Crowley, Heyerman, Michael, Reeser, Torres

Improving access for at-risk adults with prediabetes:

The implementation of the National Diabetes Prevention Program at the
Free Clinic of Southwest Washington
Goals and Objectives
The Free Clinic of Southwest Washington has an increasing number of prediabetes
patients who have little access to affordable nutrition education. Implementing the National
Diabetes Prevention Program will allow this lower income population to receive knowledge and
skills that will ultimately help reduce the incidence of type 2 diabetes.
Goal 1: Increase access to evidence-based nutrition education.
Objective 1: Develop and facilitate ten lessons from the Center for Disease Control and
Preventions (CDC) National Diabetes Prevention Program (DPP) for prediabetes
patients at the Free Clinic of Southwest Washington by March 2016.
Objective 2: Develop six nutrition education handouts on the topics of hypertension,
hyperlipidemia, prediabetes, diabetes, physical activity and healthy eating, and eating
out by January 27, 2016 for patients at Free Clinic of Southwest Washington.
Goal 2: Evaluate the effectiveness of a modified program for the prevention of type 2 diabetes in
at-risk adults with prediabetes.
Objective 1: Conduct program assessments using participant knowledge surveys,
weight information, blood pressure and blood glucose measurements, physical activity
and food logs and self-efficacy surveys at week one, week five, and week ten.
Objective 2: Conduct a qualitative assessment of program participants experience as
part of the modified prediabetes prevention program.
Qualitative Assessment of Organizations Needs
As is common with most free health clinics, the Free Clinic of Southwest Washington
provides services based on volunteers and donations. The scope and practice of the clinic is
also dependent on the volunteers, working equipment, and pharmaceutical donations. Providers
volunteer for at least one shift per month and are experts across the medical field. They work
alongside and are supported by pharmacists, registered dietitians nutritionists (RDN), clinic
specialists, laboratory technicians, and interpreters. Most of the support staff are working
towards medical certification and find value in the experiences gained at the clinic. Some clients
are homeless and seek urgent care type of services stated a clinic specialist. Other clients
come to the clinic because their income is too high to qualify for Medicaid, yet they struggle with
feeding their families and food insecurity. Clinic services range from prescription of pain, cold, or
flu medication to minor surgical procedures like abscess drainage or result in specialist referrals.
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The qualitative assessment of the Free Clinic of Southwest Washington was conducted
by all five members assigned to this community outreach project. Each member was able to
attend and experience a Thursday night shift with the project mentor, Lexie Jackson MS, RDN,
CDE. During each attended shift, interviews were conducted and observations noted. Interview
questions posed to clinic volunteers in a range of capacities are as follows:
1.
2.
3.
4.
5.
6.
7.
8.

What is your role at the clinic?

What kind of population do you work with?
What are your biggest challenges at the clinic?
What do you like most about the current program?
Do you feel like the classes in the past have made an impact on the clients?
What are the three top needs of the program?
What would you change about the program?
Is there anything else youd like to add?
A clinic specialist estimated that 70% of the clinics clients are Spanish speaking, and
use the clinic because they dont have anywhere else to go for their healthcare. There is also a
large Russian population, which requires a laboratory technician to also serve as an interpreter
on some shifts. This supports a few common themes across the clinic.
First, resources need to be used efficiently. Second, communication can be difficult,
especially with limited interpreters. Third, and probably the most important, clients are best
served from teamwork. The last theme was very evident during a diabetes counseling
appointment. While the primary provider was an RDN with a Certified Diabetes Educator (CDE)
credential, client vitals and blood glucose levels were assessed by a clinic specialist and
laboratory technician. A provider offered confirmation on the clients treatment plan, and lastly,
insulin prescriptions were facilitated by the pharmacist. All interview subjects agreed that their
work matters; they know they are working together to help an underserved population.
Literature Review
Prediabetes and Diabetes
The DPP is a CDC-recognized diabetes prevention lifestyle change program, information
on the program can be found on the CDCs website. For potential participants there is general
information about prediabetes and type 2 diabetes, what the DPP is and the research behind
the program, details of the program and what to expect, testimonials from participants, and
where to find a program. For professionals, the CDC website provides information on how to
implement, screen and refer participants to a program, add a program as a covered benefit and
where to find facts, figures and a registry of recognized organizations (1).
This research article is considered a classic article because it is the study the DPP
originated from. This randomized clinical trial took 3,234 study participants from 27 clinical
centers around the U.S. and randomly divided them into three intervention groups. All
participants were overweight and had prediabetes (a plasma glucose concentration of 95 to 125
mg/dl in the fasting state and 140 to 199 mg/dl two hours after a 75-g oral glucose load). The
first intervention group received intensive diet, physical activity and behavioral modification
training. This group focused on eating less fat, fewer calories and getting 150 minutes of
physical activity with the end goal of losing 7 percent body weight and maintaining this loss.
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This was promoted using a 16-week curriculum about diet, exercise and behavior modification.
The second group received 850 mg metformin two times a day and the third group received a
placebo pill. Groups two and three received standard lifestyle recommendations without
intensive motivational counseling. Participants were followed for an average of 2.8 years. At
the end of this time period, the participants in the intensive lifestyle intervention group
decreased their risk of developing diabetes by 58 percent, with adults over 60 lowering their risk
by 71 percent, in comparison to the placebo group. The metformin group lowered their risk by
31 percent as compared to the placebo group. While the participants in the metformin group
lowered their risk of developing type 2 diabetes, the results were not as strong as those for the
lifestyle intervention. These results show that people at risk of developing type 2 diabetes can
delay or avoid the development of the disease through lifestyle modifications of diet, regular
physical activity and modest weight loss (2).
This is a review article looking at the randomized control trials and translational studies
completed that have shown a delay in the onset of type 2 diabetes through lifestyle intervention.
RCTs in the U.S., Finland, Japan, China and India have found a 30-60% reduction in diabetes
incidence with one-on-one or small group interventions using a structured curriculum over 6
months to one year. Each program had a maintenance period following the intervention period
to prevent relapse. This article also discusses how the CDC established the DPP and the four
core elements necessary for program implementation. The four elements are training,
recognition program, lifestyle change program sites and payment model, and health marketing,
and make up the CDCs strategic approach for program success (3).
This is a 10-year follow-up to the original DPP randomized clinical trial. This study,
called the Diabetes Prevention Program Outcome Study (DPPOS), investigated whether the
delay in the development of diabetes could be sustained over time. After the DPP lifestyle
intervention was shown to be most beneficial in delaying the onset of type 2 diabetes, the
placebo and metformin group were unmasked and all three groups completed a 16-week
lifestyle curriculum as a bridge protocol. During the 10-year follow up the researchers found
that participants in the intensive lifestyle group had a diabetes incidence rate of 5.9 cases per
100 persons per year. The metformin group had a diabetes incidence rate of 4.9 cases per 100
persons per year and the placebo group had 5.6 cases per 100 persons per year. While both
the metformin and placebo group had diabetes incidence rates similar to the lifestyle group after
10 years, the cumulative incidence of diabetes starting at the randomization of subjects and
ending 10 years later was still lowest in the original lifestyle group. These results show that
diabetes can be delayed for at least 10 years with lifestyle intervention or for those on a
metformin regimen (4).
Hypertension
This is a 4 week randomized controlled clinical trial of 40 hypertensive patients with type
2 diabetes. The researchers looked at the effectiveness of the DASH diet and walking 15- 20
minutes per day opposed to the diet recommended by the American Diabetes Association. The
DASH diet is composed of fruits, vegetables, low-fat dairy foods, whole grains, lean meat, nuts,
seeds, and beans. The intake of salt, fats, and sweets is discouraged. Whole bread and soya oil
were provided for the intervention group while in the control group they were not. A combination
of increased exercise and the DASH diet had a greater reduction on blood pressure than the
controlled group. This article shows that even in patients with type 2 diabetes, the DASH diet
and exercise is beneficial for decreasing blood pressure (5).
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This is a systematic review that assessed 5 randomized trials looking at blood pressure
lower than the standard (<130/85 mmHg) and if it has a greater benefits for people with type two
diabetes compared to the standard blood pressure (<140-160/90-100 mmHg). The participants
were separated into two groups based on lowering blood pressure to the standard and then an
even lower target. For the group that was in the lower than standard systolic blood pressure
there was a reduction in incidence of stroke. There was no other benefit of the lower than
standard blood pressure (6).
Hyperlipidemia
This study conducted a 40-week randomized control trial with 141 men and women with
hyperlipidemia in order to compare efficacy of different educational approaches by dietitians.
The educational approaches studied were the Stages of Change model and usual care
education, used in four education sessions during a 1-month period with follow up every 6
weeks. The Stages of Change model uses tailored educational messages for each stage, based
on their level of readiness. Usual care education focused on those who are ready to make
changes, so information is less tailored. Results showed that total cholesterol, low-density
lipoprotein cholesterol, and body weight decreased over time in both education groups. The
researchers drew conclusions that neither study method was more effective than the other;
however, it is clear that short-term dietary interventions by RDNs can be effective in reducing
serum cholesterol. Nutrition education interventions are most effective in those who are
physically active and motivated to change. Additionally, this article highlights that providing
follow-up to initial nutrition education is necessary for maintenance of change (7).
This article reviews recommended practices regarding diet and exercise for those with
hyperlipidemia. The Adult Treatment Panel III (ATP III) of the National Cholesterol Education
Program recommends non-pharmacological treatments as the first approach to management of
hyperlipidemia. The three key non-pharmacological approaches are change of diet, aerobic
exercise, and individualized counseling. The ATP found that diet and exercise can have a
positive change on serum levels of total cholesterol, low-density lipoprotein (LDL) cholesterol,
high-density lipoprotein cholesterol (HDL), and triglycerides. The most beneficial lifestyle
changes related to nutrition are reduction of saturated and trans fats, an increase of mono- and
polyunsaturated fats, an increase of nut and plant based fats, and adopting an overall healthy
diet. Regular aerobic exercise can have beneficial effects on blood lipid levels if performed at
least 120 minutes a week. The third factor to management of hyperlipidemia is patient
counseling; specifically for those who are motivated and ready for change (8).
Healthy Eating and Activity
Based on cultural differences and life experiences, successful strategies related to
healthier eating and physical activity do not always translate across populations. The intent of
this study was to look at the efficacy of a community-based, culturally relevant intervention in
promotion of healthy eating and physical activity among African American women between the
ages of 45 and 65 years residing in rural counties in Alabama. The participants were divided into
two groups, the screening intervention and the healthy lifestyle intervention. The healthy lifestyle
participants attended a five-week class adapted from New leaf . . . Choices for Healthy Living
with Diabetes, with a focus on healthy lifestyle behaviors, healthy eating and physical activity,
not weight loss in the prevention of chronic disease. The identified outcomes for both study
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groups were five or more serving of fruit and vegetables per day, consumption of fried food less
than once per week, and engagement in physical activity at least 5 times per week. Through
the use of a questionnaire, all three outcomes were measured at baseline and at 12 and 24
months. At the end of the study the outcomes were compared between the screening and
healthy lifestyle intervention groups. Significance was found with a 69% increase of healthy
lifestyle participants eating five or more servings of fresh fruits and vegetables compared to a
31% decrease in the screening group. Additionally, there was a 24% increase of healthy
lifestyle participants reporting engagement in physical activity at least 5 times per week
compared to a 3% increase from the screening group. Implementing a healthy eating and
physical activity intervention that took into account cultural differences and life experiences was
successful at impacting lifestyle behaviors (9).
This study focused on a one-time education intervention through a primary care clinic.
Participants with a self-reported prediabetes diagnosis completed a baseline questionnaire
related to diet, physical activity, and weight related behaviors. All participants then attended a
three hour class instructed by dietitians that focused on limiting dietary fat and increasing dietary
fiber consumption, as well as increasing physical activity levels to 30min, 5 times per week.
Following the intervention, participants were requested to complete the same survey at the
three month and sixth month mark. The researchers observed general trends towards improved
diet, physical activity, and weight related behaviors, no significant changes were observed
between the intervention and follow up. This finding was in accordance with the literature that
suggests increased contact and high intensity interventions, usually high resource, are effective
in achieving the desired lifestyle modifications to delay or prevent diabetes (10).
Dining Out
The study aimed to review current research in relation to fast food patterns and
cardiometabolic risk factors. Studies ranged from one-year follow-ups to twenty-year follow-ups
with 380-84,555 participants. The study found that individuals who ate outside of their home
more than 2 times week were 27-68% and 56%-162% more likely to develop a risk of insulin
resistance, type 2 diabetes and metabolic syndrome. Individuals who ate more than 1-3 times
per week outside their home were 20%-129% more time a risk for developing obesity. Potential
factors discussed in this study that could contribute to undesirable health effects in individuals
include high energy density, high-fat, large portion size, high amount of carbohydrates, added
sugars and high sodium content. As a result of this research, future food policies should
emphasize healthy alternatives and nutrition information on menus to potentially help
consumers make healthier choices (11).
This study aimed to investigate the relationship between fast food meal consumption
and incidence of type 2 diabetes in African American women. Participants were recruited in
1995 through postal questionnaires mailed to subscribers of Essence Magazine. Questionnaires
requested information on food-frequency, demographics, medical history, physical activity,
weight and height. The study included 44,072 women aged 30-69 years old who were free of
diabetes at baseline. Follow-up questionnaires were mailed every 2 years until 2001. Cox
proportional hazards models were used to calculate incidence rate ratio and association of type
2 diabetes with food consumed in restaurants. Results indicated that restaurant meals
containing hamburgers, fried chicken, fried fish and Chinese food were all associated with
increased risk of type 2 diabetes development. Modifying what individuals eat in restaurants can
help reduce the risk of type 2 diabetes (12).
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Significance
The implementation of a prediabetes class at the Free Clinic of Southwest Washington
fills an important gap where information is not currently provided. Although Certified Diabetes
Educators (CDE) are present at the clinic, they do usually discuss prediabetes with clients, as
there is not currently a prediabetes program in place. In addition, there is not currently a way of
referring patients who may be at risk for diabetes. Research shows that within 3-4 years, 25% of
prediabetes diagnoses progress to diabetes. In addition, a recent randomized controlled trial
found that lifestyle interventions in patients with prediabetes can lead to a 50% reduced rate of
disease development (1). By implementing the prediabetes class, we will be able to provide vital
education to underserved members of the Vancouver community who are at risk of developing
diabetes.
By using lesson plans provided by the CDCs DPP, we are able to provide a rigorously
tested, evidence based, effective program. Piloting this program will help determine the
feasibility of providing a prediabetes class to patients at the clinic. We hope that the initial
program implementation is successful and repeated in the coming years as other volunteers are
able to keep the program running, and in turn impact many more patients.
Methods and Design
Target Audience
The target audience are patients with prediabetes at the Free Clinic of Southwest
Washington. They must meet the following criteria:

> 18 year of age

BMI greater than 24 except Asians which are 22
HgA1C of 5.7-6.4%, or fasting plasma glucose of 100-125 mg/dL, or a two-hour plasma glucose
(after a 75 g glucose load) of 140-199 mg/dL
Previously diagnosed with gestational diabetes
Patients who have previously been diagnosed with diabetes will not be able to participate in
the program.
Implementation Details
Oregon Health and Science University (OHSU) dietetic interns will visit the Free Clinic of
Southwest Washington and interview staff and volunteers at the free clinic to gain an
understanding of clinic population characteristics and needs. Flyers will be created to advertise
the DPP and recruit participants. The program will develop nutrition education handouts on the
topics of prediabetes, diabetes, hypertension, healthy living, hyperlipidemia and healthy
eating/activity, and eating out to provide to patients of the clinic. In January of 2017, OHSU
dietetic interns will facilitate the DPP curriculum over a 10-week period at the Free Clinic of
Southwest Washington. Evaluation and assessment will be conducted during week one, week
five, and week ten of the program.
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Timetable
Class Flyers

Handouts

DPP class

Implement

November 2016

December 2016

January 2016

Evaluate

January 2016

November 2016

March 2016

Facilities and Personnel Required

OHSU dietetic interns will use the Free Clinic of Southwest Washington facility to teach
the DPP classes. The following equipment will be utilized: Printer/copy machine, computer, food
models, modified CDC DPP curriculum, binders, pens, water pitcher and plastic cups. A CDE
mentor will be in attendance to assist and provide support during the classes.
Budget
Supported by Free Clinic of
SW Washington

Unsubsidized Clinic

Facility Requirements
Classroom set-up
AV Equipment
Restrooms

No Cost

$2400.00

Instruction Requirements
2 per session ($28/hr)

Volunteers, No Cost

$1120.00

Class Requirements
Sphygmomanometer
Class Supplies (binders, pens,
water, white board and marker)
Print handouts (150 sheets/class
x $.10/sheet over 10 weeks)

Use of clinics
Sphygmomanometer,
$250.00

$300.00

Total Cost

$250.00

$3820.00

Cost per participant (15)

$17.00

$255.00

Assessment
The following chart outlines the course assessments and course impacts over the 10week class.
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Before
program

Each
session

5 weeks

After program

Course Assessment
Participant Survey / Evaluation

Instructor Peer Evaluations

Students debrief

Course Impact
Pre-and Post-Knowledge Test

Blood Test (Hemoglobin A1C,

Fasting plasma glucose, twohour plasma glucose)

Weekly weigh-in

Blood pressure measurements

Food and Physical Activity Log

Food Security Screen and

Intervene

Self-Efficacy

Generalized Anxiety Disorder

Depression

The course assessment includes participant surveys and evaluations that will help
evaluate the efficacy of the program with the current participants, and improve the program.
Mentor and instructor peer evaluations will be done at the end of every class with verbal
feedback. Additionally, the mentor and instructor peer feedback as well as a class update will be
emailed to all instructors.
The course impact includes participants pre- and post-knowledge test, blood test results
comparison (Hemoglobin A1C, fasting plasma glucose, two-hour plasma glucose), and weekly
weigh-in and blood pressure measurements using sphygmomanometer. Participants will be
asked to maintain weekly food and physical activity logs and will bring entries to class for
review. Screen and Intervene will be used to assess food security. A questionnaire will be
taken by participants at baseline and during the last day of class to access food security, self8

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efficacy for diabetes, generalized anxiety disorders, and depression. The following
questionnaires will be used:

Childhood Hunger Coalition Screen and Intervene Program

Stanford Patient Education Research Center Self-Efficacy for Diabetes
Anxiety and Depression Association of America: Screening for Generalized Anxiety Disorder
(GAD)
Anxiety and Depression Association of America: Screening for Depression
Sustainability
All documents such as handouts, class outlines, assessments, and evaluations will be
archived. Surveys throughout the course will be evaluated to measure the effectiveness of the
class. Assessment results will be used for future class development. Based on the success of
DPP, recommendations will be made to continue an OHSU partnership with the Free Clinic of
Southwest Washington.

I have received a draft version of this proposal and was given time to provide feedback. I have
reviewed and approved this final version of the project proposal.

Mentor Approval: ______________________________

Lexie Jackson MS, RDN, CDE
References
1. Centers for Disease Control and Prevention. National Diabetes Prevention Program. January
2016. Internet: http://www.cdc.gov/diabetes/prevention/index.html (accessed 10 November
2016).
2. Knowler WC, Barrett-Conner E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM.
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J
Med 2002;346:393403.
3. Albright A, Gregg EW. Preventing type 2 diabetes in communities across the US: the National
Diabetes Prevention Program. Am J Prev Med 2013;44(4):S346-S351.
4. Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, BrownFriday JO, Goldberg R, Venditti E, Nathan DM. 10-year follow-up of diabetes incidence and
weight loss in the Diabetes Prevention Program Outcomes Study. Lancet.
2009;374(9702):167786.
5. Paula TP, Viana L V, Neto ATZ, Leito CB, Gross JL, Azevedo MJ. Effects of the DASH Diet and
Walking on Blood Pressure in Patients With Type 2 Diabetes and Uncontrolled Hypertension: A
Randomized Controlled Trial. J Clin Hypertens (Greenwich) [Internet]. 2015;17:895902.
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Available from: http://eds.a.ebscohost.com.ezproxy.endeavour.edu.au/eds/pdfviewer/pdfviewer?
vid=4&sid=4abece31-9292-4185-a6fa-ba55229812fd@sessionmgr4001&hid=4105
6. Arguedas J, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes
mellitus. Cochrane Database Syst Rev [Internet]. 2013;10:145. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/24170669 intervention and type 2 diabetes.
7. Nasser R, Cook S.L., Dorsch K.D., Haennel R.G. Comparison of Two Nutrition Education
Approaches to Reduce Dietary Fat Intake and Serum Lipids Reveals Registered Dietitians Are
Effective at Disseminating Information Regardless of the Educational Approach. Journal of the
American Dietetic Association. 2006; 106(6): 850-59.
8. Kelly, R.B. Diet and Exercise in the Management of Hyperlipidemia. Am Fam Physician.
2010;81(9):1097-1102.
9. Scarinci IC, Moore A, Wynn-Wallace T, Cherrington A, Fouad M, Li Y. A community-based,
culturally relevant intervention to promote healthy eating and physical activity among middleaged African American women in rural Alabama: Findings from a group randomized controlled
trial. Prev Med (Baltim). Elsevier Inc.; 2014;69:1320.
10. Weir DL, Johnson ST, Mundt C, Bray D, Taylor L, Eurich DT, Johnson JA. A primary care based
healthy-eating and active living education session for weight reduction in the pre-diabetic
population. Prim Care Diabetes. Primary Care Diabetes Europe; 2014;8:3017.
11. Bahadoran Z, Mirmiran P, Azizi F. Fast Food Pattern and Cardiometabolic Disorders: A Review
of Current Studies. Health Promotion Perspectives Health Promot Perspect. 2015;5:23140.
12. Krishnan S, Coogan PF, Boggs D a, Rosenberg L, Palmer JR. Consumption of restaurant foods
and incidence of type 2 diabetes in African American women 1 3. 2010;102.

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