Outcome dissimilarities in age group and delivery modality studied in the prediabetes lifestyle change program conducted by virginia cooperative extension

Corresponding Author:

Dezfin
Department of Human Nutrition, Food, and Exercise, Virginia Tech, Blacksburg, VA 24061. USA
E-mail: Dezfin@vt.edu

Received: 17-Jan-2024, Manuscript No. FMDM-24-125142; Editor assigned: 22-Jan-2024, PreQC No. FMDM-24-125142 (PQ); Reviewed: 05-Feb-2024, QC No. FMDM-24-125142; Revised: 12-Feb-2024, Manuscript No. FMDM-24-125142 (R); Published: 19-Feb-2024, DOI: 10.37532/1758-1907.2024.13(S1).125-131.

Abstract

Objective: This study evaluated the effects of age on Lifestyle Change Program (LCP) outcomes conducted by Virginia Cooperative Extension in different delivery methods.

Methods: Outcomes of LCP conducted by VCE between 2018-2022 were collected and tabulated for further analysis. Among the 189 enrolled participants, 56% were above 60 years old, and 51% enrolled in distance learning. The statistical analysis assessed LCP outcome differences among age groups and delivery modalities at 6 and 12 months.

Results: At six months, older participants had significant higher attendance, especially in distance learning programs, and demonstrated greater weight loss in this modality. Additionally, among participants achieving 150 minutes of physical activity per week, 67% were above 60 years old.

Conclusion: The results showed that older participants were more successful than their younger counterparts in meeting LCP goals. These findings suggest that targeting different age groups and intervention delivery methods can improve program outcomes.

Keywords

■ Lifestyle change program ■ Prediabetes prevention ■ Older adults ■ Cooperative extension

Introduction

The Centers for Disease Control (CDC) has estimated that approximately 96 million (38%) adults over the age of 18 in the United States had prediabetes in 2021. Of these, 26.4 million, or nearly one-third, were aged 65 years or older [1]. According to the CDC, between 15%-30% of individuals with prediabetes will develop diabetes within five years of diagnosis, and the percentage is higher in the long term [1]. Adults aged 60 years and older are the fastest-growing sector of the U.S. population. They made up 23.22% of the population in 2021 and are projected to increase to 26% by 2030 [2]. Access and critical analysis of older adult health-related data can expand the scope of services provided and positively affect program outcomes for the growing older adult population [3].

The CDC is disseminating an evidence-based Lifestyle Change Program (LCP) to community organizations for adoption [4,5]. The 12-month program promotes dietary and physical activity changes and modest weight loss in a group setting [6]. It has shown a decrease in the risk of developing diabetes up to 58% and 70% for older adults [7]. Many organizations have adopted the program, including Cooperative Extension. The Cooperative Extension-National Diabetes Prevention Program working group (CE-NDPP) was formed in 2017 to expand diabetes prevention program delivery through Extension [8].

Virginia Cooperative Extension (VCE) conducts an LCP in distance learning and in-person formats [9]. The COVID-19 pandemic accelerated distance learning and other technology-enabled options for delivering essential healthcare services while preserving social distancing requirements. Furthermore, others have shown distance learning programs to be more accessible, targeted, cost-effective, and easier to implement [9-11]. Despite their increased use, the relative effectiveness of the LCP program implemented by Cooperative Extension in the distance learning format has not been evaluated.

A number of studies show that implementing the LCP in various settings is viable and feasible, and the program has enough flexibility to be delivered in various formats [12,13]. Aziz and colleagues reviewed 28 studies that have mainly focused on program efficacy and implementation of the programs in real-world settings over the last 15 years [14]. The result shows that even if an intervention is only somewhat successful in weight loss, it may significantly influence the population’s disease development. Ali et al., in the systematic review of twenty-eight studies of lifestyle change program interventions in the real-world setting, found that participants lost an average of 3.99 percent of their body weight after one year [15]. Studies showed that participants’ demographics (age, sex, race, ethnicity, and education level) and program delivery method are significant parts of the program reach and outcomes [10,11]. However, there is no specific research on the relationship between delivery methods and program outcomes studied between different age groups conducted by Cooperative Extension. Therefore, we examined the program effectiveness and the relationship of age and delivery methods to outcomes at six and 12 months of participation in the diabetes lifestyle change program conducted by Virginia Cooperative Extension between 2018-2022.

Materials and Methods

The study is a retrospective observational study that assessed the effects of setting-level factors and participants’ demographic factors effects on the program outcomes of the LCP conducted by Virginia Cooperative Extension from 2018- 2022.

Study population

Eligibility for participating in the LCP included being 18 years or older, being overweight or obese (Body Mass Index (BMI) of 25 or higher, 23 or higher if Asian American), and being at risk of diabetes scoring in the high-risk category (score of 5 or higher) on the CDC/ADA Prediabetes Risk Test, being diagnosed with prediabetes within the past year through a blood test, or previously being diagnosed with gestational diabetes [16]. Participants agreed to the year-long program, the structure of meetings, and the component of tracking food and physical activity minutes. Among 189 participants enrolled in the LCP, 139 (73%) completed eight or more sessions, and 56% were above 60 years of age. Among the enrolled population, 51% of participants enrolled in the distance learning LCP program, while 49% preferred in-person.

During the registration process, participants acknowledged acceptance of the VCE terms and conditions and privacy policy, which stated that participants understand that all data collected could be used for various reasons, including research. Participants provided informed consent when completing a pre-program survey. A decision not to consent to participate in the research project did not affect an individual’s ability to participate in the VCE LCP program. Approval from the Virginia Tech Review Board was obtained.

Interventions

The LCP is a 12-month program that consists of a minimum of 22 and up to 26 sessions, offers in-person and virtual synchronous meetings utilizing the Prevent T2 evidence-based, CDC- approved curriculum, and enhances the delivery with individualized coaching support. The first 16 sessions occur in the program’s first six months, and the remaining six sessions occur monthly in the second six months [1]. To evaluate program outcomes, maintain quality programming, and receive recognition as an LCP provider by the CDC, information is collected from participants in the LCP programs at each session. This information is used for program quality control, evaluation of program efficacy, and National impact reporting.

Measures

LCP outcomes were weight loss percentage, average physical activity per week, and program attendance at 6 and 12 months. The LCP program goals are for program participants to achieve ≥ 5% weight loss and increase physical activity to at least 150 minutes per week. Weight loss percentage was calculated using the beginning weight recorded to the last weight reported for the participant. The average physical activity minutes increase was calculated from the difference between the average of the first three weeks of reported physical activity and the average of the last three weeks of reported physical activity per week. Attendance was calculated as the number of sessions attended. Required data for the VCE DPP program were collected from participants upon entry into the program. These included demographic information (age, gender, race, ethnicity, education) and selfreported biometric data of height and weight and average physical activity minutes per week. Attendance was recorded during each distance learning session, and current weight and physical activity minutes were self-reported. For the inperson program, the coach weighed participants individually and logged their weight and activity minutes at the beginning of each session.

Statistical analysis

Data collected in this study include Diabetes Prevention Recognition Program (DPRP) data between January 2018 to August 2022 programs conducted by VCE. The participant data used for this study was anonymous and consisted of participant ID, cohort ID, age, sex, race, ethnicity, education, session date, session delivery mode of delivery, session weight, and session physical activity minutes. A full specification of all the columns of data can be found in CDC DPRP Standards and Operating Procedures [17]. General data cleanup procedures we applied: Any entries with missing data in weight, age, or physical activity were removed. For statistical analysis involving the outcomes of the LCP program, only the data for participants that completed at least eight sessions within the first six months of the program were considered [6].

Before performing any statistical analysis, we summarized the data within a specific period (6 and 12 months) by calculating the average physical activity change, weight loss normalized by the initial weight (hereafter referred to as percent weight loss), and the number of sessions attended. Each participant appears once in this summary table; therefore, the study is a betweensubject design.

To assess the differences in LCP outcomes between different age groups (under 60 and 60 years old and above) and delivery modalities (in-person and distance learning), we performed t-tests followed up by posthoc tests to assess various hypotheses about the means of outcomes among different groups and quantify the effect strengths. We will briefly discuss the rationale for the statistical tests: Our underlying assumption is that the means of any outcome variable is a normally distributed random variable. The conventional ANOVA analysis requires the extra assumption that the variance of the random variable considered is the same across different groups. Our analysis uses the more robust Welch- ANOVA tests that work better with unequal variances across groups [18]. If the main effect was observed, a pairwise Games-Howell test was administered to establish the effect in different groups [19]. Using the Hedges formula for small sample sizes is recommended to assess the effect size. A rule of thumb for interpreting the effect size value is the following: Values smaller than 0.2 are considered small, between 0.5 and 0.8 are medium, and values above 0.8 are considered large effects [20].

All data analysis is performed using Python with data aggregation and cleanup using Pandas [21]. For statistical tests, we used the Pingouin package [22].

Results

Between Jan 2018 and August 2022, a total of 189 participants enrolled in the LCP in Virginia conducted by VCE, and 73% completed eight or more sessions (n=139). See TABLE 1 for demographic information. Both men and women participated in the study, with a larger percentage being women (73%). Multiple races and ethnicities were represented among participants. The race with the largest representation was white (63%), followed by black (27%), and 50% of participants had a college (4 years or more) education.

Table 1: Enrolled participants' demographics data (n=189).

Results show that black participants’ median age was 59, white 63, asian 64, and 53 for notreported. Fifty-one percent of participants were enrolled in the distance learning LCP program, and forty-nine percent were enrolled in the inperson LCP. Among participants 60 years or older, 43% (n=43) participated in the distance learning program, and 57% (n=58) participated in the in-person LCP program. Among participants under 60 years of age, 62% (n=54) participated in the distance learning program, and 38% (n=18) participated in the in-person program.

TABLE 2 shows the program outcomes for 6-12 month data by age group and delivery modality. Among 139 participants who completed at least eight sessions, participants attended an average of 16 sessions in the first six months and 21 sessions across the 12 months. At six months, participants 60 years and older had significantly higher attendance compared to participants under 60 years old (17 vs. 15, p<0.001). However, there was no significant difference in participant attendance by 12 months. LCP participation resulted in an average weight loss of 2.78% of body weight in the first six months and 3.99% in 12 months. Forty-nine people (35%) had at least 5.00% weight loss. Comparison of 12-month program outcomes between adults under 60 years of age to adults 60 years and older showed that adults 60 years and older had higher average percent weight loss (4.98%) compared to participants under 60 years old (2.79%); however, the difference was not statistically significant.

Table 2: Virginia cooperative extension lifestyle change program outcomes.

Participants started the program with an average of 165 minutes of physical activity per week. At the end of the six months, participants’ average physical activity had increased by 33.47 minutes (46%), and the average physical activity per week was 199 minutes. At the end of 12 months, participants had an average of 186.54 minutes per week which showed 13.13 minutes (30%) increase compared to the beginning of the program. Study results showed the physical activity increase was not significantly different between those under 60 years old and above 60 years old participants.

Outcomes by delivery modality (in- person vs. distance learning)

TABLES 3 and 4 show the program outcomes considering program delivery mode and participants’ age. Considering the different age groups (TABLE 3), results showed participants 60 years and older had significantly higher attendance compared to participants under 60 in the distance learning programs at the end of six months (17 vs. 15, p=0.05).

Table 3: Outcomes in different delivery modalities compared against age groups.

When considering the program delivery methods (TABLE 4), participants 60 years and older had significantly higher attendance in distance learning programs by the end of six (15 vs. 17, p<0.001) and 12 months (18 vs. 21, p<0.001). Also, this age group who attended the distance learning programs had significantly higher weight loss compared to those who attended the in-person program at the end of the six months (4.61% vs. 2.07, p=0.02).

Table 4: Outcomes in different age groups compared against delivery modalities.

Discussion

The study showed that the VCE LCP program resulted in 49 (35%) program participants experiencing at least 5% percent weight loss. Among them, 29 persons were 60 years or older (59%). When considering the program delivery method, more individuals enrolled in distance learning programs (53%) had at least 5% weight loss compared to the in-person program (47%). Meanwhile, 86 persons (62%) had at least an average of 150 minutes of physical activity per week by the end of the program. Among them, the majority were 60 and older (67%) and enrolled in in-person programs (64%).

The results showed that older participants were more successful than their younger counterparts in meeting LCP goals for having an average of 150 minutes of physical activity and 5% weight loss. These findings back up previous research that found older adults are more likely than younger adults to participate in physical activity group activities and improve their eating behaviors [3]. Study showed that LCP effectively reduces the risk of developing type 2 diabetes in prediabetes people who had 5%-7% weight loss by 71% for adults above 60, which is higher than for adults under 60 (56%) [23-25]. A number of studies evaluated the LCP outcome, and a few studies evaluated the LCP results for older adults over 65 [24,26]. The current study is the only one that found a difference in LCP outcomes between participants under 60 years old and those 60 years old and older conducted by Extension. The decrease in in-person activities during COVID-19 resulted in the development of distance learning LCP conducted by Virginia Cooperative Extension. It increased the reach of VCE to the target audience, which is one of the biggest challenges in LCP implementation [27]. The study results showed that the participants recruited to the program were primarily collegeeducated (70%), and slightly more than half were older adults (53%).

Implications for research and practice

The higher level of attendance in VCE LCP conducted through distance learning compared to the in-person LCP demonstrates the distance learning program’s feasibility. Slightly more adults over 60 participated in the in-person program compared to the distance learning LCP program. Despite this, results showed that adults over 60 who participated in distance learning programs had significantly higher percent weight loss than in-person program participants. Many studies have shown that these populations can engage in virtual programs and achieve significant results if appropriate methods are used [28-30].

Researchers have shown that while many tools and applications exist to increase online engagement in health interventions when working with older adults, it may be best to keep the online session simple and focus on improving engagement through facilitated dialogue. Other considerations that may be applicable for older adults, in general, include difficulties understanding complex sentences, less proficiency in drawing inferences than younger participants, and the need to present new information slower than younger participants [31-33]. In addition, distance learning LCP programs report that technical difficulties in the registration and login processes are significant barriers to engaging in an online program. That said, online LCP participants were likelier to complete eight or more sessions/modules than in-person participants [10,11].

Conclusion

The distance learning program provides accessibility and flexibility. The authors have identified the sample size as a study limitation. The VCE LCP was compelled to adopt the distance learning program due to COVID-19 restrictions, and the program was only implemented in Virginia by VCE. This restricts the generalizability of the findings as the outcomes may have been influenced by the unique context in which the program was implemented.

Funding Statement

This work was supported by the Virginia Department of Health Living Well grant (CDC DP18-1815) and InnoVAte grant (CDC DP18- 1817).

Declaration of Competing Interest

The authors have no conflict of interest to declare.

Acknowledgment

We would like to thank the Virginia Cooperative Extension for their efforts in implementing the programs.

Author Contributions

AP, CR, and LM have contributed to the conception and design of the study and the acquisition of the data. AP and AS have contributed to the analysis and interpretation of data. All authors have contributed to the drafting and revising of the article.

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