The inability to access good quality healthcare has been implicated in several studies as being responsible for the poor health outcomes of minority populations (Agardh et al 2011).

For low-income households, making healthy food choices can prove to be an expensive undertaking. Government assistance programs such as Food stamps, Women Infants and Children (WIC) can help. Social welfare programs like WIC and food stamps can go a long way to supplement the efforts of the intervention in making healthy food choices a regular part of participants’ diet.

Negative Contributing Factors

Attrition, low class attendance rate, and low survey response rate are potential issues to consider. Attrition could be due to relocation or death. Low class attendance rate could happen because of difficulties in accessing transportation to the Community Health Network location. The Community Health Network system is a fairly extensive one with locations spread out throughout the city of Indianapolis but the transportation system within the city is not the most efficient and often people get around in their own cars. Most low income households may not have access to a car and that could be a potential problem in ensuring that they get to the class as and when they should. Low class attendance rate, attrition and low survey response rate altogether have the potential to skew the overall results due to a reduction in sample size available for analysis.

Conclusion

The Eat Right, Live Right for a Healthier You program is an evidenced-based intervention. The program has its theoretical framework in the Social Cognitive Theory and tackles the intrapersonal level of the socioeconomic model. The population of interest is the 40 year and above age group of African-American males and females in the city of Indianapolis.

 The target population is a low income one and many studies have put forth evidence showing that it is a vulnerable population especially when it comes to managing chronic conditions such as type 2 diabetes (Robbins et al 2001). This is mostly due to the costs involved in managing the condition, including but not limited to proper education and health literacy.

The intervention involves randomly assigning individuals into two groups and carrying out a pre- and post- intervention test to determine the effectiveness of the program. Of particular interest will be the hemoglobin A1c, physical activity levels and healthy dietary choices of the participants. Group A – the experimental group – will be expected to have much better outcomes because of the intervention applied. Group B on the other hand will have very little change from baseline data.

The Eat Right, Live Right Program is a timely one for the target population. According to the CDC (2011), between 90 to 95% of type 2 diabetes diagnoses are found among adults. There are associated complications suffered by type 2 diabetics due to a lack of effective management techniques, procedures and knowledge. The lack of diabetes self-management knowledge and techniques make the current program – Eat Right, Live Right Program a timely and necessary one for one for the target population. A successful implementation of the intervention will likely reduce the chances of type 2 diabetes’ progression into nerve damage, blindness, and other debilitating health conditions.

References

Abate, N. and M. Chandalia (2003). "The impact of ethnicity on type 2 diabetes." Journal of Diabetes and its Complications 17(1): 39-58.

Agardh, E., Allebeck, P., Hallqvist, J., Moradi, T., & Sidorchuk, A. (2011). Type 2 diabetes incidence and socio-economic position: a systematic review and meta-analysis. International journal of epidemiology, dyr029.

Centers for Disease Control and Prevention (CDC), & Centers for Disease Control and Prevention (CDC). (2011). National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 201.

Chandalia, M., Garg, A., Lutjohann, D., von Bergmann, K., Grundy, S. M., & Brinkley, L. J. (2000). Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. New England Journal of Medicine, 342(19), 1392-1398.

Dadzie, J. (2015). Evidence Based Paper. Unpublished manuscript, Indiana University - Purdue University Indianapolis.

Department of Health and Human Services. "Diabetes." Retrieved 01/09/2015, 2015, from http://www.healthypeople.gov/2020/topics-objectives/topic/diabetes.

Polikandrioti, M., & Dokoutsidou, H. (2009). The role of exercise and nutrition in type II diabetes mellitus management. studies, 1, 5.

Rimer, B. K., & Glanz, K. (2005). Theory at a glance: a guide for health promotion practice .

Robbins, J. M., Vaccarino, V., Zhang, H., & Kasl, S. V. (2001). Socioeconomic status and type 2 diabetes in African American and non-Hispanic white women and men: evidence from the Third National Health and Nutrition Examination Survey. American Journal of Public Health, 91(1), 76.

Two Feathers, J., Kieffer, E. C., Palmisano, G., Anderson, M., Sinco, B., Janz, N., ... & Wisdom, K. (2005). Racial and Ethnic Approaches to Community Health (REACH) Detroit partnership: improving diabetes-related outcomes among African American and Latino adults. American Journal of Public Health, 95(9), 1552-1560.

Thackeray, R., et al. (2004). "Disparities in diabetes management practice between racial and ethnic groups in the United States." The Diabetes Educator 30(4): 665-675.

Robbins, J. M., Vaccarino, V., Zhang, H., & Kasl, S. V. (2001). Socioeconomic status and type 2 diabetes in African American and non-Hispanic white women and men: evidence from the Third National Health and Nutrition Examination Survey. American Journal of Public Health, 91(1), 76.