The ubiquity of diabetes distress among adults with type 1 diabetes in an urban, academic practice: A template for intervention.

AIMS: The aim of this study was to assess the patterns of diabetes distress within an urban, technology-oriented academic clinical practice to inform staff training and intervention. METHODS: Adults with type 1 diabetes completed the Type 1 Diabetes Distress Scale at their regular clinic visit. Descriptive statistics were generated to document the prevalence of diabetes distress overall, and from seven primary sources of distress: powerlessness, disease management, hypoglycaemia, negative social perceptions, eating, physician and family/friends. Additional analyses explored relations between diabetes distress, demographic characteristics and disease status. RESULTS: The prevalence of elevated diabetes distress was 30% overall, with 88% of the sample reporting elevated distress from at least one primary source. Women reported more elevated distress overall, and from the primary sources. There was an inverse relationship between diabetes duration with total diabetes distress (r = -0.19) and with the powerlessness subscale (r = -0.28). Also, those without micro- and/or macrovascular complications more frequently reported elevated distress from powerlessness (85%) compared to those having complications (61%). Use of technology (continuous glucose monitoring, insulin pumps) was not significantly related to diabetes distress. Diabetes distress was positively correlated with HbA1c. About 22% of individuals with HbA1c <53 mmol/mol (<7%) had elevated total distress. About a third of the sample (34%-39%) reported elevated distress from powerlessness, hypoglycaemia, negative social perceptions, eating, or family/friends. CONCLUSIONS: It is critical to understand clinic-specific patterns of diabetes distress in order to customise staff training and intervention programmes, and thereby reduce distress among unique populations of adults with type 1 diabetes in different settings.

Hyperlactatemia in diabetic ketoacidosis.

AIMS: The study examined the prevalence and degree of lactate elevation in diabetic ketoacidosis, and explored which biochemical abnormalities predicted L-lactate levels. METHODS: We reviewed episodes of diabetic ketoacidosis from 79 diabetes patients (one episode per patient). Separate univariate linear regression models were specified to predict lactate level from each of nine biochemical variables. Significant predictors from the univariate models were included in a final multivariate linear regression model to predict lactate levels. RESULTS: Mean (SD) lactate level was 3.05 (1.66) mmol/L; about 65% of patients had lactate levels >2 mmol/L. In the final multivariate linear regression model (R2  = 0.45), higher lactate levels were associated with greater hydrogen ion concentration (standardised ß = .60, t = 4.16, p < 0.0001), higher blood glucose (standardised ß = .28, t = 2.67, p = 0.009) and lower glomerular filtration rate estimated from creatinine (standardised ß = -.23, t = 2.29, p = 0.025). Bicarbonate, beta-hydroxybutyrate, body mass index, mean arterial pressure and calculated osmolality were not significant predictors of lactate level. There were three distinct patterns of lactate levels with treatment of diabetic ketoacidosis: group 1 = gradual decline, group 2 = initial increase and then decline and group 3 = initial decline followed by a transient peak and subsequent decline. CONCLUSIONS: Elevated lactate level is the norm in patients with diabetic ketoacidosis. Higher blood glucose levels and higher hydrogen ion concentrations are related to greater lactate. With treatment, there are different patterns of decline in lactate levels.

Acculturation and bicultural efficacy effects on Chinese American immigrants' diabetes and health management.

The primary goal of this study was to examine effects of bicultural efficacy, or perceived confidence in dealing with bicultural acculturation stressors, on type 2 diabetes management and health for first-generation, Cantonese-speaking, Chinese American immigrants (N = 162) recruited for a larger community-based diabetes intervention study (Chesla et al. in Res Nurs Health 36(4):359-372, 2013. doi: 10.1002/nur.21543 ). The current study also tested whether a new Bicultural Efficacy in Health Management (BEFF-HM) scale is a more robust predictor of diabetes and health outcomes than proxy (years in the U.S.) and general acculturation measures. Hierarchical regression analyses of cross-sectional data revealed that high BEFF-HM was significantly related to positive outcomes on five of six diabetes and health measures as hypothesized after accounting for participant characteristics, proxy and general acculturation measures, and social support. Proxy and general acculturation measures failed to predict any study outcome supporting our secondary hypothesis that BEFF-HM is a better predictor of Chinese American immigrants' diabetes and health management. An immigrant-focused research approach advances understanding of acculturation and bicultural efficacy effects on health by identifying key acculturation domains for study.

Relations of Neighborhood Environment Influences, Physical Activity, and Active Transportation to/from School across African American, Latino American, and White Girls in the United States.

BACKGROUND: Neighborhood environment influences may be particularly important for understanding physical activity (PA) patterns across ethnic subgroups of early adolescent girls. PURPOSE: This study examined relationships between neighborhood variables, moderate to vigorous physical activity (MVPA), and active transportation to/from school across African American, Latino American, and White early adolescent girls living in an urban/suburban community in the northwestern U.S.A. Relations between the neighborhood variables across ethnic groups also were examined. METHOD: The sample comprised 372 African American, Latino American, and White girls living in the U.S.A. (mean age = 12.06 years; SD = 1.69). RESULTS: Data were analyzed using multiple-sample structural equation modeling. Results showed that girls' MVPA was positively related to physical activity facility accessibility and negatively related to age. Active transport was positively related to physical activity facility accessibility, neighborhood walkability, and age, and negatively related to distance to the nearest school and household income. CONCLUSIONS: Findings highlight the importance of both perceived and objective neighborhood influences on girls' MVPA and active transport. Consistencies in findings across African American, Latino American, and White girls suggest that neighborhood-level PA promotion has the potential for broad impact across all three ethnic groups.

Relative contributions of naturalistic and constructed support: two studies of women with type 2 diabetes.

Do distinct sources of social support have differential effects on health? Although previous research has contrasted family and friend support (naturalistic support), research on the relative effects of naturalistic support and constructed support (e.g., support groups) is extremely rare. Two studies of women with type 2 diabetes were conducted that assessed the independent effects of naturalistic and constructed support on physical activity and glycosylated hemoglobin (HbA1c). Participants were women diagnosed with type 2 diabetes from the intervention arms of two randomized controlled trials: primarily European American women (Study 1; N = 163) and exclusively Hispanic women (Study 2; N = 142). Measures assessed physical activity, HbA1c, and friend and family support at baseline and at 6 months, as well as group support after 6 months of intervention. In Study 1, only group support was related to increases in physical activity (ΔR(2) = .036). In Study 2, group support and family support showed independent effects on increases in physical activity (ΔR(2) = .047 and .060, respectively). Also, group support was related to decreases in HbA1c in Study 1 (ΔR(2) = .031) and Study 2 (ΔR(2) = .065). Overall, constructed (group) support was related to outcomes most consistently, but naturalistic (family) support showed some independent relation to physical activity improvement.

Short-term administration of progesterone and estradiol independently alter carotid-vasomotor, but not carotid-cardiac, baroreflex function in young women.

The individual effects of estrogen and progesterone on baroreflex function remain poorly understood. We sought to determine how estradiol (E2) and progesterone (P4) independently alter the carotid-cardiac and carotid-vasomotor baroreflexes in young women by using a hormone suppression and exogenous add-back design. Thirty-two young women were divided into two groups and studied under three conditions: 1) after 4 days of endogenous hormone suppression with a gonadotropin releasing hormone antagonist (control condition), 2) after continued suppression and 3 to 4 days of supplementation with either 200 mg/day oral progesterone (N = 16) or 0.1 to 0.2 mg/day transdermal 17ß-estradiol (N = 16), and 3) after continued suppression and 3 to 4 days of supplementation with both hormones. Changes in heart rate (HR), mean arterial pressure (MAP), and femoral vascular conductance (FVC) were measured in response to 5 s of +50 mmHg external neck pressure to unload the carotid baroreceptors. Significant hormone effects on the change in HR, MAP, and FVC from baseline at the onset of neck pressure were determined using mixed model covariate analyses accounting for P4 and E2 plasma concentrations. Neither P4 (P = 0.95) nor E2 (P = 0.95) affected the HR response to neck pressure. Higher P4 concentrations were associated with an attenuated fall in FVC (P = 0.01), whereas higher E2 concentrations were associated with an augmented fall in FVC (P = 0.02). Higher E2 was also associated with an augmented rise in MAP (P = 0.01). We conclude that progesterone blunts whereas estradiol enhances carotid-vasomotor baroreflex sensitivity, perhaps explaining why no differences in sympathetic baroreflex sensitivity are commonly reported between low and high combined hormone phases of the menstrual cycle.

Testing the efficacy of culturally adapted coping skills training for Chinese American immigrants with type 2 diabetes using community-based participatory research.

Chinese Americans demonstrate greater prevalence of diabetes than non-Hispanic whites and find standard diabetes care disregards their cultural health beliefs. Academic researchers and Chinatown agencies collaborated to culturally adapt and test an efficacious cognitive-behavioral intervention using community-based participatory research. Using a delayed-treatment repeated-measures design, 145 adult Chinese immigrants with Type 2 diabetes completed treatment. Immediate benefits of treatment were evident in the improvement (p < .05) in diabetes self-efficacy, diabetes knowledge, bicultural efficacy, family emotional and instrumental support, diabetes quality of life, and diabetes distress. Prolonged benefits were evident in all changed variables 2 months post-intervention. The CBPR approach enabled the development of a culturally acceptable, efficacious behavioral intervention, and provides a model for working with communities that demonstrate health disparities.

Alcohol use of African Americans and Whites from ages 9-20: descriptive results from a longitudinal study.

African American and White youth (N = 405) were assessed annually for 8 years, providing alcohol use data spanning from ages 9-20 years. Alcohol use increased with age, as did binge drinking, drunkenness, peer alcohol use, and ease of obtaining alcohol. At younger ages, the usual alcoholic drink was wine; other drinks were preferred at older ages. Fewer African Americans than Whites reported alcohol use, binge drinking, drunkenness, peer alcohol use, and encouragement of alcohol. These results support and extend previous findings and suggest that contextual influences may help explain alcohol use differences and similarities between African American and White youth.

Outcomes from a multiple risk factor diabetes self-management trial for Latinas: ¡Viva Bien!

BACKGROUND: Culturally appropriate interventions are needed to assist Latinas in making multiple healthful lifestyle changes. PURPOSE: The purpose of this study was to test a cultural adaptation of a successful multiple health behavior change program, ¡Viva Bien! METHODS: Random assignment of 280 Latinas with type 2 diabetes to usual care only or to usual care + ¡Viva Bien!, which included group meetings for building skills to promote the Mediterranean diet, physical activity, stress management, supportive resources, and smoking cessation. RESULTS: ¡Viva Bien! participants compared to usual care significantly improved psychosocial and behavioral outcomes (fat intake, stress management practice, physical activity, and social-environmental support) at 6 months, and some improvements were maintained at 12 months. Biological improvements included hemoglobin A1c and heart disease risk factors. CONCLUSIONS: The ¡Viva Bien! multiple lifestyle behavior program was effective in improving psychosocial, behavioral, and biological/quality of life outcomes related to heart health for Latinas with type 2 diabetes.

Use of voter registration records to recruit a representative sample.

Research samples are not often compared to broader community samples to evaluate their representativeness, a critical factor in determining the generalizability of study findings. This study evaluated the use of voter-registration records for recruiting a representative sample of community-dwelling, older, and overweight participants for research on improving measures of diet and physical activity. County voter-registration records were used to identify individuals between 45 and 75 years of age and living in the two cities closest to the research lab. The data were collected from July, 2007 through November, 2008. Prospective participants were mailed an introductory letter and opt-out postcard, and received a follow-up recruitment phone call in which they underwent further screening if interested in participating. The representativeness of the final voter-recruited sample (N = 191) was evaluated by comparisons of demographic variables with Behavioral Risk Factor Surveillance System (BRFSS) data at the county and state levels. The voter-recruited sample was only partially comparable to that of the BRFSS sample, with expected differences in variables related to race/ethnicity, the proportion of women, employment status, and educational attainment. Voter-registration records are a relatively low-cost ($75 per participant) method of recruiting a community sample that avoids some biases of other recruitment methods, but may not achieve a fully representative sample.

A measurement model of youth physical activity using pedometer and self, parent, and peer reports.

BACKGROUND: Because no single measure is able to accurately assess all types of physical activity (PA), some researchers advocate use of multiple methods and multiple informants to measure PA. However, little research has tested the validity of proxy reports of youth PA. PURPOSE: The current study determined whether peer, parent, and self-reports reflects a latent measure of youth PA. As a test of construct validity, pedometer data were included in the model and covaried with the second-order target youth PA factor to determine the relationship between the youth PA factor and an objective measure of PA. METHOD: Participants included 291 target youth (ages 10, 12, or 14 years), a peer, and a parent of each target child (N = 873). Each participant reported about target children's vigorous PA during the past 7 days, days of PA in a typical week, and PA compared to others the same age and sex. Pedometers recorded the average number of steps taken per day by target youth over 7 days. RESULTS: Analyses indicated an acceptable fit of the model to the data, as all variables loaded significantly on their respective factors, and all factors had significant loadings on the higher-order target PA factor. A moderate correlation was observed between the higher-order youth PA factor and the pedometer measure. CONCLUSION: Combining multiple reports of youth PA has the potential to yield a more comprehensive measure of youth PA but may not be practical for all studies.

Methods for the cultural adaptation of a diabetes lifestyle intervention for Latinas: an illustrative project.

Because Latinas experience a high prevalence of type 2 diabetes and its complications, there is an urgent need to reach them with interventions that promote healthful lifestyles. This article illustrates a sequential approach that took an effective multiple-risk-factor behavior-change program and adapted it for Latinas with type 2 diabetes. Adaptation stages include (a) information gathering from literature and focus groups, (b) preliminary adaptation design, and (c) preliminary adaptation test. In this third stage, a pilot study finds that participants were highly satisfied with the intervention and showed improvement across diverse outcomes. Key implications for applications include the importance of a model for guiding cultural adaptations, and the value of procedures for obtaining continuous feedback from staff and participants during the preliminary adaptation test.

Measuring Explicit Instruction Using Classroom Observations of Student-Teacher Interactions (COSTI).

This article describes the development and technical adequacy of the Classroom Observations of Student Teacher Interactions (COSTI) instrument, a tool for measuring the frequency and rate of explicit instructional interactions, such as those used in Direct Instruction curricula, for teaching children basic reading and math skills. COSTI was originally developed to provide teachers with coaching feedback to improve their explicit reading instructional practices, and has been shown in multiple studies to be a reliable and valid predictor of student gains in beginning reading and math skills. This article discusses potential uses of the instrument for training and coaching across curricula with varying instructional design features, and lays out a future research agenda to further improve COSTI and related observation tools for studying explicit instructional practices and their contribution to student learning.

Outcomes of minimal and moderate support versions of an internet-based diabetes self-management support program.

OBJECTIVE: Internet and other interactive technology-based programs offer great potential for practical, effective, and cost-efficient diabetes self-management (DSM) programs capable of reaching large numbers of patients. This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program, compared to an enhanced usual care condition. RESEARCH DESIGN AND METHODS: A three-arm practical randomized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program, offered in English and Spanish, compared to enhanced usual care. A heterogeneous sample of 463 type 2 patients was randomized and 82.5% completed a 4-month follow-up. Primary outcomes were behavior changes in healthy eating, physical activity, and medication taking. Secondary outcomes included hemoglobin A1c, body mass index, lipids, and blood pressure. RESULTS: The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes (effect sizes [d] for healthy eating = 0.32; fat intake = 0.28; physical activity= 0.19) in both intent-to-treat and complete-cases analyses. These changes did not translate into differential improvements in biological outcomes during the 4-month study period. Added contact did not further enhance outcomes beyond the minimal contact intervention. CONCLUSIONS: The Internet intervention meets several of the RE-AIM criteria for potential public health impact, including reaching a large number of persons, and being practical, feasible, and engaging for participants, but with mixed effectiveness in improving outcomes, and consistent results across different subgroups. Additional research is needed to evaluate longer-term outcomes, enhance effectiveness and cost-effectiveness, and understand the linkages between intervention processes and outcomes.

Recruitment for an internet-based diabetes self-management program: scientific and ethical implications.

BACKGROUND: Little is known about the reach of Internet self-management interventions. PURPOSE: The aim of this study was to evaluate different definitions of participation rate and compare characteristics among subcategories of participants and nonparticipants on demographic and clinical factors using de-identified electronic medical record data. METHODS: Data are presented on recruitment results and characteristics of 2,603 health maintenance organization members having type 2 diabetes invited to participate in an Internet self-management program. RESULTS: There was a 37% participation rate among all members attempted to contact and presumed eligible. There were several significant differences between participants and nonparticipants and among subgroups of participants (e.g., proactive volunteers vs. telephone respondents) on factors including age, income, ethnicity, smoking rate, education, blood pressure, and hemoglobin A1c. CONCLUSION: These results have important implications for the impact of different recruitment methods on health disparities and generalization of results. We provide recommendations for reporting of eligibility rate, participation rate, and representativeness analyses.

Cellular and morphological changes with EAA supplementation before and after total knee arthroplasty.

Investigate the underlying cellular basis of muscle atrophy (Placebo) and atrophy reduction (essential amino acid supplementation, EAAs) in total knee arthroplasty (TKA) patients by examining satellite cells and other key histological markers of inflammation, recovery, and fibrosis. Forty-one subjects (53-76 yr) scheduled for TKA were randomized into two groups, ingesting 20 g of EAAs or placebo, twice-daily, for 7 days before TKA and for 6 wk after surgery. A first set of muscle biopsies was obtained from both legs before surgery in the operating room, and patients were randomly assigned and equally allocated to have two additional biopsies at either 1 or 2 wk after surgery. Biopsies were processed for gene expression and immunohistochemistry. Satellite cells were significantly higher in patients ingesting 20 g of essential amino acids twice daily for the 7 days leading up to surgery compared with Placebo (operative leg P = 0.03 for satellite cells/fiber and P = 0.05 for satellite cell proportions for Type I-associated cells and P = 0.05 for satellite cells/fiber for Type II-associated cells.) Myogenic regulatory factor gene expression was different between groups, with the Placebo Group having elevated MyoD expression at 1 wk and EAAs having elevated myogenin expression at 1 wk. M1 macrophages were more prevalent in Placebo than the EAAs Group. IL-6 and TNF-α transcripts were elevated postsurgery in both groups; however, TNF-α declined by 2 wk in the EAAs Group. EAAs starting 7 days before surgery increased satellite cells on the day of surgery and promoted a more favorable inflammatory environment postsurgery.NEW & NOTEWORTHY Clinical studies by our group indicate that the majority of muscle atrophy after total knee arthroplasty (TKA) in older adults occurs rapidly, within the first 2 wks. We have also shown that essential amino acid supplementation (EAAs) before and after TKA mitigates muscle atrophy; however, the mechanisms are unknown. These results suggest that satellite cell numbers are elevated with EAA ingestion before surgery, and after surgery, EAA ingestion positively influences markers of inflammation. Combined, these data may help inform further studies designed to address the accelerated sarcopenia that occurs in older adults after major surgery.

Use of a Local Worker Survey as a Source of Neighborhood Information.

Researchers increasingly recognize the potential influence of the neighborhood environment on individual health and social behavior. To examine these influences, it is important to use varying measures and sources of neighborhood characteristics. Though neighborhood residents are often surveyed, the perceptions of neighborhood workers have been largely ignored. The current study documents procedures and findings from two longitudinal studies in which workers in 60 neighborhoods were surveyed about neighborhood social cohesion and social control (collective efficacy), and neighborhood problems. Results indicated that workers within neighborhoods were more homogeneous in their views of neighborhood collective efficacy and neighborhood problems than were workers across neighborhoods. In addition, workers' perceptions of their neighborhoods were similar to the perceptions of neighborhood residents, but also provided unique information. Overall, this study demonstrates the viability and usefulness of local workers as an additional source of neighborhood information.

Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Substantial muscle atrophy occurs after total knee arthroplasty (TKA), resulting in decreased strength and impaired mobility. We sought to determine whether perioperative supplementation with essential amino acids (EAA) would attenuate muscle atrophy following TKA and whether the supplements were safe for ingestion in an older surgical population. METHODS: We performed a double-blind, placebo-controlled, randomized trial of 39 adults (age range, 53 to 76 years) undergoing primary unilateral TKA who ingested 20 g of EAA (n = 19) or placebo (n = 20) twice daily for 7 days preoperatively and for 6 weeks postoperatively. At baseline and 6 weeks postoperatively, magnetic resonance imaging (MRI) scans were obtained to measure quadriceps and hamstrings muscle volume. Secondary outcomes included functional mobility and strength. Data on physical activity, diet, and patient-reported outcomes (Veterans RAND 12-Item Health Survey and Knee injury and Osteoarthritis Outcome Score) were collected. Safety was determined through blood tests evaluating blood urea nitrogen, creatinine, creatinine clearance, homocysteine, and renal and liver function. Laboratory values at baseline, on the day of surgery, and at 2 days, 2 weeks, and 6 weeks postoperatively were compared between treatment groups. Analysis of covariance models, with baseline values as covariates, were used to evaluate outcomes between treatment groups. P values were adjusted for multiple tests. RESULTS: Compared with baseline, the EAA group had significantly less decrease in mean quadriceps muscle volume compared with the placebo group in the involved leg (-8.5% ± 2.5% compared with -13.4% ± 1.9%; p = 0.033) and the contralateral leg (-1.5% ± 1.6% compared with -7.2% ± 1.4%; p = 0.014). The hamstrings also demonstrated a greater muscle-volume-sparing effect for the EAA group than for the placebo group in the involved leg (-7.4% ± 2.0% compared with -12.2% ± 1.4%; p = 0.036) and contralateral leg (-2.1% ± 1.3% compared with -7.5% ± 1.5%; p = 0.005). There were no differences between the groups in terms of functional measures or strength. Blood chemistry values varied significantly between assessments periods but did not statistically differ between groups. CONCLUSIONS: The results of the present study suggest that EAA supplementation is safe and reduces the loss of muscle volume in older adults recovering from TKA. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Reliability of pedometer data in samples of youth and older women.

BACKGROUND: Pedometers offer researchers a convenient and inexpensive tool for objective measurement of physical activity. However, many unanswered questions remain about expected values for steps/day for different populations, sources of variation in the data, and reliability of pedometer measurements. METHODS: This study documented and compared mean steps/day, demographic predictors of steps/day, and pedometer reliability in two longitudinal investigations, one involving a population-based youth sample (N = 367) and the other targeting postmenopausal women with type 2 diabetes (N = 270). Individuals were asked to wear pedometers (Yamax model SW-701) at the waist for 7 days and record steps/per day. They were also asked to record daily physical activities, duration, and perceived intensity (1 = low/light, 2 = medium/moderate, 3 = high/hard) for the same 7 days. In addition, survey data regarding usual physical activity was collected. Analyses of variance (ANOVA) were conducted to determine whether there were significant differences in pedometer results according to sex, age, and body mass index. Repeated measures ANOVAs were used to examine potential differences in results among differing numbers of days. RESULTS: Mean steps/day were 10,365 steps in the youth sample and 4,352 steps in the sample of older women. Girls took significantly fewer steps than boys, older women took fewer steps than younger women, and both youth and women with greater body mass took fewer steps than those with lower body mass. Reliability coefficients of .80 or greater were obtained with 5 or more days of data collection in the youth sample and 2 or more days in the sample of older women. Youth and older women were more active on weekdays than on weekends. Low but significant associations were found between step counts and self-report measures of physical activity in both samples. CONCLUSION: Mean steps/day and reliability estimates in the two samples were generally consistent with previously published studies of pedometer use. Based on these two studies, unsealed pedometers were found to offer an easy-to-use and cost-effective objective measure of physical activity in both youth and older adult populations.

Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes.

BACKGROUND: Multiple-risk-factor interventions offer a promising means for addressing the complex interactions between lifestyle behaviors, psychosocial factors, and the social environment. This report examines the long-term effects of a multiple-risk-factor intervention. METHODS: Postmenopausal women (N = 279) with type 2 diabetes participated in the Mediterranean Lifestyle Program (MLP), a randomized, comprehensive lifestyle intervention study. The intervention targeted healthful eating, physical activity, stress management, smoking cessation, and social support. Outcomes included lifestyle behaviors (i.e., dietary intake, physical activity, stress management, smoking cessation), psychosocial variables (e.g., social support, problem solving, self-efficacy, depression, quality of life), and cost analyses at baseline, and 6, 12, and 24 months. RESULTS: MLP participants showed significant 12- and 24-month improvements in all targeted lifestyle behaviors with one exception (there were too few smokers to analyze tobacco use effects), and in psychosocial measures of use of supportive resources, problem solving, self-efficacy, and quality of life. CONCLUSION: The MLP was more effective than usual care over 24 months in producing improvements on behavioral and psychosocial outcomes. Directions for future research include replication with other populations.