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Diabetes is a growing health concern among those in rural locations. Rural residents smoke more, exercise less, have less nutritious diets and are more likely to be obese than urban residents. Evidence-based diabetes prevention programs targeting behavior change are available to this population yet participation remains low. This study examined the self-reported barriers and health beliefs of those who declined participation in a diabetes prevention program (DPP). Of 269 clients identified to be at risk for developing Type II Diabetes (T2D), only 85 answered the phone and 33 were interviewed to discuss their health beliefs and reasons for not participating in a diabetes prevention program. Almost half of the participants who expressed their lack of desire to participate in the DPP cited a low level of interest and not seeing any personal benefit as their primary reasons. Participants were closed off when asked what it would take to get them to participate in the program with 63% citing “nothing” as the most common answer when questioned as to what would encourage their participation. In order to limit barriers to participation in prevention-based programs for rural populations special attention needs to address improving general interest and knowledge about the efficacy of a DPP.

Master of Public Health / OBJECTIVES: In Australia, diabetes causes significant morbidity and mortality. Whilst the need to prevent diabetes and its complications has been widely recognised, the capacity of health care systems - which organise diabetes care - to facilitate prevention has not been fully established. METHODS: A series of seven population-based case-control studies were used to examine the effectiveness of the Australian health care system and its capacity to manage diabetes. Six of the studies compared the patterns of care of patients who had developed advanced diabetes complications in 2000 (cases), to similar patients who remained free of the condition (controls) across Australia and for various risk groups. A secondary study investigated the role of treating GPs in the development of the outcome. RESULTS: A strong relationship between the patterns of care and the development of advanced diabetes complications was found and is described in Chapter 4. In Chapter 5, this same relationship was investigated for each Australian state and territory, and similar findings were made. The study in Chapter 6 investigated whether late diagnosis or the patterns of care was the stronger risk factor for advanced diabetes complications, finding that the greatest risk was associated with the latter. In Chapter 7 the influence of medical care during the pre-diagnosis period was explored, and a strong relationship between care obtained in this period and the development of advanced complications was found. In Chapter 8, which investigated the role of socio-economic status in the development of advanced complications, found that the risk of advanced diabetes complications was higher in low socio-economic groups. Chapter 9 investigated geographic isolation and the development of advanced diabetes complications and found that the risk of advanced complications was higher in geographically isolated populations. Finally, Chapter 10, which utilised a provider database, found that some GP characteristics were associated with the development of advanced diabetes complications in patients. CONCLUSION: A number of major risk factors for the development of advanced complications in Australia was found. These related to poorer diabetes management, later diagnosis, low socioeconomic status and geographic isolation. Strategies must be devised to promote effective diabetes management and the early diagnosis of diabetes across the Australian population.

Gestational diabetes mellitus is a risk factor for future diabetes, a condition largely preventable by healthy eating, increased physical activity and weight management. Postpartum women with young children face many barriers to adopting healthy lifestyle programs including time constraints, multiple commitments, tiredness and resuming work. Clearly, to prevent diabetes occurring health professionals need to understand how to help post-partum women adopt healthy lifestyles. Behaviour change occurs in five stages and matching healthy lifestyle information to stage of change can promote readiness to change. The aim of the current study was to identify whether a stage-matched intervention could promote diabetes risk reduction behaviours in a cohort of women with previous GDM in the Goulburn Murray catchment area. A total of 210 eligible women, identified from medical records as GDM in the past five years were invited to participate in a healthy lifestyle program incorporating stage-matched information reinforced with telephone contact or to receive routine information only. / Data were collected via a mailed health behaviour questionnaire incorporating validated tools; the Active Australia Survey, Stage of Change tool and Fat and Fibre questionnaire at baseline and post-intervention. At follow-up women answered a series of open-ended questions describing the promoters of and the barriers to behaviour change. Results were coded and analysed using Statistical Package for the Social Sciences (Version 14). Seventy-seven women (mean age 35 years) agreed to participate and were randomly assigned to a treatment or control group. Eighty-eight percent completed the six-month assessment. The attrition rate was similar in both groups. There was a positive trend towards increased readiness to be active (progression of one or more stages, p< 0.05) in the intervention group compared to standard information only. There was no difference between groups in progression of stage readiness to reduce fat intake or lose weight. Both groups increased the total amount of activity undertaken by approximately 60 minutes per week and the proportion of women meeting activity guidelines increased to a similar extent in each group. There was minimal difference between the groups for weight loss or reducing fat intake. The women stressed the importance of having a goal, especially a health goal, and strong social support as important promoters of health behaviour change. In contrast, low mood, emotional eating, tiredness, lack of time and support reduced the likelihood that behaviour change would occur. / Conclusion: It is possible to implement and meaningfully evaluate an intervention incorporating stage-matched information and regular telephone reminder calls for women with a history of GDM. Despite the small sample size, this intervention can increase readiness to be more active compared to routine health promotion information. However, the intervention was unable to produce any difference between the groups in engagement in any of the diabetes risk reduction behaviours measured. Further research is needed to explore these findings in a larger population, such as with a multi-centre study. The intervention should be enhanced with strategies to address social support, post-natal depression, self-efficacy for behaviour change, mood and emotional eating.

Master of Public Health / OBJECTIVES: In Australia, diabetes causes significant morbidity and mortality. Whilst the need to prevent diabetes and its complications has been widely recognised, the capacity of health care systems - which organise diabetes care - to facilitate prevention has not been fully established. METHODS: A series of seven population-based case-control studies were used to examine the effectiveness of the Australian health care system and its capacity to manage diabetes. Six of the studies compared the patterns of care of patients who had developed advanced diabetes complications in 2000 (cases), to similar patients who remained free of the condition (controls) across Australia and for various risk groups. A secondary study investigated the role of treating GPs in the development of the outcome. RESULTS: A strong relationship between the patterns of care and the development of advanced diabetes complications was found and is described in Chapter 4. In Chapter 5, this same relationship was investigated for each Australian state and territory, and similar findings were made. The study in Chapter 6 investigated whether late diagnosis or the patterns of care was the stronger risk factor for advanced diabetes complications, finding that the greatest risk was associated with the latter. In Chapter 7 the influence of medical care during the pre-diagnosis period was explored, and a strong relationship between care obtained in this period and the development of advanced complications was found. In Chapter 8, which investigated the role of socio-economic status in the development of advanced complications, found that the risk of advanced diabetes complications was higher in low socio-economic groups. Chapter 9 investigated geographic isolation and the development of advanced diabetes complications and found that the risk of advanced complications was higher in geographically isolated populations. Finally, Chapter 10, which utilised a provider database, found that some GP characteristics were associated with the development of advanced diabetes complications in patients. CONCLUSION: A number of major risk factors for the development of advanced complications in Australia was found. These related to poorer diabetes management, later diagnosis, low socioeconomic status and geographic isolation. Strategies must be devised to promote effective diabetes management and the early diagnosis of diabetes across the Australian population.

Type 2 diabetes mellitus (DM) is a progressive disease characterised by hyperglycaemia caused by defects in insulin secretion and insulin action. In early stages of type 2 DM, dietary and lifestyle changes are often sufficient to control blood glucose levels. However, over time, many patients experience β cell dysfunction and require insulin therapy, either alone or in combination with oral agents. There are guidelines available to structure the management of this disease state, including both the use of oral hypoglycaemic agents and or insulin. Besides health complications, there are economic burdens associated with the management of type 2 diabetes mellitus. The aim of this study was to determine the management of type 2 DM in a South African sample group of patients drawn from a large medical aid database. The objectives of the study were: to establish the prevalence of type 2 DM relative to age, examine the nature of chronic comorbid disease states, establish trends in the prescribing of insulin relative to other oral hypoglycaemic agents, investigate cost implications, and determine trends in the use of blood and urine monitoring materials by patients. The study was quantitative and retrospective and descriptive statistics were used in the analysis. DM was found to be most prevalent amongst patients between 50 and 59 years old. Results also demonstrated that 83% of DM patients also suffered from other chronic comorbid diseases, with cardiovascular diseases, especially hypertension and hypercholesterolaemia being the most prominent. This study also revealed that DM is predominantly managed with oral hypoglycaemic agents. Changes in drug prescribing, for chronic disease states such as DM may have medical, social and economic implications both for individual patients and for society and it is envisaged that the results of this study can be used to influence future management of DM. Keywords: Pharmacoepidemiology, management, type 2 diabetes mellitus

Background. Type 2 diabetes is the fifth-leading cause of death in Latinos in the United States. Diabetes is a commonly occurring health condition in older adults, leading to complications that can severely impact quality of life and hasten death. The burden of diabetes is considerable in the older adult population; almost four-fifths of adults with diabetes are older than 59 years. Diabetes mortality can be reduced or delayed with effective management of the illness. Older minority adults are more likely to have higher rates of adult-onset diabetes than non-Hispanic Whites, yet few studies have examined the diabetes self-management practices of this group. These issues are particularly important to investigate in older Dominican adults in Washington Heights/Inwood, New York City, because this group has unique cultural beliefs and practices, is rapidly increasing in population, and has a variety of unmet health-related needs. This study explored specific barriers encountered (cultural and structural) and the extent to which external factors are associated with self-management practices among older Dominican community residents living in mainland US with type 2 diabetes. After 20 years of health disparities research and intervention older adults continue to have problems accessing health care due to structural and socio-cultural barriers. Methods. This investigation utilized qualitative in-depth interviews to examine the cultural and structural barriers to health care and self-management practices existing in this group. Results. Thirty Dominicans 55 years and older were recruited through a community-based senior resource center from the mainland US. Self-management practices for type 2 diabetes vary and are represented by commonly known factors, including: 1) diet modifications; 2) glucose monitoring; 3) medication adherence; 4) exercise, and 5) diabetes classes. Findings from this study illustrate that male and female participants have mixed self-management practices that assist them in managing their diabetes. In addition, participants are interested in “learning” how to manage their diabetes through their participation in classes and diabetes-related workshops. Home remedies (remedies caseros) for type 2 diabetes were identified in this study. Conclusions. Programs and services that promote healthy self-management practices of older Latino adults need to include a focus on the unique cultural beliefs and behaviors of the individual as well as the broader situational context that impacts their diabetes self-management. Such information is invaluable for researchers and health practitioners interested in diabetes self-management practices of older minority adults.

While the strict boundaries and ideal measurement of prediabetes remain contested internationally, health officials and private donors in the health sector in Mexico have promoted its diagnosis and treatment as a key strategy in the nation’s fight against diabetes. This dissertation examines the circumstances under which officials have come to view prediabetes diagnosis as a feasible strategy for the Mexican context and the implications of treating individuals, situated across deep lines of social inequality, who are not yet sick, but deemed at risk of developing disease. Set against Mexico’s chronic disease crisis, where diabetes was declared a national sanitary emergency in 2016 and where experts suggest up to 40% of adults likely have prediabetes, this dissertation engages the prediabetes diagnosis as a lens through which to illuminate the social forces, values, and assumptions currently at work in Mexican health politics. The project foregrounds the dilemmas raised by highly medicalized and clinic-based approaches to chronic disease prevention and mobilizes the case of prediabetes in Mexico to illustrate the broader convergence of the fields of biomedicine and public health. Centered in Mexico City, field research for this project was carried out over 30 months, employing multi-sited ethnographic methods, including 106 in-depth interviews (47 of which were with individuals diagnosed with prediabetes and their families), observations of 382 medical exams, and attendance at 71 scientific, community health, and activist-hosted events. Alongside the powerful influence of the pharmaceutical industry, my findings bring to the fore a new set of actors and circumstances involved in the circulation of predisease diagnosis to this developing country context. These include (1) the epistemological limits imposed by “projectification” in global health science, (2) the influence and ideologies of an elite-mega philanthropist and his Foundation’s conviction that technological innovation will foster better health, and (3) local and global imaginaries that endorse the power of Big Data analytics to solve a plethora of development challenges. Further, in tracing the enactment of the prediabetes diagnosis across public and private clinics, I show that the pre-disease condition that economic elites experience when they are diagnosed contrasts sharply with that experienced by working class and low-income patients—I argue that in practice, prediabetes is multiple and its diagnosis amplifies existing social inequities. I also show that the emotional and ethical responses to the diagnosis among patients can differ substantially, particularly across socioeconomic divides. I argue that in Mexico, increased access to risk knowledge does not foster a spirit of “optimization” among the majority of Mexicans, but rather an alternative ethic, which I term “strategic preservation.” Finally, I show that many health experts in Mexico share a common set of values and norms in thinking about diabetes risk. On a macro level, they discursively link the looming threat of prediabetes, diabetes risk, and diabetes itself to the nation’s potentially disastrous macroeconomic future, effectively charging individuals with the responsibility to mitigate this threat through behavior and lifestyle modification. Health experts in this arena also frequently communicate the notion that the Mexican body itself is a key source of diabetes risk. I point to other elites in Mexico who, relying on a similar conception of the Mexican body, are investing in molecular technologies to better detect embodied diabetes risk, and to expand the reach and precision of medicalized prevention strategies in the future. These findings have implications for developing countries globally, which now bear the highest burden of chronic disease. Developing countries are already or will soon grapple with a similar epidemiological crisis and, as this occurs, Mexico’s strategies and experience will set precedents and establish key paradigms for public health action globally. With this in mind, I call for the disentanglement of expertise between the fields of biomedicine and public health and for a turn toward more structural, indeed socially radical, policies for chronic disease prevention at the population level.

Worldwide, there were 463 million adults (20-79 years) with diabetes in 2019. These figures are expected to increase to 700 million by 2045. Additionally, approximately 4.2 million deaths worldwide were attributable to diabetes, and global health care expenditures on individuals with diabetes were estimated to be 760 billion U.S. dollars. One of the most effective ways to control this debilitating disease is to prevent it before it happens, which, based on evidence from the Diabetes Prevention Program (DPP) randomized controlled trial and other studies in different countries, is feasible with a change in weight, dietary habits, and physical activity levels. While many studies have shown the benefits of plant-based diets in diabetes prevention, no DPP studies have been found that have incorporated a plant-based diet for their dietary component. The purpose of this pilot study was to explore the feasibility, acceptability, and preliminary efficacy of implementing a worksite plant-based diabetes prevention program to inform larger randomized trials to be conducted in the future. This was a mixed-methods pilot study using a one group pretest-posttest design. The study was delivered to Teachers College, Columbia University employees and staff and was designed to use a modified version of the CDC’s national curriculum, one that emphasizes plant-based eating patterns. The sessions ran during lunch hour where a healthy lunch that supported the behavior change goal of the session was provided. The Health Action Process Approach (HAPA) framework was used for both curriculum design and program evaluation. The principles of facilitated group discussion in a safe environment were used to deliver the sessions. The program was conducted in the spring semester of 2020, once a week, for a series of 13 weeks plus two voluntary booster sessions held 1 and 2 months after the program was completed. Midway through the semester, the program went virtual using synchronous video-conferencing technology due to the COVID-19 pandemic. Data on consumption of healthy and unhealthy plant- and animal-based foods, physical activity, and psychosocial variables were measured pre and post program using validated questionnaires; blood glucose values were measured as HbA1c using A1CNow® SELFCHECK; and weights were measured weekly using Tanita SC-331S scales when classes were in-person and home scales when classes went virtual. Evaluations of participants’ acceptability and satisfaction were assessed at the end of the program both quantitatively and through interviews. Finally, fidelity to the plant-based curriculum and evaluation of educational plan completion and engagement were done weekly. Forty-one individuals expressed interest in the study, but only 18 met the eligibility criteria, of whom 14 were finally enrolled, constituting 78%. The participants were ethnically/racially diverse. Attrition was very low with only one dropout, and this did not change when the program went virtual. Program delivery was in fact feasible and all 13 lessons and booster sessions were completed. The plant-based DPP was received with a high degree of acceptability and satisfaction by the participants. Participants described the safe environment created and the facilitated dialogue approach in the sessions, along with peer support as instrumental for their behavior changes. There were some significant improvements in the physiological, behavioral, and psychosocial outcome measures explored in the study which included: weight, diet quality in terms of plant-based and animal-based foods, physical activity levels, blood glucose levels, and behavioral and psychosocial determinants of behavior change of the Health Action Process Approach (HAPA) theoretical framework. After study completion and analysis of results, it is clear that conducting a worksite plant-based diabetes prevention program is in fact feasible and acceptable, and may be efficacious at eliciting positive changes in physiological, behavioral, and psychosocial variables that can potentially attenuate risk of developing diabetes. The findings will be useful for designing larger controlled studies.