Ontario’s Primary Care Diabetes

Prevention Program – Group

Lifestyle Balance

November 2, 2017

12:00 pm – 1:30 pm EST

Preventing

Chronic Disease

in Primary Care

The webinar will start start shortly

at 12:00 pm

• Download presentation slides from Links and Materials pod

• Share comments or questions into the Chat box

• For technical assistance, chat with OPHA Host

• The webinar is being recorded

• Funded by the Ministry of Health and Long-Term Care

• One of 14 health promotion resource centres in Ontario

• Operated under the Ontario Public Health Association since 1999

Our Mission…..

Strengthening the capacity of health promotion professionals and

community partners involved with healthy eating and nutrition across

Ontario.

About the Nutrition Resource Centre

Team of Registered Dietitians and public health consultants:

• Expertise in nutrition, food and healthy eating (e.g., food environment, food literacy, food insecurity, etc.)

• Expertise in public health: applying evidence-based health promotion strategies, program planning, implementation, evaluation and policy development

Provide consultation and support services:

• KTE, training and educational services (e.g., resource development/review, facts sheets, toolkits, webinars, workshops, digital communications etc.)

• Consultations to provide evidence synthesis, technical advice recommendations, and strategies

• Offer group facilitation and coordination services, bringing together diverse practitioners and sectors

For more information about NRC’s services, please contact:

Donna Smith, Policy and Program Consultant, dsmith@opha.on.ca

About the Nutrition Resource Centre

Ophea’s Physical Activity Resource Centre (PARC)

PARC is the Centre of Excellence for physical activity promotion in Ontario.

We provide professional learning & networking opportunities, quality

resources, and consultation services to enhance the capacity of physical

activity promoters who work across the lifespan in Ontario.

• To learn more about PARC, visit parc.ophea.net.

• To learn more about Ophea, visit ophea.net.

• Explore the history and evidence supporting Group Lifestyle BalanceTM

• Discuss the results of Ontario’s PCDPP demonstration project

• Describe adaptations made to GLB for the Ontario/Canadian context

• Share firsthand experience running the PCDPP in primary care

organizations from Ontario’s Lifestyle Coaches and Master Trainers

• Provide details regarding training and supports available in Ontario

• Introduce the manual – Ontario’s Primary Care Diabetes Prevention

Program – Implementation Manual for Your Primary Care Organization

Learning Objectives

• Kaye Kramer, Adjunct Professor of Epidemiology, Graduate School of Public

Health, University of Pittsburgh

• Linda Semler, Senior Research Manager, Department of Health and Physical

Activity, University of Pittsburgh

• Michael Hillmer, Executive Director, Information Management, Data and Analytics,

Ontario Ministry of Health and Long-Term Care

• Sarah Pink, GLB Lifestyle Coach/Master Trainer (PCDPP), Mount Forest Family

Health Team

• Given Cortes, GLB Lifestyle Coach/Master Trainer (PCDPP) , Assiginack Family

Health Team

• Diane Horrigan, GLB Lifestyle Coach/Master Trainer (PCDPP), Mount Forest

Family Health Team

• Donna Smith, Policy and Program Consultant, Nutrition Resource Centre at

Ontario Public Health Association

Presenters

NCR: Preventing Chronic Disease in Primary Care

Part 1: Diabetes Prevention Program

and Translation to the Community M. Kaye Kramer, DrPH, MPH, RN

Part 2: Rationale and Goals for Dietary Behavior Change to Prevent or Delay

Type 2 Diabetes Linda N. Semler, MS, RD, LDN

Copyright © University of Pittsburgh, 2017

Diabetes Prevention Program

From Efficacy to Effectiveness… Translating Lifestyle Intervention to the Community

We know that the DPP healthy lifestyle intervention worked in a clinical trial setting, but how do we successfully implement this program in the “real world”?

The Diabetes Prevention Support Center

University of Pittsburgh

The DPSC goal is to guide translation efforts in the community thru facilitating all aspects of the delivery of a modified, up-to-date Diabetes Prevention Program lifestyle intervention program.

How to Translate to the Real World?

1. Modification of the DPP Individual Lifestyle Balance Program

2. Standardized, expert training for intervention implementation

3. Ongoing support for program delivery

4. Intervention feasibility and effectiveness evaluation

Modification of the DPP Individual

Lifestyle Balance Program

• DPP Group Lifestyle Balance (GLB) Program

• Program components

• Individual vs. Group

• Up to date

• 16 sessions in 6 months followed by 6 monthly sessions

DPSC Today

Training

Comprehensive training workshops

Availability of online training

Provision of “DPP Master Trainer” programs

Support

Telephone, e-mail and web

Program Evaluation

http://www.diabetesprevention.pitt.edu/index.php/for-the-public/for-health-providers/glb-publications/

Largest national effort to mobilize and bring effective lifestyle change programs to communities across the country!

National Diabetes Prevention Program (NDPP)

• Assessed participant level results from the first 4 years of the NDPP

• Data from 14, 747 adults enrolled in the year-long program 2/2012-1/2016 (all curricula)

• Average weight loss was 4% • 35.5% achieved the 5% weight loss goal

• Participants reported a weekly average of 152 minutes of PA • 41.8% met the PA goal of 150 minutes/week

Ely, EK, et. Al, A National Effort to Prevent Type 2 Diabetes: Participant-Level Evaluation of CDC's National Diabetes Prevention Program, Diabetes Care, 2017 May 12..

National DPP Evaluation - 2017

Type 2 Diabetes Prevention Evidence Summary

Part 2: Rationale and Goals for Dietary Behavior

Change to Prevent or Delay Type 2 Diabetes

What is the DPP-GLB dietary approach?

To achieve weight loss of about 1-2 pounds per week:

Reduce calorie intake to 1200 – 2000 per day (according to baseline weight)

Reduce fat intake to <30% of total calories (goal is 25%)

Good starting point. Can always be adapted

Why the 25% calories from fat goal?

Supports a decrease in:

Total energy intake* (primary reason)

BMI

Waist circumference (central body fat)

Likely to improve:

Insulin sensitivity

“Broad spectrum” health risk factors

Many studies support a reduced-fat dietary approach

A “westernized” eating pattern (red and processed meats, refined grains, fried foods, high fat dairy and desserts) are linked to higher weight and CVD risk

A “prudent” eating pattern (high in whole or plant-based foods) has been shown to be protective

Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet. 2014

Why the 7% weight loss goal?

Safe and achievable

Feasible interventions are available

Likely to prevent/delay diabetes

Likely to produce other broad spectrum health benefits

Modest weight loss is feasible Behavioral weight control studies have shown*

(1974-present):

Up to 10% loss at 6 months

Longer duration treatments = more weight loss

More contacts = slower rate of regain

Large multi-site trials, more diverse samples (e.g. DPP) have shown:

5%-7% average weight loss at 3+ years

*Wadden et al. Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy. Circulation 2012; 125: 1157-70.

Perri et al. Relapse prevention training and problem-solving therapy in the long-term

management of obesity, Journal Consulting Clinical Psychology 2001; 69: 722–726.

Weight loss is a strong predictor of reduced diabetes risk

In DPP, each kilogram of weight loss was associated with 16% reduction in diabetes risk

Lower percent calories from fat predicted weight loss

Increased physical activity predicted weight loss more strongly over time

Hamman et al, Diabetes Care 2006; 29: 2102–2107, 2006

How did the weight loss happen? DPP calorie and fat changes

At 1 year:

Mean change in calories

450/day (from 2137 to 1687)

Mean percent calories from fat

6.6% (from 34.1% to 27.5%)

A good dose of lifestyle

treatment has a basic delivery sequence

1-8: Self-management of diet, physical activity, weight, cues in the environment

9-16: Psychological and behavioral skills for ongoing problem solving and support

What contributed to the overall success of the DPP lifestyle

intervention? 1. Goal based 2. Standardized sequence 3. Well trained “lifestyle coaches” 4. Less frequent but regular contact post

initial curriculum delivery 5. Toolbox for struggling participants

(least costly options prior to more costly)

6. Tailoring to address ethnic/cultural differences (but fidelity to behavioral approach)

7. Training, feedback, and clinical support for intervention teams (locally, nationally)

Diabetes Risk Reduction Primary Care:

Evaluation of the Ontario Primary Care Diabetes

Prevention Program Dr. Michael Hillmer, Executive Director

Information Management Data and Analytics (IMDA)

Health System Information Management Division

Ontario Ministry of Health and Long-Term Care

November 2nd, 2017

Publication Link

https://www.ncbi.nlm.nih.gov/m/pubmed/28621654/

ADAPTING THE GLB TO

WORK FOR ONTARIANS Sarah Pink,

Registered Dietitian

Mount Forest Family Health Team

PCDPP/GLB Master Trainer

Canadian Content and Guidelines

• Canada’s Food Guide

• Canadian Resources – cookbooks, websites, tracking

tools

Post-Core Session Frequency

• Post Core – Bi-weekly vs Monthly

• Improved retention rates

• Possible explanations why this worked?

• Less time between sessions to forget about class time

• Less time between missed sessions. Possible feelings of no longer

being part of the group

• More frequent accountability

• Possible drawbacks

• Shorter program duration ? Effect on maintenance of behaviour

change over long term.

• Some sites added additional follow up sessions

Expanding Eligibility

• Diabetes Prevention

• Those with pre-diabetes classification

• Diabetes Prevention and general healthy lifestyle program

• Those with pre-diabetes, those at high risk of developing diabetes

(CAN-RISK assessment), and those interested in making healthy

lifestyle changes

• Diabetes prevention and healthy lifestyle program

including those living with Chronic Disease

• Those at risk of DM, those interested in changing and those living

with diabetes and cardiovascular disease

Why Expand?

• Primary care is inclusive of all health conditions from

wellness to living with chronic disease

• Putting programs into silos can limit the service to some

who may benefit

• Expand the use of FHT resources to a broader audience

to use resources more efficiently

• GLB is built on teaching overall healthy eating activity

guidelines set for healthy lifestyle.

Weight Loss Targets

• The GLB program goals include weight loss of 7% body

weight

• The PCDPP encourages weight loss between 5-10% to

better match the Diabetes Canada Clinical Practice

Guidelines

Food-Focused vs Nutrient Focused

Messages

Why shift?

• HAES – Health At Every Size

• Negatives of calorie counting and eating

disorder/disordered eating awareness

• Benefits of teaching self awareness tools to guide

nutrition and lifestyle decisions.

• Shift in nutrition guidelines from nutrients to overall diet

patterns to prevent and manage chronic disease

• Better matches other programing across the province on

food skills/food literacy

Including Food Focused messages

• Remove weight loss targets from the session handouts • focus on behaviour change goals of the program (eat well and

increase activity to 150 min /week)

• Discuss benefits and drawbacks of calorie counting with participants. Give them a choice about using this tool. • Have participants journal without use of calories. (hunger fullness

scales, other nutrient information (fiber, food guide portions, balanced plate etc..)

• Focus on self awareness tools for monitoring early on in the program and remind participants to use them throughout • Mindfullness, hunger/satiety, triggers (external and internal)

• Change focus from tipping the calorie balance planning ahead for success (menu planning and planning ahead activity)

Including Food Focused Messages

• Include the programs additional resources on healthy

cooking, tips and recipes early on in the program and

repeat them throughout

• Add in food demos, recipe swaps, food samples etc..

• Some sites included follow up cooking classes as part of

their ongoing support for their GLB participants.

Conclusion

• GLB has been used in various organizations and sites across

the US and Canada with adaptions made to make the program

model work

• In Ontario the most consistent adaptations included

• Canadian content

• Frequency of sessions

• Program eligibility

• Weight loss targets

• Many RDs who have been involved with the program adapted

some of the language and focused more strongly on building

food literacy and a mindful approach to a healthy lifestyle

Implementing the GLB in Mount Forest

Diane Horrigan

Nurse Clinician

Mount Forest Family Health Team

PCDPP/GLB Master Trainer

Mount Forest was Pilot site in 2011 for the Primary Care Diabetes Prevention Program

Recruitment of participants included educating the staff on the GLB program and getting by in from the Physicians and NP’s.

Greatest referrals were self referrals

Larger numbers

Higher motivation and readiness to change

Word of mouth is a powerful tool

Open referrals

any health care professional including primary care provider

Community referrals

– local gyms/fitness programs

Experiences

We have run the program at our Family Health

Team

Churches

Library

Back of stores

Organizations

Condo buildings

or where ever we could find free space.

Any allied health care professional can be a lifestyle coach. We have an RD and a Nurse Clinician as Lifestyle coaches.

Check in with local libraries for resources

Search out expertise in your team and within your community

Registered Dietitians

Physiotherapists

Group/personal trainers

Mental health therapists

Social Workers

Laughter clubs

Local fitness facilities

Local activity experts

Kinesiologists

Physiotherapists

Personal Trainings

Group fitness instructors

Have guests come in to demo what they are doing

in the community

Partnerships for Activity are Key

Set realistic expectations

Post Core – Bi-weekly vs Monthly

Try offering a variety of times

Day and night time, allow people to attend both sessions

Catch up classes, individual appointments, telephone calls.

Reminder calls, emails or come back letters

Admin time is essential for this

Offer different locations for the classes to reduce barriers for participants.

Retention

Search out expertise in your team and within your community

Turn Key Program

Evidence based and well researched

Ongoing support from Ontario and the US programs

Program updated regularly with new evidence and resources

Activity goals are more likely to be reached and maintained when people have supervised activity sessions

Any allied health care professional can be a lifestyle coach

Works in rural and urban settings

Adaptable

Lessons Learned

There are 4 Master Trainers in Ontario

Training available in Ontario for minimal cost

To date we have trained 44 Lifestyle coaches in Ontario

Those trained include:

FHTs

Public Health Unit

Community Mental Health

Community Health Centers

Dieticians, Nurses, Health Educators, CDE’s, Mental

Health Workers

GLB Lifestyle Coach Training

Owen Sound

Bancroft

Markham

St Catharines

East Elgin

Timiskaming

Kirkland Lake

Sites Trained

PCDPP-Group Lifestyle Balance (GLB) Program

training is a 2 day training workshop

Completing training certifies you as a GLB Lifestyle

Coach and equips you with the knowledge and

understanding needed to run the Group Lifestyle

Balance program.

On-site training - all 4 Master Trainers will attend

on site

One Master Trainer on site at the training site and

the other Master Trainers via OTN/PCVC.

Training via OTN/PCVC.

Training

Master Trainers will look after coordinating the enrollment with the University of Pittsburgh.

After completing training you will be registered with the Diabetes Prevention Support Center at the University of Pittsburgh.

This portal will give you access to all GLB materials and resources needed to start the GLB program

Training includes all trainers prep time, and delivery of presentation. Sites will be responsible for photocopying of manuals and any additional materials that may be needed. An electronic copy will be provided to you for printing.

For on-site training; sites will be billed for travel time, accommodations and any meals that may be incurred.

Thank you

Introducing an Implementation Manual

• Supported by the MOHLTC

• Developed in collaboration

with the NRC, PARC, and

PCDPP demonstration sites

• Process included leveraging

an advisory committee of

relevant subject-matter

experts

• PCDPP MTs/LCs and

program managers

• MOHLTC advisors

• External primary care and

health promotion experts

• We acknowledge the UPDPSC

for provision and use of DPP-

Group Lifestyle BalanceTM

Manual available from the NRC Navigator: Ontario’s PCDPP - Implementation Manual for Your Primary Care Organization

How to Use the Manual

• The PCDPP and the implementation manual is based on

UPDPSC’s Group Lifestyle BalanceTM (GLB) program, however, it is

NOT intended to replace GLB materials

• The PCDPP implementation manual was developed for:

• Administrators, decision-makers, health promotion and

health/allied health professionals responsible for primary care

diabetes and chronic disease prevention

Purpose of the Manual:

• Support effective and efficient implementation of PCDPP in a

variety of primary care organizations

• Provide examples, strategies, considerations, and testimonials – all

from an Ontario context

Manual available from the NRC Navigator: Ontario’s PCDPP - Implementation Manual for Your Primary Care Organization

PCDPP Implementation Manual

Ten key sections to support decision-making, planning,

implementation and evaluation

1. How to Use the Manual

2. Executive Summary

3. Program Overview

4. Program Logistics for Getting Started

5. Participant Recruitment and Promotion Strategies

6. Implementation Considerations

7. Program Evaluation

8. Participant Outcomes and Lasting Change

Practice-based experience from Ontario’s PCDPP is featured in each section:

lessons learned, implementation considerations, testimonials, and strategies

to take action

Manual available from the NRC Navigator: Ontario’s PCDPP - Implementation Manual for Your Primary Care Organization

Program Logistics for Getting Started

Provides the essential start-up, decision-making and planning information for

administrators and program staff, for example:

• Participant volume expectations

• Staffing required for PCDPP

• Full-time equivalents expectations

• Responsibilities of lifestyle coaches and administration support

• Considerations when staffing interdisciplinary lifestyle coaches

• Suggestions for cost savings that maintains program quality assurance

• Staffing model examples

• Timing of sessions – adjusting timing to improve attendance/retention

• Location and space required, room lay out, session materials

• Estimated costs

• Managing resources, cost savings and value-adds identified by PCDPP

sites

With a focus on improving healthy eating and physical activity behaviours, all pilot sites reported it

beneficial to have lifestyle coaches with healthy eating and physical activity expertise

PCDPP found that partnering with local community groups, municipality offices/buildings, and

businesses offered cost-saving space solutions and/or space available free of charge

Participant Recruitment and Promotion Strategies

Recruitment strategies for:

• Internal referral system

• External referral system

• Self-referral

• Diabetes risk screening

Promotion strategies

Planning and Implementation

Retention Challenges

• Referral gaps created issues with retention

• Length/timing throughout the year

• Frequency of classes during the maintenance phase

• Timing of sessions offered

• Weather

• Healthy eating and nutrition support

• Physical activity support

• Group size

• Participants’ personal/social circumstances

Questions?

Donna Smith Policy and Program Consultant Nutrition Resource Centre Ontario Public Health Association Dsmith@opha.on.ca

www.nutritionrc.ca