The EPIC Kids Study: a randomized family-focused YMCA-based intervention to prevent type 2 diabetes in at-risk youth.

BACKGROUND: It is well established that behavioral lifestyle interventions resulting in modest weight reduction in adults can prevent or delay type 2 diabetes mellitus; however in children, successful weight management interventions are rarely found outside of controlled clinical settings. The lack of effective community-based programs is a barrier to reducing obesity prevalence and diabetes risk in children. The objective of our study is to develop and test a group-randomized family-centered community-based type 2 diabetes prevention intervention targeting at-risk children, 9- to 12-years-old. METHODS/DESIGN: Using participatory methods, the adult-focused YMCA Diabetes Prevention Program was adapted for families, creating a novel lifestyle behavior change program focused on healthy eating, physical activity, and a supportive home environment. The program will be tested in sixty 9- to 12-year-old children at risk of diabetes and sixty parents over 12 consecutive weeks with two intervention formats randomized by location: a face-to-face instructor-led program, or a hybrid program with alternating face-to-face and mobile technology-delivered content. Anthropometric, behavioral, psychosocial and physiological outcomes will be assessed at baseline, post-intervention (12 weeks), and follow-up (24 weeks). Secondary outcomes are participant acceptability, feasibility, and adherence. The RE-AIM framework (reach, efficacy, adoption, implementation, and maintenance) will guide intervention implementation and evaluation. Changes at 12 weeks will be assessed using a paired t-test combining both delivery formats. Exploratory models using linear regression analysis will estimate the magnitude of the difference between the face-to-face and hybrid format. The sample size of 60 children, informed by a previous YMCA intervention in which -4.3 % change in overweight (SE = 1.1) was observed over 6 months, will give us 80 % power to detect an effect size of this magnitude, assuming a one-sided test at alpha = 0.05. DISCUSSION: The proposed study capitalizes on a partnership with the YMCA, a popular and widespread community organization, and uses mobile technologies to extend program reach while potentially reducing burden associated with weekly attendance. The long-term goal is to create a scalable, replicable, and sustainable pediatric "diabesity" prevention program that overcomes existing barriers to the translation of efficacious interventions into effective community programs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02421198 on April 15, 2015.

A Multi-Modality Intervention Improves Obesity Bias among Medical Students.

Background: Obesity is linked to chronic diseases in adults and children. Its prevalence continues to grow in the United States, necessitating the need for healthcare provider training and presenting an opportunity for the education of future medical providers. Despite this need, effectively implementing obesity education into medical school curricula has been challenging. Anti-obesity bias amongst healthcare providers and trainees represents a significant obstacle to the care of patients with obesity. Obesity bias may affect up to 1/3 of medical students. Methods: This study describes the development and preliminary testing of a brief, 2.5 h multi-modality teaching intervention consisting of online, interactive, and independent learning modules for first-year medical students and a patient panel focused on obesity, obesity bias, and motivational interviewing. The participants took Crandall's anti-fat attitude (AFA) questionnaire before and after an online independent learning module on motivational interviewing and obesity bias. The AFA consists of three subscales ("dislike", "fear of fat", and "willpower"). Individual responses were measured using a nine-point Likert-type response format (0 = very strongly disagree; 9 = very strongly agree). An average composite score was calculated for each subscale. Results: Data were analyzed from 103 first-year medical students enrolled at a college of medicine in the southwestern United States in 2022. The AFA mean composite scores decreased significantly, indicating a decrease in explicit anti-obesity attitude bias after completing the online module. This decrease was present in all three domains of fear (4.63 vs. 3.72, p < 0.001), dislike (1.25 vs. 0.88, p < 0.001) and willpower (3.23 vs. 2.31, p < 0.001). Conclusions: Relatively brief educational interventions can positively impact students' anti-obesity attitudes.

Group Medical Visits for Addressing Weight and Blood Pressure in an Underserved Population.

The effect of group medical visits (GMV) compared to individual medical visits (IMV), on weight and blood pressure in a large primary care practice serving a predominantly underserved population, was assessed. The records of 304 patients attending a weight-loss program were analyzed using mixed-effects regression models. Patients in GMV lost an average of 11.63 lbs, whereas patients in IMV lost an average of 3.99 lbs (p < 0.001). A total of 55% of patients lost ≥7% in GMV compared to 11% of patients in IMV (p ≤ 0.001). Individuals who lost >5% of their baseline weight had a higher reduction in overall blood pressure. For systolic and diastolic blood pressure, the differences between baseline and three months for GMV and IMV were −7.4 vs. 4.1 mm of Hg (p = 0.002) and −4.6 vs. 4.2 mm of Hg (p = 0.003), respectively. Results from this study demonstrate that GMV may be a potentially useful modality for addressing weight and blood pressure in an underserved population.

Gender, psychiatric disability, and dropout from peer support specialist training.

Although research indicates that the prevalence of psychiatric disability differs depending on gender, a paucity of information exists as to whether men and women with psychiatric disability also differ regarding service program outcomes. For a United States Southwest peer support specialist training program, this study examines whether gender moderates the association between psychiatric disability and a key outcome-training dropout. Data were collected for 78 men and 157 women with psychiatric disability and 137 men and 203 women with mental illness only. Logistic regression was used to examine the association between psychiatric disability and dropout, with gender as a moderator variable, and age, education, race/ethnicity, and substance use disorder as control variables. Of trainees with psychiatric disability, dropout was greater among men than women (34.6% and 20.4%, respectively; p < .05). Dropout was also greater among men with psychiatric disability than among men with mental illness only (34.6% and 15.3%; p < .01). In contrast, dropout was similar for women with psychiatric disability and mental illness only (20.4% and 18.7%; p > .05), and dropout was comparable among men and women with mental illness only (15.3% and 18.7%; p > .05). In summary, risk of dropout was substantially higher among men with psychiatric disability than women with psychiatric disability. Gender tailoring of the program's services should be considered to better support training completion. This study's findings also raise questions as to possible underrepresentation of men with psychiatric disability in the peer support workforce training pipeline. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Teaching culturally effective diabetes care: results of a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Increased cultural competence is a tool in the fight to eliminate health disparities in people with diabetes. However, questions remain regarding the best cultural competence teaching, evaluation, and dissemination methods. An Internet-based approach requires less facilitator time and provides greater ease of dissemination. We developed and tested a skills-focused, Internet-based course on cultural competence in the context of type 2 diabetes. METHODS: To test the effectiveness of the course, a randomized controlled trial was conducted on a national sample of 122 family medicine residents. The primary outcome was measured by changes in score on the Cultural Competence Assessment Tool (CCAT), a new self-assessment tool developed for this study. RESULTS: Total CCAT score increased significantly after the completion of the Internet course for 58 residents in the experimental group (83.55 before the course, 192.09 after the course) but did not change for the 64 residents in the control group (177.58 at baseline, 177.84 at end of study). On multivariate analysis, the only significant predictor of total CCAT score change was having taken the online course. CONCLUSIONS: A skills-based course on cultural competence, delivered via the Internet, is an effective educational strategy. It has potential for dissemination of standardized content.

Feasibility of a family-focused YMCA-based diabetes prevention program in youth: The E.P.I.C. Kids (Encourage, Practice, and Inspire Change) Study.

Efficacious lifestyle modification programs for children at risk of type 2 diabetes (T2D) have not been well established outside of clinical settings. In this study, the feasibility of a family-focused, YMCA-based prevention program for children at risk of T2D was evaluated between September 2015 and July 2016 in Tucson, Arizona. A 12-week YMCA-led lifestyle intervention was adapted for 9-12-year-old children and their families to encourage healthy eating, physical activity, and supportive home environments. Two YMCA locations were randomized to offer either a face-to-face lifestyle coach-led intervention or an alternating face-to-face and digitally-delivered intervention. Program feasibility and preliminary effects on child anthropometric and behavioral outcomes were assessed at baseline and post-intervention. Changes were assessed using linear regression combining delivery formats, with adjustment for clustering of participants within site/format. Forty-eight children (10.9 ±â€¯1.2 years old; 45% female; 40% Hispanic; 43% White; 87% obese) and their parents enrolled, and 36 (75%) completed 12-week measures. Weekly program attendance averaged 61%. Participants and coaches highly rated program content and engagement strategies. Statistically significant changes in child BMI-z score (-0.05, p = 0.03) and family food and physical activity environment (+5.5% family nutrition and physical activity score, p = 0.01) were observed. A YMCA-led family-focused T2D intervention was feasible for the YMCA and participants and effects on child weight, behavior, and the home environment warranted further investigation.

KnowPain-50: a tool for assessing physician pain management education.

BACKGROUND: Despite a need for better physician pain management education, there are no widely accepted assessment or outcome measures to support this work. OBJECTIVE: Create a self-assessment tool to measure physician educational needs and the effectiveness of chronic pain educational programs. DESIGN: We used expert consensus to draft a 142-item survey that covered essential areas of chronic pain management. We tested the survey in 106 physicians, including 22 pain management experts and used predefined psychometric criteria to eliminate 70 items. We then eliminated 22 remaining items that did not correlate with the management of a standardized chronic pain patient by 27 academic physicians. We evaluated internal consistency using Cronbach's alpha. RESULTS: The final 50-item survey assessed physician knowledge, attitudes, and beliefs in: 1) initial pain assessment; 2) defining goals and expectations; 3) development of a treatment plan; 4) implementation of a treatment plan; 5) reassessment and management of longitudinal care; and 6) management of environmental issues. The survey demonstrated good internal consistency in all physician populations studied (alpha = 0.77-0.85). Average scores in 84 "pilot" physician users of a CME Website (135.8-138.5) were significantly lower (P < 0.01) than scores in 27 academic physicians (150.0), or 22 pain experts (177.5). CONCLUSIONS: This survey, the KnowPain-50, has good psychometric properties, correlates with clinical behaviors, and appears to distinguish between physicians with different levels of pain management expertise. It may be a useful measure of the effectiveness of physician pain management education programs.

Relationship Between Marital Transitions, Health Behaviors, and Health Indicators of Postmenopausal Women: Results from the Women's Health Initiative.

BACKGROUND: Historically, marital status has been associated with lower mortality and transitions into marriage were generally accompanied by improved health status. Conversely, divorce has been associated with increased mortality, possibly mediated by changes in health behaviors. METHODS: This study uses data from a prospective cohort of 79,094 postmenopausal women participating in the Women's Health Initiative Observational Study (WHI-OS) to examine the relationship between marital transition and health indicators (blood pressure, waist circumference, body mass index [BMI]) as well as health behaviors (diet pattern, alcohol use, physical activity, and smoking) in a sample of relatively healthy and employed women. Linear and logistic regression modeling were used to test associations, controlling for confounding factors. RESULTS: Women's transitions into marriage/marriage-like relationship after menopause were associated with greater increase in BMI (ß = 0.22; confidence interval (95% CI), 0.11-0.33) and alcohol intake (ß = 0.08; 95% CI, 0.04-0.11) relative to remaining unmarried. Divorce/separation was associated with a reduction in BMI and waist circumference, changes that were accompanied by improvements in diet quality (ß = 0.78, 95% CI, 0.10-1.47) and physical activity (ß = 0.98, 95% CI, 0.12-1.85), relative to women who remained married. CONCLUSION: Contrary to earlier literature, these findings among well-educated, predominantly non-Hispanic white women suggest that marital transitions after menopause are accompanied by modifiable health outcomes/behaviors that are more favorable for women experiencing divorce/separation than those entering a new marriage.

Artificially sweetened beverages, sugar-sweetened beverages, plain water, and incident diabetes mellitus in postmenopausal women: the prospective Women's Health Initiative observational study.

Background: Sugar-sweetened beverages (SSBs) have been associated with an increased risk of diabetes mellitus (DM), whereas the association with artificially sweetened beverages (ASBs) is unclear.Objective: We aimed to evaluate the associations of ASB and SSB consumption with the risk of developing DM and the potential benefit of replacing SSBs with ASBs or water.Design: The national Women's Health Initiative recruited a large prospective cohort of postmenopausal women between 1993 and 1998. ASB, SSB, and water consumption was measured by lifestyle questionnaires, and DM was self-reported.Results: Of 64,850 women, 4675 developed diabetes over an average of 8.4 y of follow-up. ASBs and SSBs were both associated with an increased risk of DM with an HR of 1.21 (95% CI: 1.08, 1.36) comparing ASB consumption of ≥2 serving/d to never or <3 serving/mo, and an HR of 1.43 (95% CI: 1.17, 1.75) comparing SSB consumption of ≥2 serving/d to <1 serving/wk (1 serving = one 12-ounce can or 355 mL). Subgroup analysis found an increased risk of DM associated with ASBs only in the obese group. Modeling the substitution of SSBs with an equal amount of ASBs did not significantly reduce the risk of developing DM. However, statistically substituting 1 serving of ASBs with water was associated with a significant risk reduction of 5% (HR: 0.95; 95% CI: 0.91, 0.99), whereas substituting 1 serving of SSBs with water was associated with a risk reduction of 10% (HR: 0.90; 95% CI: 0.85, 0.95).Conclusions: ASBs were associated with a 21% increased risk of developing DM, approximately half the magnitude of SSBs (associated with a 43% increased risk). Replacing ASBs and SSBs with water could potentially reduce the risk. However, caution should be taken in interpreting these results as causal because both residual confounding and reverse causation could explain these results.

The diverse functions of role models across primary care specialties.

BACKGROUND AND OBJECTIVES: This study investigated the relationship of role models to primary care specialty and gathered information on the attributes and functions of role models. METHODS: A questionnaire on medical school experiences and attitudes was administered to primary care graduates from 24 US medical schools. RESULTS: Questionnaires were completed by 1,457 physicians. Sixty-three percent of primary care respondents had a role model. Having a role model was significantly related to current specialty and ethnicity. Respondents most valued their role models' patient relationships. For family medicine and internal medicine graduates, having a role model was related to more contact and more-positive views of faculty in their specialty. Those with a role model reported that primary care was encouraged at their medical school and were more satisfied with their specialty choice. CONCLUSIONS: Role models may be more important to students who are not well represented among medical school faculty, namely women, underrepresented ethnic minorities, and those interested in family medicine. For family medicine graduates, role models function to moderate negative stereotypes. Role models may also make explicit the values of physicians in that specialty, making students more informed when choosing a specialty and as a consequence more satisfied with the decision.

Family medicine specialty choice and interest in research.

BACKGROUND AND OBJECTIVES: This study investigated interest in research related to declining interest in family medicine by US medical school graduates. METHODS: Twenty-four schools were selected for study based on American Academy of Family Physicians data on the number of their graduates entering family medicine. Data for all graduates in 1997, 1998, and 1999 were obtained from the Association of American Medical Schools matriculation and graduation questionnaires for 23 of 24 schools. RESULTS: Measures of research activity or interest were available on matriculation during medical school and at graduation. All were inversely related to interest in family medicine. Students interested in family medicine were less likely to have selected the field of medicine because of research interests, were less likely to have participated in a research project during medical school, and at graduation were less likely to plan on a career involving research. CONCLUSIONS: Given this pervasive negative relationship between interest in research and interest in family medicine, initiatives intended to increase research within the specialty of family medicine should be evaluated for their effects on student career choices. These initiatives may decrease interest in family medicine among students who don't want to do research but who otherwise might have been interested in family medicine. Conversely, they may increase interest in family medicine among students with research interest, or they may do both.

Lessons not learned from the generalist initiatives.

The grouping of the primary care specialties (general internal medicine, general pediatrics, and family medicine) for research purposes is at best limiting the value of the information that is found and, at worst, leading researchers to erroneous conclusions. For example, three large studies each showed differences in abilities to predict students' specialty choices in primary care (e.g., in one study, the investigators correctly predicted 3% of those choosing general internal medicine, 29% considering general pediatrics, and 51% considering family medicine). These and related findings suggest that medical students entering the three primary care specialties are not a homogeneous group. While there were some factors predictive for all primary care specialties, there were more factors that were unique to the individual specialties Grouping the specialties may not reveal factors that are significantly related to only one of the specialties. In addition, when a variable operates in different ways for different specialties, findings where the specialties are combined can show a reduced effect of that variable or even no effect, because the directions of effects cancel each other. Researchers can fruitfully examine the primary care specialties as a group but at the same time report their data for the individual specialties, which would greatly increase our knowledge both of primary care and also about the similarities and dissimilarities of its component specialties. However, the best models continue to be either research in which the sample size is large enough to compare specialty groups statistically or research with a focus on just one of the primary care specialties.

A comparison of primary care graduates from schools with increasing production of family physicians to those from schools with decreasing production.

BACKGROUND AND OBJECTIVES: This study investigated factors related to declining interest in family medicine by US medical school graduates. METHODS: A questionnaire was sent to all physicians who graduated from 24 medical schools in 1997-1999, and who entered a family medicine residency, and a randomly selected equal number of graduates from the same years who entered other primary care specialties. Between 1997 and 1999, 12 of these schools had increases and 12 had decreases in the proportion of graduates choosing family medicine residencies. RESULTS: Between 1997 and 1999, at schools with increasing proportions of graduates choosing family medicine, there were significant increases in the proportion of graduates who (1). had entered medical school with a specialty preference of family medicine, (2). spent their required family medicine clerkship at two or more sites, (3). ranked the competence of family medicine faculty highly, (4). reported the faculty member they most wanted to be like was a family physician, and (5). experienced clinical rotations in both family medicine and primary care. At schools with declines in the proportion of graduates choosing family medicine, there were significant declines in the proportion of graduates who (1). ranked the competence of family medicine faculty highly, (2). stated that they were encouraged to go into family medicine, and (3). reported that the faculty member they most wanted to be like was a family physician. In schools with decreases in family medicine graduates, there was a significant increase in the proportion of graduates intending a large city or suburban practice. Using binary logistic regression, the variables that remained significantly correlated with attending a school with increases or decreases in students selecting family medicine were the number of required clinical rotations in family medicine and primary care, the perception of the clinical competence of the family medicine faculty, and an intent to practice, or subsequently having a practice, in a rural area. CONCLUSIONS: Schools that want to increase their production of family physicians should consider admissions policies that select students inclined toward family medicine and rural practice, should adopt a curriculum that maximizes clinical training with family physicians and other primary care physicians, and should ensure that their family medicine faculty are perceived as competent role models.

Which primary care specialty? Factors that relate to a choice of family medicine, internal medicine, combined internal medicine-pediatrics, or pediatrics.

BACKGROUND AND OBJECTIVES: This study was conducted to examine factors used by medical students to select a primary care specialty that may differentiate students who choose the primary care specialties of family medicine, internal medicine, pediatrics, and combined internal medicine-pediatrics. METHODS: A questionnaire was sent to all family physicians and an equal number of other primary care physicians graduating from one of 24 medical schools in 1997-1999. Twelve schools had increasing proportions of graduates choosing family medicine in this study period, and 12 had decreasing proportions. The questionnaire asked about factors related to choice of specialty, which could be grouped into the specialty domains of type of patients, process, content, and setting. RESULTS: For family physicians, the most important factor was patient relationships, and the second most important was wanting an approach to the practice of medicine similar to that of family physicians. Internists indicated as most important wanting to work with adults and as the next most important an "internal medicine approach" to the practice of medicine. Most important for pediatricians was working with children and next most important was having patient relationships like other pediatricians. Those in combined internal medicine-pediatrics most often indicated a desire to work with children and next most important was an approach to medicine like others in their specialty. CONCLUSIONS: The most important reasons for choice of specialty were similar for all primary care specialties and related to congruence between the graduate and the physicians in the specialty or the process of providing care within that specialty. The factors that differentiated the four specialties related to the content of the specialty.

Comments heard by US medical students about family practice.

BACKGROUND AND OBJECTIVES: This study was conducted to explore the hypothesis that negative comments from faculty and residents about family practice are related to the recent decline in student selection of this specialty. METHODS: A questionnaire was sent to all family physicians and an equal number of other primary care physicians who graduated from one of 24 medical schools in 1997-1999. Twelve schools had increasing proportions of graduates choosing family practice in the study period, and 12 had decreasing proportions. The questionnaire asked about negative comments heard about family practice and other primary care specialties. RESULTS: Most graduates heard negative comments about family practice during medical school, and many students heard these comments often. However, the frequency and content of negative comments was not related to increases or decreases in the proportion of students choosing family practice. Negative comments were heard more frequently about family practice than about other primary care specialties. Negative comments increased in frequency during the study period. The negative comments on the questionnaire heard most often were that family physicians cannot master the content of the specialty and that they are not as smart as other physicians. Compared to other graduates, those with an initial interest in family practice who chose another specialty more frequently reported hearing that family physicians can't master the specialty content. There was an inverse relationship between the number of groups (students, residents, and faculty) that negative comments were heard from and ranking of family medicine faculty on respectability, influence, and competence. CONCLUSIONS: After 3 decades of being an officially recognized specialty, family practice is not recognized by some other medical school faculty as an equal to other primary care disciplines, and these faculty frequently express this view to students. While the frequency of these negative comments is increasing and is related to trainees' perceptions of family medicine faculty, it does not explain the recent decline in student interest in family practice. There is some evidence that students who change their career plans away from family practice might be concerned with their ability to master the specialty content. The prevalence of negative comments is related to trainees' perceptions of family medicine faculty.

Declining interest in family medicine: perspectives of department heads and faculty.

BACKGROUND AND OBJECTIVES: In 2003, US seniors filled 42% of family practice residency positions, the lowest percentage in the specialty's recent history. We hypothesized that institutional support, contact with family medicine faculty, and faculty satisfaction would be positively related to choice of family practice and that faculty satisfaction would be negatively affected by increasing pressure for clinical productivity. METHODS: We surveyed department heads and faculty at 24 US allopathic medical schools, selected by their rate of family medicine graduates from 1997 to 1999 and the size of the school. Twelve of these schools had an increase in rates of graduates selecting family practice, and 12 showed decreases. RESULTS: Department heads and faculty from schools with an increase in student entry into family practice residencies were significantly more likely to report financial and philosophical support from their state legislature or medical school administration. Faculty ranked patient care as most valued at their institutions, followed by teaching, research, and service. A common theme emerging from both the faculty and department head surveys was an inverse relationship between research activity and graduates choosing family practice. CONCLUSIONS: This study demonstrates the importance of upper-level institutional support on family practice specialty choice. It also highlights a need for further examination of the specialty's relationship to research.

Can Internet-based education improve physician confidence in dealing with domestic violence?

BACKGROUND AND OBJECTIVES: Domestic violence (DV) is a common, under-recognized source of visits to health care professionals. Even when recognized, physicians are reluctant to deal with DV, citing a lack of education and lack of confidence in addressing issues presented by DV patients. Only a small number of DV education programs have been shown to lead to improvements in professional knowledge and confidence, and these are intensive, multi-day courses. We sought to develop an on-line DV education program that could achieve improvements in physician confidence and attitudes in managing DV patients comparable to classroom-based courses. METHODS: We created an interactive, case-based DV education program targeted to physicians caring for DV patients. We tested the effectiveness of this program in changing attitudes and beliefs in a randomized, controlled trial of Kansas physicians who volunteered to participate in a study of on-line continuing medical education. We measured program effectiveness with an externally developed and validated pretest/posttest instrument. RESULTS: Sixty-five physicians completed the pretest/posttest, 28 of whom were assigned to receive the on-line DV program. We found a +17.8% mean change in confidence (self efficacy) for physicians who took the DV program versus a -.6% change for physicians who did not take the program. We also found improvements in other important areas associated with poor management of DV patients. These changes were similar or greater in magnitude to those reported by others who have used the same survey tool to evaluate an intensive, multi-hour classroom approach to DV education. User satisfaction with the on-line program was high. CONCLUSIONS: An interactive, case-based, on-line DV education program that teaches problem-solving skills improves physician confidence and beliefs in managing DV patients as effectively as an intensive classroom-based approach. Such programs may be of benefit to those seeking to improve their personal skills or their health care delivery system's response to DV.

Families United/Familias Unidas: family group office visits to reduce risk factors for type 2 diabetes.

PURPOSE: The purpose of the Families United/Familias Unidas study was to evaluate the feasibility and efficacy of group office visits on reducing diabetes risk in a multiethnic, primary care population. METHODS: Adults, ages 18 to 70 years, with any diabetes risk factor were recruited to attend 12 group office visits over 6 months. Each participant identified 1 support person, age 14 to 70 years, to accompany them. Data were collected at baseline, postintervention, 6 months, and 12 months. Primary outcome measures were reduction in the total number of predefined, modifiable risk factors (ie, body mass index ≥25 kg/m(2); waist circumference ≥88 cm [women], ≥102 cm [men]; blood pressure ≥140/90 mm Hg; hemoglobin A1C ≥5.7%; fasting insulin ≥15 µU/mL; glycemic index ≥52.5% [women], ≥53.4% [men]; and physical activity <150 min/wk). RESULTS: Thirty-nine participants/supporters completed the intervention (mean age 47.8 ± 12.3 years, 69.2% female, 61.5% white, 35.9% Latino). Risk reduction analysis included only participants/supporters who remained paired at the intervention's end (n = 36). At baseline, primary participants (n = 18) had an average of 4.8 ± 1.6 (standard error) predefined risk factors; supporters (n = 18), 4.1 ± 1.4. Primary participants' risk factors decreased approximately 15% immediately after the 6-month intervention (absolute reduction of 1.1 risk factors) and increased to ~20% reduction 1 year postintervention (absolute reduction of 1.4 risk factors). Risk reduction was primarily due to decreases in dietary glycemic index and fasting insulin levels. CONCLUSIONS: Group visits provide an innovative and potentially efficacious model of diabetes prevention in multiethnic patients with heterogeneous risk factors.

Assessing culturally competent diabetes care with unannounced standardized patients.

BACKGROUND AND OBJECTIVES: More effective diabetes care is desperately needed, especially for ethnic minority populations. Provider cultural competence promises to be an important means for reducing disparities in outcomes for patients with diabetes. The objectives of this study were to understand the role of cultural competence in the diabetes office visit. METHODS: Unannounced standardized patients (SPs) were sent to the offices of 29 family and internal medicine residents and practicing physicians. The SPs portrayed a Mexican American woman newly diagnosed with type 2 diabetes. Using a checklist developed with the input of experts in Hispanic/Latino health care and cultural competence, the SPs evaluated physicians' cultural competence, diabetes care, and general communications skills. RESULTS: The average total SP Checklist score was 70.7-11.0%, with a range of 43.9% to 90.2%. Physicians scored highly on items that measured general communication skills (95.9%) but were less likely to ask about social history (ie, family and community support issues, 51.9% and 48.1%, respectively). Sixty-seven percent of physicians ordered a hemoglobin A1c, 44% referred to ophthalmology, and 15% performed a monofilament exam. Physicians' inquiry into SPs explanatory model of disease (ie, asking about the SPs' views regarding their disease and its treatment) correlated with the performance of several diabetes treatment-related behaviors, Spearman's rho=.466. CONCLUSIONS: The findings provide support for a relationship between inquiry into patients' explanatory models of disease and effective diabetes care. Social history and explanatory model elicitation skills are vital parts of cultural competence training programs and potentially valuable tools for mitigating health disparities.