标题：Pounds Off With Empowerment (POWER): A Clinical Trial of Weight Management Strategies for Black and White Adults With Diabetes Who Live in Medically Underserved Rural Communities
摘要：Objectives . We evaluated lifestyle interventions for diabetic persons who live in rural communities. Methods . We conducted a 12-month randomized clinical trial (n = 152) of “intensive-lifestyle” (modeled after the NIH Diabetes Prevention Program) and “reimbursable-lifestyle” (intensive-lifestyle intervention delivered in the time allotted for Medicare reimbursement for diabetes education related to nutrition and physical activity) interventions with usual care as a control. Results . Modest weight loss occurred by 6 months among intensive-lifestyle participants and was greater than the weight loss among usual-care participants (2.6 kg vs 0.4 kg, P <.01). At 12 months, a greater proportion of intensive-lifestyle participants had lost 2 kg or more than usual-care participants (49% vs 25%, P <.05). No differences in weight change were observed between reimbursable-lifestyle and usual-care participants. Glycated hemoglobin was reduced among all groups ( P <.05) but was not different between groups. Conclusions . Improvement in both weight and glycemia was attainable by lifestyle interventions designed for persons who had type 2 diabetes and lived in rural communities. Individuals who live in rural medically underserved communities are an important target population for translational research. Such research evaluates interventions that are designed and implemented for various population settings on the basis of efficacy established during previous randomized controlled trials. In South Carolina, 75% of counties are designated as “medically underserved” by the US Public Health Service, 1 and the prevalence of overweight, obesity, and physician-diagnosed diabetes is among the highest in the nation. 2 Approximately 30% of the state population is Black, and among Black adults who have type 2 diabetes, glucose control as indicated by glycated hemoglobin (HbA1c) has been shown to be considerably higher than among White adults (10.5% vs 8.4%). 3 Previous clinical trials have shown that among persons who have type 2 diabetes, moderate weight loss can improve glycemic control and lipoprotein profile and reduce blood pressure. 4– 6 Although definitive data on the benefits of long-term weight loss to reduce risk for clinical complications of diabetes are not yet available, the evidence-based nutrition recommendations of the American Diabetes Association emphasize the importance of weight management as a key element of medical nutrition therapy for diabetes. The American Diabetes Association also emphasizes the importance of glycemic control and management of cardiovascular risk factors, regardless of weight status. 7 Among urban Black populations, including those who have diabetes, the success of culturally sensitive behavioral weight loss programs has been reported, 5, 8– 12 although some studies reported that, compared with Whites, Blacks lost less weight 10 and had an increased tendency to regain weight. 11 To date, only a limited number of studies of behavioral programs for persons who have type 2 diabetes have been conducted in rural or semirural communities, where improvements in glycemic control and weight loss varied. 13– 16 The goal of our study was to develop, implement, and evaluate a 1-year primary care–based lifestyle intervention for weight management that was designed to improve metabolic control among individuals who have type 2 diabetes and live in rural medically underserved communities. The state-of-the art lifestyle intervention program developed for the National Institutes of Health–funded Diabetes Prevention Program (DPP), 17 in combination with experiences gained from an 8-week pilot study 13 and focus groups, was used to guide the planning and the implementation of our 12-month randomized controlled trial (“intensive-lifestyle” intervention). Because of the limited amount of time for health education that is normally reimbursed by health insurance, we evaluated a second weight management strategy. It was designed to deliver the most salient elements of the intensive-lifestyle intervention within the approximate number of hours that are usually reimbursed by Medicare for 12-month nutritional education among persons who have recently been diagnosed with diabetes (“reimbursable-lifesyle” intervention).
