Addressing Social Determinants of Health to Improve Diabetes Prevention Program Outcomes Among African Americans

Abstract: African Americans (AAs) are disproportionately burdened by DM with rates twice as high as Whites (13% vs 7.5%), and increased rates of DM-related complications/comorbidities (e.g. amputations, cardiovascular disease). A key pre-DM risk factor is overweight/obesity. Nearly 70% of AAs are overweight/obese, with higher rates among those of low-income. A critical component of national efforts to reduce growing obesity rates and prevent DM is the Diabetes Prevention Program (DPP), a rigorously evaluated lifestyle intervention proven to reduce or delay DM onset with diet change, exercise, and modest weight loss (>5%). A group-based version of the DPP is being widely disseminated and numerous community-based trials generally support its efficacy. In spite of these successes there are important health disparities in DPP attendance and outcomes and considerable room for improving success rates among AAs, a population that tends to experience half the amount of DPP weight loss compared to Whites (2 versus 4%, respectively). We aim to build on our promising pilot studies by tailoring the DPP via a social determinants of health (SD) lens to achieve optimal DPP attendance and clinically meaningful weight loss with pre-DM AAs. This includes tailoring on cultural and socioeconomic SD mechanisms that are associated with improving health outcomes and align with predisposing needs among AAs who are primarily of low-income and live in low-resource AA communities. We propose a randomized controlled trial to test a standard DPP (S-DPP) against a DPP tailored culturally (TC-DPP) and a TC-DPP further enhanced to address economic-related (TCE-DPP) SD determinants on percent weight loss and attendance with pre-DM AA primarily of low-income from an academic safety net hospital (SNH). Using a community-engaged approach, Cultural Sensitivity and SDOH models will be used to fully tailor the DPP and will provide a theoretical framework for enhanced DPP delivery to increase weight loss and attendance. For our proposed study, 360 pre-DM SNH AA patients will be assigned to 3 arms: 1) S-DPP; 2) TC-DPP with comprehensive cultural tailoring including language, foods, values, social norms and connectedness; and 3) TCE-DPP, a hybrid group/text/online DPP tailored for attendance flexibility, financial incentives, and ongoing community health worker support to improve access to DPP classes, healthy food, exercise, and other basic resources in accessible home community settings over 12 months. Our multidimensional TCE-DPP is guided by our past pilots, and based on components that, all together, were needed to drive clinically important outcomes in the original DPP trial – and are certainly needed to achieve similar outcomes with SNH AA. To our knowledge this is the first study to test tailoring via an SD lens to truly impact DPP attendance and outcomes, and has potential to be a feasible, scalable model to reduce DM disparities among AA at great risk.