Evaluation of an adapted version of the Diabetes Prevention Program for low- and middle-income countries: A cluster randomized trial to evaluate "Lifestyle Africa" in South Africa

被引:9
作者
Catley, Delwyn [1 ,2 ]
Puoane, Thandi [3 ]
Tsolekile, Lungiswa [3 ]
Resnicow, Ken [4 ]
Fleming, Kandace K. [5 ]
Hurley, Emily A. [2 ,6 ]
Smyth, Joshua M. [7 ]
Materia, Frank T. [6 ]
Lambert, Estelle, V [8 ]
Vitolins, Mara Z. [9 ]
Levitt, Naomi S. [10 ]
Goggin, Kathy [2 ,6 ,11 ]
机构
[1] Childrens Mercy Kansas City, Ctr Childrens Hlth Lifestyles & Nutr, Kansas City, MO 64108 USA
[2] Univ Missouri, Sch Med, Kansas City, MO 64108 USA
[3] Univ Western Cape, Sch Publ Hlth, Cape Town, South Africa
[4] Univ Michigan, Sch Publ Hlth, Ann Arbor, MI 48109 USA
[5] Univ Kansas, Life Span Inst, Lawrence, KS 66045 USA
[6] Childrens Mercy Hosp & Clin, Hlth Serv & Outcomes Res, Kansas City, MO USA
[7] Penn State Univ, Coll Hlth & Human Dev, University Pk, PA 16802 USA
[8] Univ Cape Town, Fac Hlth Sci, UCT Res Ctr Hlth Phys Act Lifestyle & Sport HPALS, Div Res Unit Exercise Sci & Sports Med, Cape Town, South Africa
[9] Wake Forest Sch Med, Dept Epidemiol & Prevent, Winston Salem, NC 27101 USA
[10] Univ Cape Town, Fac Hlth Sci, Dept Med & Chron Dis Initiat Africa, Cape Town, South Africa
[11] Univ Missouri, Sch Pharm, Kansas City, MO 64110 USA
基金
美国国家卫生研究院;
关键词
OBESITY; INTERVENTION; DETERMINANTS; OVERWEIGHT; ANALYZER; POINT;
D O I
10.1371/journal.pmed.1003964
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
Background & nbsp;Low- and middle-income countries (LMICs) are experiencing major increases in diabetes and cardiovascular conditions linked to overweight and obesity. Lifestyle interventions such as the United States National Diabetes Prevention Program (DPP) developed in high-income countries require adaptation and cultural tailoring for LMICs. The objective of this study was to evaluate the efficacy of Lifestyle Africa, an adapted version of the DPP tailored for an underresourced community in South Africa compared to usual care.& nbsp;Methods and findings & nbsp;Participants were residents of a predominantly Xhosa-speaking urban township of Cape Town, South Africa characterized by high rates of poverty. Participants with body mass index (BMI) >= 25 kg/m(2) who were members of existing social support groups or "clubs " receiving health services from local nongovernmental organizations (NGOs) were enrolled in a cluster randomized controlled trial that compared Lifestyle Africa (the intervention condition) to usual care (the control condition). The Lifestyle Africa intervention consisted of 17 video-based group sessions delivered by trained community health workers (CHWs). Clusters were randomized using a numbered list of the CHWs and their assigned clubs based on a computer-based random allocation scheme. CHWs, participants, and research team members could not be blinded to condition. Percentage weight loss (primary outcome), hemoglobin A1c (HbA1c), blood pressure, triglycerides, and low-density lipoprotein (LDL) cholesterol were assessed 7 to 9 months after enrollment. An individual-level intention-to-treat analysis was conducted adjusting for clustering within clubs and baseline values. Trial registration is at ClinicalTrials.gov (NCT03342274). Between February 2018 and May 2019, 782 individuals were screened, and 494 were enrolled. Participants were predominantly retired (57% were receiving a pension) and female (89%) with a mean age of 68 years. Participants from 28 clusters were allocated to Lifestyle Africa (15, n = 240) or usual care (13, n = 254). Fidelity assessments indicated that the intervention was generally delivered as intended. The modal number of sessions held across all clubs was 17, and the mean attendance of participants across all sessions was 61%. Outcome assessment was completed by 215 (90%) intervention and 223 (88%) control participants. Intent-to-treat analyses utilizing multilevel modeling included all randomized participants. Mean weight change (primary outcome) was -0.61% (95% confidence interval (CI) = -1.22, -0.01) in Lifestyle Africa and -0.44% (95% CI = -1.06, 0.18) in control with no significant difference (group difference = -0.17%; 95% CI = -1.04, 0.71; p = 0.71). However, HbA1c was significantly lower at follow-up in Lifestyle Africa compared to the usual care group (mean difference = -0.24, 95% CI = -0.39, -0.09, p = 0.001). None of the other secondary outcomes differed at follow-up: systolic blood pressure (group difference = -1.36; 95% CI = -6.92, 4.21; p = 0.63), diastolic blood pressure (group difference = -0.39; 95% CI = -3.25, 2.30; p = 0.78), LDL (group difference = -0.07; 95% CI = -0.19, 0.05; p = 0.26), triglycerides (group difference = -0.02; 95% CI = -0.20, 0.16; p = 0.80). There were no unanticipated problems and serious adverse events were rare, unrelated to the intervention, and similar across groups (11 in Lifestyle Africa versus 13 in usual care).& nbsp;Limitations of the study include the lack of a rigorous dietary intake measure and the high representation of older women. & nbsp;Conclusions & nbsp;In this study, we found that Lifestyle Africa was feasible for CHWs to deliver and, although it had no effect on the primary outcome of weight loss or secondary outcomes of blood pressure or triglycerides, it had an apparent small significant effect on HbA1c. The study demonstrates the potential feasibility of CHWs to deliver a program without expert involvement by utilizing video-based sessions. The intervention may hold promise for addressing cardiovascular disease (CVD) and diabetes at scale in LMICs.
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