BACKGROUND AND RATIONALE

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West Virginians are disproportionately burdened by diabetes with approximately 12% of the population having been diagnosed with diabetes (www.wvdiabetes.org). Diabetes is associated with many micro- and macro-vascular complications and leads to increased risk for blindness, stroke, heart attack, lower limb amputation, and kidney failure. It carries high costs to individuals and society (1,2). In addition, approximately 466,000 individuals have pre-diabetes [or elevated blood sugar level 100-125 mg/dl] (www.altfutures.org/diabetes2025). Factors that contribute for high rates of diagnosed and undiagnosed diabetes and pre-diabetes in West Virginia include geography, lack of access to quality care, aging population, and the Appalachian culture. Obesity, physical inactivity, and smoking are also contributing factors. 

Although diabetes and its resulting complications are of grave concern in W.Va., evidence that behavioral lifestyle intervention can decrease weight, improve diet, increase physical activity, and prevent or delay the development of type 2 diabetes and reduce risk for cardiovascular disease has been demonstrated in the U.S. Diabetes Prevention Program (DPP)(3). While the DPP clinical trial demonstrated a reduction in the incidence (new cases) of type 2 diabetes with lifestyle intervention or the drug, metformin, lifestyle intervention was more effective in preventing or delaying onset of diabetes compared to metformin (58% vs. 31% respectively). The DPP lifestyle intervention was shown to be effective in both genders, all races/ethnicities, and across all age groups, particularly in those aged 60 and older (3).

    The Diabetes Prevention Program was a large, multi-center clinical trial that randomized adults with pre-diabetes to one of three interventions: intensive lifestyle intervention, metformin therapy, or placebo control. The intensive lifestyle intervention was delivered by individual case managers (lifestyle coaches) and included individual and group sessions; training in diet, exercise, behavior modification skills, and supervised bi-weekly group exercise sessions (4). Ten-year follow-up showed that the lifestyle intervention group maintained a 34% lower incidence of diabetes compared to placebo (5). While the costs of the lifestyle intervention were considered modest at $3,540 per participant over three years (6), others believed the program to be cost-prohibitive for most health plans (7). There was a need to find a more cost-effective method for program delivery. Researchers at the University of Indiana partnered with the YMCA to translate the DPP lifestyle intervention program to a group-based, community setting using YMCA trainers to deliver the program (8, 9). At six months, the intervention group had greater decreases in body weight compared to controls (6% v. 2%, p<0.001) and these differences were maintained at 12 months. 

    The authors concluded that the YMCA was a potential avenue for broad dissemination of the program at lower cost. In similar studies, credentialed diabetes educators who worked in established community-based diabetes self-management education programs were trained to deliver a modified version of the DPP called the Group Lifestyle Balance (GLB) program (10). They reported significant decreases in weight, waist circumference, and body mass index at 3 months compared to baseline in the entire group (n=81) as well as in those who completed the series of classes (n=68). Community health workers with well-controlled diabetes were trained as lifestyle coaches to deliver the DPP through an established diabetes education program in North Carolina (11). Program participants had significantly greater weight loss (7.2% vs. 1.3%, p<0.001) and decreases in fasting glucose levels (-4.3 vs. -0.4 mg/dL, p<0.001) compared to controls. 

    West Virginia is the only state entirely within Appalachia, a region of geographic isolation, mountainous terrain, and economic underdevelopment. Striking health disparities exist in WV, and it ranks among the highest among all states in diabetes (1st), obesity (4th), and depression (1st), which may in part be attributed to insufficient health care resources and a shortage of healthcare providers.6 The NIH identifies Appalachians and other rural residents as populations with significant health disparities. Chronic conditions among rural adults (46.7%) are higher than they are among those in urban areas (39.2%). Similarly, the low socioeconomic populations of WV are at increased risk for mortality, morbidity, unhealthy behaviors,7 and reduced access to health care and inadequate quality of care.

    The CDC’s 2011 Health Disparities and Inequalities Report notes that health disparities are also associated with poverty and lower educational attainment.8 These conditions abound in WV, where two-thirds of its 1.8 million people live in communities with fewer than 2,500 residents, and 49 of 55 counties are designated fully or in part as Health Professional Shortage Areas and/or Medically Underserved Areas. WV ranks fifth in the percent of people (17.6%) living at or below the poverty level, 36th in the percent of adults aged 25 to 64 with only a high school diploma (86.0%), and 50th in adults with a bachelor’s degree or higher (18.7%). Disparagingly, in 2008, 8 of the 10 leading causes of death in WV were chronic diseases. In 2009, WV ranked poorest nationally in coronary artery disease, heart attacks, hypertension, current smoking, and no exercise.

Diabetes rates in West Virginia. WV ranks second in the nation in diabetes prevalence. West Virginians also experience a higher prevalence of co-morbid cardiovascular conditions such as obesity, physical inactivity, hypertension, and hyperlipidemia that puts them at risk for diabetes and complications thereafter. The WV Community Genetics Project established a model of community engagement centered on FHH and the concept of epigenetics to educate and develop partnerships to empower WV communities to promote healthy behavior change. This project has laid the groundwork for developing educational initiatives and extending genomic research projects into our rural Appalachian communities to address the prevalent health disparities in our state. The state ranked 2nd highest incidence in diabetes, 4th in stroke, and 6th in obesity. Poor nutrition, smoking, and physical inactivity are “the big three” chronic disease risk factors that individually and synergistically are implicated in all of chronic diseases found in the state. The CDC estimates that eliminating these three risk factors would prevent 80% of heart disease and stroke, 80% of type 2 diabetes, and 40% of cancer.