NEW YORK (Reuters Health) – A community-based, patient-centered intervention called DREAM led to improvements in the management of type 2 diabetes among Bangladeshi immigrants in New York City, researchers say.
“Although the intervention was designed to measure improvement of hemoglobin A1c as the primary outcome, we learned early on during the intervention that in this community, which is low-income and has limited English proficiency, participants often did not have access to culturally relevant resources in their language to help them engage in health-promoting behaviors to manage their diabetes,” Dr. Nadia Islam of New York University School of Medicine in New York City told Reuters Health.
“With input from our community advisory board and our community health workers (CHWs),” she said by email, “we integrated education and activities for our participants that promoted physical activity and nutrition in a way that was meaningful and useful.”
Dr. Islam and colleagues enrolled 336 self-identified Bangladeshis (mean age, 55; 40% women) with type 2 diabetes (i.e., hemoglobin A1c level of 6.5% or higher) and randomly assigned 176 patients to the intervention group and 160 to a control group. Follow-up lasted six months.
All participants completed a two-hour educational session that provided an overview of diabetes. The intervention group received four additional two-hour monthly educational sessions led by bilingual Bangladeshi health workers and two, one-on-one visits to set individual health goals.
As reported online January 31 in Clinical Diabetes, 90% of intervention participants finished the program – defined as attending at least three of five workshops and one of the two one-on-one visits – as well as the six-month survey and clinical assessments. About 80% of controls completed the survey and assessments.
By six months, mean absolute A1c had decreased by 0.2% in the intervention group, with no change in the control group. Among participants with baseline A1c of 8.0% or more, mean absolute A1c decreased by 0.6% in the intervention group and by 0.2% for controls.
A decline in A1c by 6-month follow-up was significantly more common in the intervention than the control group (55.2% vs. 42.5%), particularly among women (59.3% vs. 37.7%). Men did not show this benefit of the intervention.
Similarly, A1c control at follow-up was significantly more common with the intervention than without it (36.3% vs. 24.6%).
Mean total cholesterol decreased significantly by 10.6 mg/dL for the intervention participants, compared to 0.6 mg/dL for controls. Significant changes in mean weight and BMI occurred in both groups, with greater declines in the intervention group. The two groups did not differ significantly from each other in changes in LDL cholesterol, HDL cholesterol or triglycerides.
Given that the magnitude of improvements was smaller in the control than in the intervention group, Dr. Islam said, “we believe that longer-term engagement and more frequent contact with CHWs produces greater and more long-term improvements in health.”
“However, this model can only be sustained with new opportunities and resources dedicated to integrating CHWs into healthcare teams, as we have had through grant funding and support from our institution.”
A new NIH-funded study will “integrate and test a CHW-led diabetes management model into 20 primary care practices across New York City that serve the South Asian community,” she noted.
“We are partnering with health insurance organizations and city agencies to ensure the models we develop are financially sustainable.”
Dr. Reshmi Srinath, assistant professor of Endocrinology, Diabetes and Bone Disease at Icahn School of Medicine at Mount Sinai, also in New York City, said, “Diabetes management can be really challenging for physicians when there are language and health literacy barriers, and this study supports the concept of having a diabetes team which may include nurses, nurse practitioners, and community health workers to assist with patient care.”
“The study also supports the concept that the more face-to-face time with the healthcare team, the better the outcome with diabetes,” she told Reuters Health by email.
Expressing surprise that there were no significant differences in some of the outcomes between groups, Dr. Srinath suggested that “there may have been a placebo effect in the control group; just by being enrolled in the study, they were more focused on improving their diabetes.”
“It’s possible that with a larger sample size and longer – beyond six months – follow-up, “there would be a higher chance of finding a significant difference,” she suggested.
“Further studies need to be done in minority groups with diabetes, using culturally sensitive interventions,” Dr. Srinath said. “In future studies, more data should be gathered related to duration of diabetes and extent of complications and other comorbidities, (all of) which can affect both glucose levels and patient-centered outcomes.”
SOURCE: http://bit.ly/2E2xhXB
Clin Diabetes 2018.
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