This document provides an overview of the Balanced Living with Diabetes (BLD) program, a community-based lifestyle intervention for improving blood glucose control among people with diabetes. BLD is based on social cognitive theory and community-based participatory research principles. It involves weekly 2-hour classes over 4 weeks that teach diabetes self-management skills like healthy eating, physical activity, and goal setting using interactive lessons and activities. Pilot programs of BLD found improvements in A1c, diet, and physical activity. A large randomized controlled trial of BLD found it effective at lowering A1c levels among African Americans with diabetes in medically underserved areas when delivered in faith-based community settings.

1. Balanced Living with Diabetes:
A Community-based Lifestyle Intervention
Program for Improved Blood Glucose
Control
Eleanor Schlenker, PhD, RD
Carlin Rafie, PhD, RD
Melissa Chase, PhD
Kathy Hosig, PhD, MPH, RD
Associate Professor
Director, Center for Public Health Practice and Research
Population Health Sciences
Virginia Tech

2. Outline
 Background
 Challenges for health behavior change
 Strategies for health behavior change
 Balanced Living with Diabetes
– Program description
– Program history
– Program tailoring and outcomes in Virginia
 Elements of success
 Next Steps
– Expand VCE reach to Hispanic population (promotora)
– BLD dissemination to rural Virginia

3. Diabetes Prevalence and Risk
 US adults > 20 years (2010-2012)
– Overall US population: 9.6%
– Non-Hispanic blacks: 13.2%
– Hispanics: 12.8%
 Rural communities
– 17% higher risk for diabetes
– Higher prevalence of diabetes risk factors
 poverty, obesity, tobacco use, low health literacy
– Less likely to engage in recommended diabetes self-care
except quarterly A1c
– Less likely to have health insurance
– Live farther from healthcare facilities

4.  7th leading cause of death in US in 2010
– Likely underreported
 Health Complications
– Heart disease and stroke
– Blindness
– Kidney failure
– Lower-limb amputation
Burden of Diabetes

5.  Chronic disease and diabetes
– 1.7 times higher risk for cardiovascular disease
– 71% have hypertension
– 65% have high LDL cholesterol
– 29% have diabetic retinopathy
– 60% of non-traumatic lower-limb amputations occur in
people with diagnosed diabetes
– Diabetes listed as primary cause for 44% of new kidney
failure cases
Burden of Diabetes

6. Burden of Diabetes
2013
Per-capita healthcare costs without diabetes = $4,305
Per-capita healthcare costs with diabetes = $14,000
Out-of-pocket costs 2.5x higher with diabetes

7. Source: American Association of Diabetes Educators

8.  American Diabetes Association recommendation:
– A1c < 7.0%
 Prevent complications
 Reduce medical costs
 For each 1% decrease in mean A1c:
– 21% decrease in risk of death related to diabetes
– 14% decrease in risk for myocardial infarction
– 37% decrease in risk for microvascular complications
Preventing Diabetes Complications

9. Challenge:
Lifestyle Behavior Change

10. Maslow’s Hierarchy of Needs
Where does health behavior change fit in?

11. Socioecological Model

12. Challenge: Underserved
 Services not available
 Services not accessible
 Target population may not take advantage of
available services
 Unique characteristics for each target
population

13. Strategies
 Health Behavior Theory
 Community-based Participatory Research
– CBPR

14. Health Behavior Theory
 Is basic information (knowledge) important for
health behavior change?
– Is it enough?
 Why do interventions that focus on providing
information (i.e. “education”) often fail to produce
change in behavior?

15. Rationale for Theory-based
Interventions
 Health behavior interventions that are fully
grounded in theory appear to be more effective
in producing change in health behavior – why?
– Fidelity to theory components
– Processes involved in maintaining fidelity to theory

16. Social Cognitive Theory
 Constructs
– Individual characteristics
 Self-efficacy
 Behavioral Capability
 Expectations
 Expectancies
 Self-control
 Emotional coping responses
– Environmental factors
 Vicarious (observational) learning
 Environment (social and physical)
 Situation (perception of environment)
 Reinforcement
 Reciprocal determinism

17. Community-based Participatory
Research (CBPR)
 Involvement of communities in designing,
implementing and evaluating community
interventions, with an emphasis on sustainability
 Community members and researchers partner to
combine knowledge and action for social change to
improve community health and often reduce health
disparities.

18. Community-based Participatory
Research (CBPR)
 Academic/research and community partners join to
develop models and approaches to building
communication, trust and capacity
 CBPR equitably involves all partners in the research
process and recognizes the unique strengths that
each brings.

19. Balanced Living with Diabetes
 Program Description
 Program History
 Program Tailoring and Outcomes in Virginia

20. Program Description

21. Balanced Living with Diabetes
Adapted from Dining with Diabetes (CBPR)
• Name developed through Project Advisory Board
• Entire curriculum completely revised
o Focus on interaction and application of basic concepts
o Tested and revised 2 times
• Stronger fidelity to Social Cognitive Theory (SCT)
• Refined assessments to include SCT variables
• Recipes tested by Virginia residents and Extension Agents
for taste, ease of preparation
• Additional physical activity content
o Aerobic, strength, stretching
o Physical Activity Readiness Questionnaire
o Goal setting and tracking
o Step log for use with pedometers

22. Balanced Living with Diabetes
Social Cognitive Theory
• Curriculum content to address expectations
• Mastery experiences to increase self-efficacy
• In-class interaction for social support
• Emphasis on self-regulation
– Goal-setting
– Tracking

23. Program Operation*
• Weekly 2-hour classes for four weeks
• Reunion class three months after last class
• Assessments at first and 3-month reunion classes:
– A1c, height/weight
– Diabetes self-management, SCT variables
• Encourage diabetes support group for class
members and family
*Considered a research study; protocol approved by VT Institutional Review Board

24. Class Structure
 Power Point interactive lecture by qualified local
health professional (CDE/RD)
 Physical Activity Discussion
 Food demonstration/tasting by local Virginia
Cooperative Extension Educator
 Personal goal-setting, sharing, and practice

25. Sample BLD Slides

26. Balanced Living with Diabetes
For People with Diabetes and their
Families

27. High Blood Sugar Causes Complications

28. Complications of Diabetes
DO NOT Have to Happen!!

29. How Can You Avoid Complications?
• Good blood sugar control

30. Lifestyle to Control Type 2 Diabetes
Choose healthy foods
Be active
Stay at a healthy weight

31. How Can Balanced Living with Diabetes
Help You?
• Manage your diabetes
• Choose healthy foods
• Be more active
• Lower your blood sugar
• Prevent complications from diabetes

32. Balanced Living with Diabetes
• Making Food Choices
– Using the Plate Method
– Learn foods to focus on
• Being Active
– Walking or other moderate physical activity
– Strength and stretching exercises
• Practicing What you Learn
– Setting goals
– Making plans
– Keeping track

33. The Plate Method
Control portion size
Control carbohydrates
Focus on healthy foods

34. Which Food Has the Most
Carbohydrate?

35. Finding Carbohydrate with Food Labels
• Compare carbohydrate in
foods using the Nutrition Facts
panel
 Total carbohydrate = 13 g
 Dietary fiber = 3 g
 Sugars = 3g
 Carbohydrate = fiber + sugar +
starch

36. Managing Type 2 Diabetes:
Take Care of Yourself

37. Can I safely become more active?
Physical
Activity
Readiness
Questionnaire
Fill it out now!

38. Balanced Living with Diabetes
Fitness
• Ways to be more active.
• Tools to help you stick to it.
• PAR-Q and your doctor
Use the PAR-Q and talk to your doctor before becoming much more active!

39. Tools for an Active Life
• Pedometer
• add 250 steps/day each week
Use the PAR-Q and talk to your doctor before becoming much more active!

40. Staying More Active
• 150 minutes a week
• exercise like walking
• slow enough to talk, but not sing!
• build to 30 minutes at least 5 days a week
Use the PAR-Q and talk to your doctor before becoming much more active!

41. Mastery Experiences

42. Practice
• Use the blank plates in your
handouts
• Plan 2 meals
–1 breakfast
–1 lunch or dinner

43. Lunch or Dinner

44. Practice:
Finding Carbohydrate with Food Labels
• Use labels at your table or handouts
• Find:
 Serving size
 Carbohydrate
 Dietary fiber
 Sugar
• Compare labels for the same types of food
 Yogurt
 Oat cereal
 Vegetables
 Wheat cereal

45. Do You Have Some Tips for Us?
• Do you have ideas that you have used
at home to make your recipes
healthier?
• Please share with us!

46. More Practice with Recipes
• Look at the recipes in the handouts
• Discuss with your group how to change
these recipes to make them healthier

47. Practice!
• Use the food labels at your table
– Oils
– Shortening, Butter and Margarine
– Spreads
– Milk
– Ranch Dressing
• Talk to the people at your table about
healthy choices using these labels

48. Practice!
• Use the food labels at your table
– Vegetable Soup
– Chicken Noodle Soup
• Talk to the people at your table
about healthy choices using these
labels

49. Practice!
• Use the menus in your handouts or that
you brought
• Talk to the people at your table about
healthy choices using these menus
• Use the Plate Method!
– Write your choices on the blank
plate

50. “Homework”

51. Bring for Next Time
• Please bring some
food labels from home.

52. Things To Do for Next Time
• Please bring
menus from your
favorite
restaurants.

53. Setting Goals
Keeping Track

54. Setting Goals & Keeping Track
• Set goals
– foods to focus on
– use Plate Method
– wear step counter
• Keep track
– foods
– Plate Method
– Steps/Walks

55. Let’s Set Goals for this Week!
• Where are you
now?
– Plate method?
– Regular meals?
• Where do you want
to go this week?
– Build slowly
• Use your diary!

56. Keep Track
• write down
goals
• notice how you
get enough
steps on days
you walk!
Use the PAR-Q and talk to your doctor before becoming much more active!

57. Let’s Review!
• Starting Point
– Plate method?
– Regular meals?
– Counting steps?
– Adding mins of
walking?
• Build slowly
• Use your diary!

58. Program History
 Virginia Department of Health (Diabetes Prevention and
Control Program) funding:
– Dining with Diabetes by Virginia Cooperative Extension (VCE) with
local healthcare professionals, local health departments
 13 counties in Southwest and Central Virginia (2006-2009)
 Obici Healthcare Foundation grant:
– VCE partnered with Virginia Diabetes Council
 6 counties in Obici service area (2011)
 National Institutes of Health grant:
– Program adapted to Balanced Living with Diabetes
– Partnering with Baptist General Convention of Virginia
 27 churches in 9 Virginia locations (2010-2015)
 Hispanic Balanced Living with Diabetes (unfunded)
– VCE partnered with Catholic churches
 5 churches in Southwest/Southside Virginia (2014-2015)

59. BLD Tailoring and Outcomes
in Virginia

60. Dining with Diabetes Pilot (2006-2009)
 N = 146 participants (8 locations analyzed)
o 80% female
o 66% > 60 years old (mean age = 66.4 ± 10.3 years)
o 53% reported income of lower than $30,000
o Race/ethnicity representative of geographic region
o 77% Caucasian
o 7% African American
o 3% Asian
o < 1% Hispanic

61. Dining with Diabetes Pilot (2006-2009)
A1c baseline to 3-month follow up:
Overall
o 7.36 ± 1.60 vs 7.27 ± 1.47 (paired t-test, p = 0.310)
> 7% A1c at baseline (n = 45)
o 8.50 ± 1.58 to 8.00 ± 1.54 (paired t-test, p < 0.001)

63. Dining with Diabetes Pilot (2006-2009)
• Self-reported behaviors baseline to 3-month
follow up:
• 5 times more likely to use a plan to control
carbohydrate at least 3 days/week
o 38% vs. 74% (OR = 4.64, 95% CI = 2.50 – 8.61; t = 5.36, p < .01)
• ↑ 30 minutes physical activity at least 3
days/week
o 73% vs 82% (OR = 1.68; 95% CI=0.84¨C3.37; t=1.49, p=.07)

64. Obici Foundation Project (2011)
(used revised BLD)
 39% lowered A1c
 51% maintained appropriate A1c levels
 65% increased days/week using a meal planning
method
 73% increased days/week with 30 minutes of
walking or similar activity

65. RCT with BLD Targeting Medically
Underserved African Americans
 5-year project funded by National Institutes of
Health (National Institute for Nursing Research)
 3 churches in each of 10 Virginia communities
(n=30)
– Churches randomly assigned to treatment condition
 BLD
 BLD plus technical assistance for monthly support
group meetings
 12-month delayed intervention

66. BLD with Medically Underserved
African Americans
Location
• African American Baptist Churches
• Medically underserved areas of Virginia
Partners
• Baptist General Convention
• Statewide association of black churches
• Health ministry infrastructure
• Virginia Cooperative Extension
• Virginia Department of Health

67. BLD with Medically Underserved
African Americans
Formative work (CBPR)
• Director of church health ministry involved
from beginning (proposal stage)
• Recipe testing at member churches
• Pilot/feasibility programs at 2 member
churches

68. BLD with Medically Underserved
African Americans
Community Advisory Board
• Key stakeholders
• Members of target population
• Members of partner agencies
• Administrative and staff
• Designed consent documents/process
• Chose recipes for testing
• Designed/approved marketing/recruiting
materials
• Continued involvement and formative evaluation
• Dissemination
• Sustainability

69. BLD with Medically Underserved
African Americans
Preliminary Results

70. BLD with Medically Underserved
African Americans
• 264 participants completed 12-month assessments
• 5 locations, 14 churches
• Demographics
• 77% female; 23% male
• 96% African American
• Retention rate
• 82% at 3 months
• 80% at 6 months
• 77% at 12 months

71. BLD with Medically Underserved African Americans
Change in A1c by Treatment Condition for Participants with Baseline A1c ≥ 7.0
(n = 106)
Treatment
Condition
Baseline
A1c
(mean ± sd)
3-month
A1c
(mean ± sd)
6-month
A1c
(mean ± sd)
12-month
A1c
(mean ± sd)
Control waiting 8.5 ± 1.5 8.1 ± 1.4 8.0 ± 1.0 7.8 ± 1.6
Standard
program
8.8 ± 1.7 8.3 ± 1.3 8.1 ± 1.4 8.3 ± 1.8
Program +
support groups
8.7 ± 1.7 8.2 ± 1.1 8.3 ± 1.2 8.2 ± 1.3

72. Identifying and Exploring Capacity & Readiness
of Faith-Based Organizations Implementing
Lifestyle-Related Chronic Disease Health
Programs
 Preliminary Research
– Explore capacity and readiness factors that influence
partner experience implementing a collaborative
lifestyle-related faith-based health program (BLD)
 Formative and Culminating Research
– Develop and pilot a tool to assess organizational
capacity and readiness of faith-based organizations to
implement lifestyle-related health programs

73. Results
 50% did not have policies to promote physical
activity
 68% did not have policies related to healthy
food/beverage options at church functions
 Most common policy = “No Smoking”

74. Results
 57% had health and wellness mission statement
 55% had health and wellness budget
 57% had health ministry
– Larger churches more likely to have health ministry
– Churches with health ministry more likely to have at
least one health-related policy that was enforced

75. Results
 Most churches had not partnered with
colleges/universities for health programming
 Only ~50% had partnered with local/state agencies
 Assessment tool is promising
– Self-assessment tool for churches
– Research tool

76. Hispanic BLD
Background
• Growing minority population in US
• Increased risk for type 2 diabetes
• Disproportionate suffering from
complications from diabetes
• ↓ access to care
• Potential for undocumented participants
• Unique influences on access to care
• Majority of Hispanic population is Catholic

77. Hispanic BLD
Location
• Catholic Churches with services in Spanish
• Identified via communication with Richmond diocese
Partners
• Richmond Diocese and 4 regional Catholic churches
• St. Mary’s Catholic Church in Blacksburg (support)
• Virginia Cooperative Extension
• Virginia Department of Health
• VT Center for Public Health Practice and Research

78. Hispanic BLD
Formative work
• Doctoral student from El Salvador worked
with BLD for MPH practicum and then……
• Interpreted BLD materials into Spanish
• Obtained permission from state Catholic
diocese to work with local churches
• Established relationship with local Catholic
churches for formative work
• Identified importance of promotora-navigator

79. Hispanic BLD
Formative work
• Recipe testing at two local churches
• Another local Catholic church helped prepare foods
and provided resources for pilot/feasibility programs
• Health fair/ A1c screening at same churches
• Pilot feasibility programs at the same churches
• Prefer Sundays after mass

80. Sample HBLD Slides

81. Vida Balanceada con Diabetes
Para personas con Diabetes y sus familias
Sesión 1

82. Lo siguiente para hoy es:
• Deguste comida deliciosa y saludable

83. Formative A1c Screening Results
(2 Catholic Churches)
Of 60 participants screened:
• 100% self-identified as
Hispanic
• 68% were female
• 64% were 40 years old or
younger
• 64% did not have a high
school degree or higher
• 75% did not have medical
insurance

84. Formative A1c Screening Results
(2 Catholic Churches)
• 54% had A1c > 5.7%
• Of these, 72% had
never been told that
they had pre-
diabetes, diabetes or
high blood sugar

85. 2-Group Randomized Control Trial

86. HBLD Pilot RCT Results
A1c-Baseline A1c- 3 months
HBLD
(n=11)
6.4 ± 0.9 6.4 ± 0.9
HBLDd
(n=10)
6.0 ± 0.5 6.2 ± 0.7
Baseline and 3-month Follow Up A1c for Intervention and Delayed Control Churches*
* No differences for change from baseline to 3-month follow up between churches
(Kruskal Wallis, p > 0.05)

87. Considerations and Lessons Learned
 High enthusiasm from churches
 Documented need
 Opportunity to reach severely underserved
 Church dissemination infrastructure weaker
 Work more closely with individual churches
 Must have approval from State Diocese
 Greater flexibility from Extension needed for
timing of classes (Sundays)
 Bilingual educator required
 Promotora navigator to improve access to care

88. Acknowledgments
J Elisha Burke, DMin (Director, Health Ministry - BGCVA)
Eleanor Schlenker, PhD, RD (Extension Nutrition Specialist - VT)
Eileen Anderson Bill (Research Assistant Professor, Psychology – VT)
Ann Forburger, MEd, CHES (Project Coordinator - VT)
Monica Motley, MPH (almost PhD)
Ivette Valenzuela, MPH (almost PhD)
Deborah Jones, MPH (Extension Specialist, Virginia State University)
Carlin Rafie, PhD, RD (Extension Nutrition Specialist - VT)
Melissa Chase, PhD (Consumer Food Safety Program Manager - VT)

89. Common Elements
 Know your target population
 CBPR
– Builds trust, empathy, capacity
 Go where the people already come together
 Work with people who are connected to the
target population
 Honor and embrace differences in perspective

90. Next Steps
 Explore promotora model for Virginia Cooperative
Extension programs
– MPH practicum/capstone (Karina Chavez)
 Impacting Rural Community Health Through
Evidence-based Program Implementation in the
Cooperative Extension Network
– USDA: National Institute of Food and Agriculture (2 yrs)

91. USDA-NIFA Rural BLD
Dissemination
Expand BLD to all qualifying rural counties/cities in
Virginia with a Family and Consumer Sciences
Extension Agent.
Conduct process evaluation to facilitate program
sustainabilty

92. US Cooperative Extension Service

94. USDA-NIFA Rural BLD
Dissemination
Goal 1: Create capacity to use Master Food
Volunteers to assist with BLD implementation
Goal 2: Create sustained capacity for
implementation of BLD in rural Virginia counties
Goal 3: Produce a BLD curriculum kit to be made
available to other state and local Extension
programs

95. Target Counties and Cities
Brunswick Orange
Dickenson Page
Emporia City Patrick
Greensville Russell
Lee Shenandoah
Louisa Surry
Madison Tazewell
Nottoway Wise

96. Discussion