Peer-led and Telehealth Comparative Effectiveness Research (CER) Adoption for Diabetes Prevention and Management

The prevalence of obesity and diabetes in older adults has increased during the past 20
years and will increasingly affect medical and social services, as well as costs over time.
Because older adults are often portrayed as less likely to change long-standing health
behaviors, health promotion in this age group has lagged behind others. In fact, little
attention has been given to the importance of diabetes prevention and management in
community-dwelling older adults.

A recent report of obesity diagnosis and care practice in the Veterans Health Administration
showed that elderly patients were less likely to receive obesity-related education or
counseling [Noel 2010]. Intentional weight loss in obese older adults has not been widely
advocated by health care providers due to the perceived uncertainty of whether the benefits
outweigh the risks. There is also a need to overcome the barriers to provide appropriate
interventions on blood pressure, glucose, and lipid management tailored to the functionality
of older adults.

The Diabetes Prevention Program (DPP) demonstrated the benefit of modest weight loss,
through diet and exercise, on the reduction of diabetes risk in participants from all
race/ethnic groups (58% overall reduction with a 71% reduction in the older population),
leading to a delay of 4 years over a 10-year period in the onset of diabetes among those
that received lifestyle intervention [DPP 2002, DPP 2009]. The DPP is considered a landmark
study in comparative effectiveness research (CER), but it has yet to be translated into
widespread public health practice.

South Florida provides a unique setting to accelerate the adoption of this CER evidence into
practice and address the obesity and diabetes challenges of the aging population. There are
more than 800,000 multi-ethnic residents age 60 and over, many of whom have one or more
chronic diseases [CDC 2008]. A large number of older veterans with or at high-risk of
diabetes currently receive care in the Miami VA Healthcare System.

Compelling scientific evidence exists that lifestyle change delays the onset of type 2
diabetes in high-risk persons. Lifestyle intervention can also lead to a reduction in
cardiovascular risk factors in individuals with type 2 diabetes [Look AHEAD research group
2007]. However, few older adults succeed in achieving intentional weight loss through
healthy diet and increased physical activity. Furthermore, some have argued that the current
US health system is not prepared to deliver lifestyle interventions [Narayan 2004].

Several issues related to integration of lifestyle intervention in clinical practice have
been raised. Currently, it is unknown whether other practicing professionals could deliver
interventions in the community with efficacy similar to that of the interventionists of the
DPP, who were trained in counseling on nutrition, exercise, and behavior modification. The
investigators propose the use of telemedicine with applications in an interactive web-based
system. This will allow participants to get just-in-time feedback from peers using targeted
information on specific areas that need reinforcement to adopt healthy lifestyle and better
self-management skills by older veterans. This will bolster the peer-participant interaction
and make them more focused around areas where there are adoption gaps. This technology
functions as a platform for social interaction that will lead to increase self-efficacy and
better health outcomes.

The VA National Center for Health Promotion and Disease Prevention (NCP) developed the MOVE!
weight management program based on the 1998/2000 Identification and Treatment of Overweight
and Obesity in Adults Evidence Report. A major goal for the MOVE! program has been to reduce
the prevalence of diabetes in veterans. Our long-term goal is to reduce the burden of
obesity-related chronic diseases and promote healthy aging in older veterans through the
implementation of best practices for prevention. The main objective of this project is to
implement evidence-informed, innovative interventions to increase adoption of findings from
comparative effectiveness research (CER) for diabetes management prevention in South Florida
older veterans.

Inclusion Criteria:

1. Age 60 years and older

2. Enrolled in HARC program

3. Body mass index (BMI) ≥ 25 kg/m²

4. Diagnosed diabetes or prediabetes [ADA 2003 criteria] HbA1c ≥ 5.7%

5. Able to operate a telemedicine device, respond to text queries, and use his/her
glucose meter, a blood pressure monitor, and a scale for daily weights

Exclusion Criteria:

1. End-stage illness

2. Anticipated survival less than 12 months

3. Imminent nursing home placement

4. Diagnosis of psychosis or significant cognitive impairment/dementia