Magister Public Health - MPH / In this study a process evaluation of the action planning process of the HealthKick programme in disadvantaged primary school settings in the Western Cape was conducted. A qualitative methodology was adopted to best determine the experiences of the participants and the underlying factors involved. Four schools were randomly selected to participate. Four focus group discussions were conducted with educators, and four in-depth interviews were conducted with principals and champions at schools, (champions are either an educator or school governing body member selected to be the driver of the project at each school, as well as the liaison person between the school and the HealthKick project team). Semi-structured interview guides were used to steer the discussions. Interviews and focus groups were audio taped and transcribed verbatim. The data was thematically analysed with the assistance of Atlas ti computer software. The results of this study indicated that the action planning process did not take place as designed by the project team. Several challenges were identified and experienced by participants. The results further indicated that the challenges of time, workload and competing priorities were intrinsically linked. Positive experiences were also reported and various enablers to the process were identified, such as the facilitation process, the receipt of the resource toolkit as well as the complementary nature of the HealthKick curriculum to the normal academic curriculum. / South Africa

Approximately 8.3% of the U. S. population has type 2 diabetes. Preventing the onset and improving the management type 2 diabetes are crucial for health care professionals. The purpose of this project was to develop and evaluate a type 2 diabetes prevention and management education program in a primary care setting using group medical appointments (GMAs). The chronic care model provided the framework for the study. The education program consisted of information from the Centers for Disease Control on the management of type 2 diabetes to be delivered by clinic staff using a GMA approach, a timeline for implementing the education program, and evaluation strategies for assessing patient health outcomes. Staff participants included 9 females and 1 male. One week after the presentation, staff responded to open-ended questions addressing the plan for prevention and management of type 2 diabetes. Findings indicated that staff unanimously approved the content of the program, thought the program could realistically be implemented, thought the proposed evaluation methods were appropriate, and thought the program would have a positive influence on patient health outcomes. Prevention and management education programs using a GMA approach may be used to reduce incidence and improve management of type 2 diabetes.

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This research focuses on obesity and other major risk factors for chronic diseases such as Type II Diabetes Mellitus, Heart Disease, and Stroke. Worksite wellness programs have been successful in this realm of health promotion and disease prevention for heart disease and stroke, but their effectiveness in treating diabetes has been uncertain partially due to poor patient compliance, lack of stress reduction strategies, poor diet and lack of persuasive health education on the risk of being obese. Published peer-reviewed articles were reviewed, coded and analyzed to determine best practices, using a modified systematic review approach. The findings from these studies yield results that were used to develop a new employer-sponsored wellness program that is in accordance with the recently passed Affordable Care Act. / Includes bibliography. / Thesis (M.S.)--Florida Atlantic University, 2014. / FAU Electronic Theses and Dissertations Collection

Bakgrund: Diabetes Mellitus typ I är ett globalt hälsoproblem som skördar många liv varje år och påverkar livskvaliteten för de drabbade. Diabetes typ I är en autoimmun sjukdom som leder till destruktion av insulinproducerande betaceller i pankreas och således rubbad glukosreglering. Huvudsakliga patogena immunceller inkluderar autoantikroppar, exempelvis riktade mot glutaminsyra dekarboxylase 65, och autoreaktiva T-celler. Diagnos sker generellt baserat på förhöjda halter plasmaglukos och eventuellt stimulering av C-peptid för att utreda status för den endogena betacellsfunktionen. Diabeteskomplikationer är en vanlig dödsorsak hos diabetespatienter. År 2019 orsakades 4,2 miljoner dödsfall av diabetes eller diabeteskomplikationer. I dagsläget är administrering av exogent insulin enda behandlingsmöjligheten för typ I diabetespatienter. Det har dock länge forskats på alternativ i form av preventiv behandling men i dagsläget finns inga preventiva behandlingar på marknaden. Syfte: Litteraturstudiens syfte var att undersöka prospektiva möjligheter till diabetespreventiv behandling inom områdena glutaminsyra dekarboxylase 65 vaccin och coxsackievirus B vaccin med avseende på effekt samt jämföra dessa två prospektiva behandlingsmöjligheter. Metod: Arbetet har utförts genom granskning av artiklar från databasen PubMed. För litteraturgranskning av studier om GAD-behandling valdes tre kliniska studier utifrån sökning med ”type 1 diabetes”, ”diabetes mellitus”, ”type 1”, ”GAD” och ”vaccine” som sökord. För artiklar om CVB och CVB-vaccin användes ”type 1 diabetes”, ”vaccine” och ”coxsackievirus” som sökord. Resultat: Kliniska studier på GAD-behandling visar ingen signifikant skillnad mellan GAD-alum och placebo i helgruppsanalyser. Vid vissa stratifierade analyser för exempelvis kön, ålder, eller antal riskfaktorer detekteras signifikanta skillnader genom ökad mängd stimulerad C-peptid eller progression till klinisk diabetes. Den prospektiva kohortstudien över diabetesincidens påvisar att CVB är en riskfaktor för diabetes hos människa. Vidare visar de prekliniska studierna på signifikant minskad diabetesincidens i CVB-vaccinerade studiepopulationer jämfört med placebo. Slutsats: Varken behandling med GAD-alum eller CVB-vaccin är möjligt att använda som preventiv behandling i nuläget. Dock visar studierna på lovande framtidsmöjligheter för CVB-vaccin som primärprevention och GAD-alum som sekundär- eller tertiärprevention. / Background: Diabetes Mellitus type I is a global health issue, causing numerous deaths each year and also influencing the quality of life of those affected. Type I diabetes is an autoimmune disease where the individuals own immune system causes destruction of insulin producing beta cells in the endocrine islets of pancreas. Main immunological features include, autoantibodies directed towards glutamic acid decarboxylase 65, and autoreactive T-cells. Diagnosis is generally based on elevated levels of plasma glucose and stimulated C-peptide, together disclosing the status of the beta cell function. The lack of endogen insulin causes disturbances in the glucose metabolism which leads to prevailing tissue damage in cells and organs of the diabetic individual’s body. Furthermore, insufficient control of plasma glucose is related to development of diabetes complications. Diabetic complications are known to be a major cause of death in diabetic patients. Diabetes and diabetic complications caused 4,2 million deaths in 2019. Insufficient adherence to treatment regimen during a long period of time is known to increase the risk for some common diabetes complications. Administration of exogenous insulin is the only current treatment available for type I diabetes, albeit recurrent attempts to find a cure or successful preventive treatment for diabetes mellitus type I. Recent promising research on diabetes preventive treatment includes the autoantigen glutamic acid decarboxylase-65 and vaccine against coxsackievirus B. Aim: The purpose of this literature study was to examine prospective possibilities for diabetes preventive treatments. Further, the purpose was to compare the promising preventive treatments of GAD65-vaccine and CVB-vaccine concerning effect and prospective treatment regimens. Methods: The thesis is a literature study based on articles found by searching the database PubMed. Clinical studies examining the effect of GAD-treatment was found by using key words such as ”type 1 diabetes”, ”diabetes mellitus”, ”type 1”, ”GAD” and ”vaccine”. Studies examining the effect of CVB and CVB-vaccines was primarily preclinical and prospective cohort studies, found by searching for the key words ”type 1 diabetes”, ”vaccine” and ”coxsackievirus”. Results: Clinical studies of GAD-treatment does not demonstrate a statistically significant difference between treatment with GAD-alum compared to placebo in full group analysis. Stratified groups occasionally prove significant differences in quantity of stimulated C-peptide or progression to clinical diabetes by age, gender or amount of risk factors for example. The prospective cohort study examining the incidence of diabetes, demonstrates that CVB is a risk factor for type I diabetes in humans. Furthermore, the preclinical studies detect a significant decrease in diabetes incidence in CVB-vaccinated mice compared with placebo. Conclusion: Neither treatment with GAD-alum nor CVB-vaccine is currently ready for use. However, the studies show a promising prospective possibility for CVB-vaccine as a primary prevention and GAD-alum as a secondary or tertiary prevention of type I diabetes.

Indiana University-Purdue University Indianapolis (IUPUI) / Medication adherence remains a problem among Type-2 diabetes (T2D) patients despite availability of effective treatments. Three analyses of extant data sets were conducted to examine barriers to using medication as prescribed as an alternate method to assess medication adherence: 1) development and psychometric evaluation of the Murage-Marrero-Monahan-Medication barriers (4M) scale to assess patients’ perceived barriers; 2) patient demographic factors associated with barriers to using medication as prescribed, and 3) the association between patients’ perceived barriers to medication use and cardiovascular disease (CVD) risk factor control.Twelve focus groups and a cross-sectional study of 362 T2D patients contributed to develop and evaluate psychometric properties of the 4M scale. A cross-sectional survey of 964 T2D patients was used for the other two studies. Analysis of covariance identified demographic factors associated with reported barriers. Multivariable logistic regression was used to identify barriers associated with CVD risk factors (glucose, blood pressure and lipids) categorized as either poor or good control. Exploratory factor analysis with Varimax rotation resulted in a 19-item 4M scale with acceptable psychometric properties. As a five-domain (or single-domain) structure, coefficient alpha ranged from 0.70 to 0.83 (0.92). Both structures demonstrated discriminant validity and known-group validity. Age was inversely associated with all identified barriers while income was inversely associated with poor communication with providers and side effects. A unit increase in the overall barrier mean score on the 4M scale was associated with 92% increase in the odds of having poor control of two or more CVD risk factors compared to good control of all three risk factors (adjusted OR=1.92, 95% CI: 1.16–3.17; p<0.05). The 4M scale demonstrated acceptable psychometric properties in assessing barriers to using medication among T2D patients. Poor medication adherence has been previously associated with CVD risk. In this study, greater barriers were associated with poorer control of CVD risk factors making barriers a potential alternative to medication adherence, whose current assessment methods are limited. The 4M scale has the advantage to identify specific barriers inhibiting medication use that can facilitate patient-provider discussions and the development of targeted interventions. / Some parts of this dissertation work were jointly funded by Program Announcement 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the funding agency(s).

Indiana University-Purdue University Indianapolis (IUPUI) / Diabetes is a significant health problem in the United States which disproportionately affects Native Americans. Despite many new prevention and intervention programs, there has been a prolific increase in the incidence of diabetes among Native Americans. The purpose of this qualitative study was to explore the experience of Coeur d’Alene tribal members living with type 2 diabetes using a Heideggerian hermeneutic framework. Participants were recruited through the local diabetes educator at the tribal clinic using purposive and snowball sampling. Individual interviews were conducted with ten Coeur d’Alene tribal members whom had type 2 diabetes and were willing to share their stories of about living with diabetes. Participants ranged in age from 26-86. Interviews lasted from 25-90 minutes and focused on gathering stories about their daily life with their diabetes, and barriers and supports to their diabetes self-management. These became the data for hermeneutic interpretations. Individual transcripts were read and reread for initial themes. Next, comparisons between and across transcripts were done through interpretive emersion into the texts. Emerging themes and patterns were brought before a group of qualitative nurse researchers and doctoral students as a means of cross-checking and validating interpretations. Perseverance was the overarching pattern in the stories of living with diabetes in the world of Schitsu’umsh. The four themes that emerged under the umbrella of perseverance were valuing tribal traditions, being inattentively caring, struggling with disease burdens, and experiencing tensions in patient-provider relations. Living with diabetes in the world of the Schitsu’umsh was always a tenuous balancing act. There was an ever present dialectic tension between strengths and barriers underlying their daily struggles for balance. By increasing our understanding of Native American experiences of living with diabetes, collaborative partnerships can be developed with the tribes to address these barriers to diabetes self-management and to develop culturally relevant diabetes education programs. There is also a need to address cultural competence by the health care community and to work at eliminating biases and prejudice in our healthcare system. This work brings new cultural understandings of what it means to live with diabetes in one Native American group.

The purpose of this study was twofold. First, the study evaluated Loma Linda University Medical Center's (LLUMC) Diabetes Treatment Center's (DTC) effectiveness in providing diabetes education and services to high risk minority populations. Second, the results of the study helped the DTC determine the need for expanding its present efforts in the form of community health prevention services to San Bernardino County residents.

Le diabète de type 2 (DT2) est une maladie chronique affectant 3 millions de canadiens. Une augmentation progressive de la résistance à l'insuline (RI) et de la sécrétion d'insuline est observée chez des sujets normoglycémiques bien avant la survenue du DT2. La moindre fonction du tissu adipeux blanc (TAB) est centrale dans le développement du DT2 car elle accroît le flux d'acides gras vers les tissus périphériques, y induisant la RI, l'hyperinsulinémie et l’inflammation chronique. Durant ma maîtrise, nous avions démontré que les lipoprotéines de basses densité (LDL) natifs réduisent la différentiation et la fonction des adipocytes et induisent la dysfonction du TAB humain. De plus, nous avions montré qu'un taux plasmatique élevé d'apolipoprotéine B (apoB), indiquant un nombre élevé d'apoB-lipoprotéines dont principalement les LDL, est associé à la RI, la sécrétion d'insuline gluco-stimulée (SIGS) élevée, la clairance plasmatique retardée des gras alimentaires et la moindre fonction du TAB chez 81 sujets obèses non diabétiques. Afin de déterminer si l'apoB plasmatique permet aussi d'identifier les sujets obèses répondant le mieux à une diète hypocalorique en termes de réduction des facteurs de risque du DT2, nous avons testé l'effet d'une intervention hypocalorique de six mois. Parmis 59 sujets qui ont terminés l’intervention, nous avons mesuré une diminution de la SIGS et une amélioration de la fonction du TAB seulement chez les sujets avec apoB plasmatique élevée. Toutefois, les mécanismes de ces effets délétères possibles des apoB-lipoprotéines n'avaient pas été explorés. Des évidences suggèrent que l'activation chronique de l'inflammasome Nucleotide- binding domain and Leucine-rich repeat Receptor containing a Pyrin domain 3 (NLRP3) et la sécrétion d'interleukine-1b (IL-1b) promeuvent la dysfonction du TAB et la RI systémique. Cependant, les signaux métaboliques induisant l'inflammasome NLRP3 dans le TAB humain sont inconnus. Afin de tester si l'activation de l'inflammasome NLRP3/système IL-1b participe au mécanisme précédemment identifié liant les apoB-lipoprotéines et les facteurs de risque du DT2, nous avons investigué l'association et l'effet direct des apoB-lipoprotéines sur le système IL-1b. Nous avons démontré chez 81 sujets obèses non-diabétiques que les individus avec apoB plasmatique élevée montrent un taux élevé d'antagoniste du récepteur à l'IL-1 (IL-1Ra) plasmatique, un marqueur de l'activation systémique de la voie IL-1b. Aussi, les associations entre l'apoB plasmatique élevée et la RI et SIGS étaient statistiquement dépendantes des niveaux d'IL-1Ra plasmatique. Dans une autre population de 32 sujets, nous avons démontrés que ceux avec apoB plasmatique élevée ont une sécrétion augmentée d'IL-1b par le TAB ex vivo. Les relations entre l'apoB plasmatique, la clairance plasmatique retardée des gras alimentaires et la sécrétion de C-peptide glucostimulée étaient statistiquement dépendantes de la sécrétion d'IL- 1b du TAB. Puis, les LDL natifs ajoutés au TAB ex vivo induisaient la sécrétion d'IL-1b, y agissant en tant que signaux d'amorçage (1er signal de l'inflammasome NLRP3/système IL-1b). En conclusion, ces résultats suggèrent que les LDL natifs, forme principale d'apoB- lipoprotéines, régulent positivement l'inflammasome NLRP3 du TAB humain. Ceci pourrait expliquer la dysfonction du TAB, l'hyperinsulinémie et l'incidence élevée du DT2 présents chez les sujets avec apoB plasmatique élevée. En outre, ils suggèrent que l'apoB plasmatique élevée pourrait être un biomarqueur permettant d'identifier les sujets obèses qui répondraient le mieux à la diète hypocalorique afin de réduire le risque de DT2. / Type 2 diabetes (T2D) is chronic disease affecting 3 million Canadians and a new case is diagnosed every 3 minutes in Canada. Long before the onset of T2D, a progressive increase in insulin resistance (IR) and insulin secretion is observed in normoglycemic subjects. A decreased white adipose tissue (WAT) function is central to the development of T2D as it promotes an increased fatty acid flux to peripheral tissues, inducing IR, hyperinsulinemia and chronic inflammation. During my MSc, we reported that low density lipoproteins (LDL) reduce the differentiation and function of adipocytes and induce the dysfunction of human WAT. Moreover, we showed that elevated plasma apolipoprotein B (apoB), indicating high numbers of circulating apoB-lipoproteins mainly in the form of LDL, is associated to IR, elevated glucose-induced insulin secretion (GIIS), delayed postprandial plasma clarance of fat and reduced WAT function in 81 non-diabetic obese subjects. To explore whether apoB also identifies obese subjects who best respond to weight loss to reduce risk factors for T2D, we tested the effect of a 6 months hypocaloric diet. We showed in the 59 completers of the hypocaloric intervention that the decrease in GIIS and increase in WAT function were significant in subjects with high plasma apoB but not in subjects with low plasma apoB. However, the mechanism underlying the negative effects apoB-lipoproteins was yet unexplored. Chronic activation of the Nucleotide-binding domain and Leucine-rich repeat Receptor containing a Pyrin domain 3 (NLRP3) inflammasome and secretion of interleukin-1b (IL-1b) promote WAT dysfunction and systemic IR. However, endogenous metabolic signals that induce the activation of WAT NLRP3 inflammasome are unknown. To test if the activation of the NLRP3 inflammasome/ IL-1b system is an underlying mechanism linking apoB- lipoproteins to risk factors for T2D, we examined the association and direct effect of apoB- lipoproteins on the IL-1b system. We observed in our cohort of 81 non-diabetic obese subects that subjects with high plasma apoB have higher plasma IL-1 receptor antagonist (IL-1Ra), which is an marker of systemic activation of the Il-1b pathway. Furthermore, the associations between high plasma apoB and IR and GIIS were statistically dependent on plasma IL-1Ra. Additionnaly, in a separate population of 32 subjects, we demonstrated that subjects with high plasma apoB have higher ex vivo WAT IL-1b secretion. The relation between plasma apoB and delayed postprandial plasma fat clearance and elevated glucose-induced C-peptide secretion were statistically dependent on WAT IL-1b secretion. Finally, native LDLs directly induce IL- 1b secretion from ex vivo WAT, acting primarily as priming signals (i.e. the first signal leading to activation of the NLRP3 inflammasome/ IL-1b system). In conclusion, the findings from this thesis suggest that native LDL, the main form of apoB-lipoproteins, upregulate human WAT NLRP3 inflammasome. This may explain WAT dysfunction, hyperinsulinemia and higher incidence of T2D in subjects with high plasma apoB. Moreover, they suggest that high apoB may serve as biomarker to identify obese subjects who best respond to a hypocaloric-intervention to reduce the risk of T2D.