1. Working with the Manual of Operations Lessons from the Diabetes Prevention Program Mary Hoskin & Carol Percy January 13, 2005 DP Meeting

2. Agenda Intro-background DPP Overview of Manual Example for curriculum Keys to Success Video

3. Key Findings from the DPP Lifestyle Intervention reduced the risk of diabetes by 58%. Treating 7 people with Lifestyle intervention will prevent 1 new case of Diabetes in 3 years. The DPP Research Group, NEJM, 346:393-403; 2002 Weight loss was the factor that prevented Diabetes in the Intensive Lifestyle group. Hamman, R. for the The DPP Research Group, ADA Oral Presentation, 2002, # 115

4. Lifestyle intervention was beneficial regardless of ethnicity, age, BMI, or sex.Lifestyle intervention was beneficial regardless of ethnicity, age, BMI, or sex. For every 1 Kg of weight lost, diabetes risk was reduced by 13%. Increased physical activity was not associated with initial weight loss but was significantly related to long term weight loss. Self-reported improvements in diet and physical activity that do not result in weight loss do not result in lower diabetes risk. Key Findings (continued)

5. Lifestyle Intervention An intensive program with the following specific goals: > 7% loss of body weight and maintenance of weight loss> 7% loss of body weight and maintenance of weight loss – Dietary fat goal -- <25% of calories from fat – Calorie intake goal -- 1200-1800 kcal/day > 150 minutes per week of physical activity> 150 minutes per week of physical activity

6. The Core Curriculum 16 easy to use sessions over 24 weeks of education and training in diet and exercise methods and behavior modification skills Emphasis on: Self monitoring techniques Problem solving Individualizing programs Empowerment and social support Frequent contact with case manager and DPP support staff

7. Lifestyle Core Class Sessions 1.Welcome and Getting Started Losing Weight. 2.Be a Fat and Calorie Detective. 3.Three Ways to Eat Less Fat. 4.Healthy Eating. 5.Move Those Muscles. 6.Being Active: A Way of Life. 7.Tip the Calorie Balance 8.Take Charge of What’s Around You

8. Lifestyle Core Class Sessions (continued) 9. Problem Solving 10. Four Keys to Healthy Eating Out. 11. Talk Back to Negative Thoughts. 12. The Slippery Slope of Lifestyle Change. 13. Jump Start Your Activity Plan. 14. Make Social Cues Work for You. 15. You Can Manage Stress. 16. Ways to Stay Motivated.

9. Overview of Manual

10. Principles from Manual of Operations 7% weight loss goal set because it was believed to be safe, effective and feasible Emphasis on group interaction and discussion Each lesson has a model script Time to plan group and not lesson Based on clearly defined study goal Intervention is based on participant self- management Tailor to participant lifestyle, learning style and culture

11. Common Questions Fat and calorie goals & one at a time 16 weeks of weekly contact Weight lifting/Thai chi, etc Focus on limiting fat, not carbohydrates questions Focus on success

12. Daily Fat and Calorie Goals Weight (lbs) Fat Goal (grams) Calorie Goal 120-174331,200 175-219421,500 220-249501,800 >250552,000 Be a Fat and Calorie Detective

13. Keeping Track Book

14. Lifestyle Core Session #3: Three ways to eat less fat Eat high fat foods less often Eat a smaller amount of high-fat foods Eat lower fat foods instead

15. How did the successful weight losers do it in DPP?

16. Keys to success Clearly defined and achievable goals and expectations Case management approach Frequent contact Relationships- staff and family Intensive, ongoing intervention

17. Keys to Success (Continued) Individualization Materials and strategies that addressed the needs of an ethnically diverse population Keeping track Provide tools to achieve goals Staff Training

18. Defined and Achievable Goals Individualized fat and calorie goals for weight loss Individual weight loss goal (7%) Physical Activity goal of 150 min per wk Time frame to meet stated goals Participant contracts

19. Case Management Consistent relationships Work with the participant as a team Hang in there- reinforcement Be supportive Utilize multidisciplinary approach

20. Frequent Contact Weekly Monthly Campaigns/Maintenance Most chose to come in more often

21. Relationships Consistency Supportive Honest Believe in you Family

22. Lifetime Maintenance Continued self-monitoring and other behavioral strategiesContinued self-monitoring and other behavioral strategies Frequent contactFrequent contact Group classes and motivational campaignsGroup classes and motivational campaigns Tool box strategiesTool box strategies

23. Individualization Goals individualized to starting weight and what makes them successfully lose weight Recipes and menus Interpersonal and individual needs like jobs, literacy and language Team approach they choose how to

24. Targeting for population Use local examples to reinforce points –3 ways to eat less fat Recipes and Foods Designed for use in many different ethnic groups Physical Activity

25. Staff Training Required reading Appendix D.1 Videotapes Observation by centrally trained personnel Audio taped practice session Ongoing team meetings

26. Weight Control Registry Keys to Success: Eat a reduced-calorie, low-fat, moderately high carbohydrate diet Eat breakfast daily Check weight regularly Regular Physical Activity

27. Motivational Interviewing Listening and Summarizing Resolving Ambivalence Building Motivation and Strengthening Commitment Providing Information

28. Services-Research Continuum Improve practice and standards of care Identify problems and research questions Research StudyHealth Services

29. SMALL STEPS BIG REWARDS

30. The risk is great.

31. The goals are important

32. The changes are modest.

33. The action steps are clear.

34. That doesn’t make it easy for you, but the DPP demonstrated that it can be done. NIH Pub. No. 03-5335 Feb 2003

35. Thanks to the DPP participants for their commitment and dedication to the goal of diabetes prevention