Development and Efficacy of an Electronic, Culturally Adapted Lifestyle Counseling Tool for Improving Diabetes-Related Dietary Knowledge: Randomized Controlled Trial Among Ethnic Minority Adults With Type 2 Diabetes Mellitus

Kathleen Abu-Saad, Havi Murad, Rivka Barid, Liraz Olmer, Arnona Ziv, Nuha Younis-Zeidan, Vered Kaufman-Shriqui, Michal Gillon-Keren, Shmuel Rigler, Yakir Berchenko, Ofra Kalter-Leibovici, Kathleen Abu-Saad, Havi Murad, Rivka Barid, Liraz Olmer, Arnona Ziv, Nuha Younis-Zeidan, Vered Kaufman-Shriqui, Michal Gillon-Keren, Shmuel Rigler, Yakir Berchenko, Ofra Kalter-Leibovici

Abstract

Background: Ethnic minority populations exhibit disproportionately high rates of type 2 diabetes mellitus (T2DM). Electronic health tools have the potential to facilitate the cultural adaptation and tailoring of T2DM education to improve the knowledge and management of diabetes mellitus (DM).

Objective: This study aimed (1) to develop an adaptable Interactive Lifestyle Assessment, Counseling, and Education (I-ACE) software to support dietitian-delivered lifestyle counseling among low-socioeconomic status (SES) ethnic minority patients with T2DM and (2) to evaluate its effect on DM-related dietary knowledge and management compared with standard lifestyle advice (SLA) in a randomized controlled trial (RCT).

Methods: The I-ACE software, developed in consultation with clinical dieticians, incorporates evidence-based dietary and physical activity (PA) recommendations and educational materials. The features and behavioral change techniques include quantitative lifestyle (dietary intake and PA) assessment and simulation, individually tailored education and recommendations, motivational interviewing, and goal setting. For the unblinded pilot RCT, 50 overweight or obese Arab adults (aged 40-62 years) with poorly controlled T2DM were recruited from primary care clinics and randomly assigned to receive 4 in-person, dietician-delivered counseling sessions over 6 months using either (1) the I-ACE tool (experimental arm) or (2) the SLA methods (comparison arm). All outcome assessments were face-to-face. DM-related dietary knowledge (primary outcome) was measured at baseline, 3, 6, and 12 months. Lifestyle and other parameters were measured before, during, and after the intervention. Multiple linear regression and repeated measures linear mixed models were used to compare the changes in study outcomes and explore time trends in between-group and within-group changes.

Results: A total of 25 participants were enrolled in each arm, of whom 24 and 21 completed the final assessment of the primary outcome in the I-ACE and SLA arms, respectively. DM-related lifestyle knowledge increased more rapidly in the I-ACE arm than in the SLA arm (P value for study arm×time interaction=.02). Within the I-ACE arm, the mean (SE) differences in added sugar and dietary fiber intakes from baseline to 12 months were -2.6% (SE 1.0%) of total energy (P=.03) and 2.7 (SE 0.0) g/1000 kcal (P=.003), respectively. The odds of engaging in any leisure PA at 12 months tended to be higher in the I-ACE arm versus SLA arm, but did not reach statistical significance (odds ratio 2.8; 95% CI 0.7-11.6; P=.16). Both arms exhibited significant reductions in HbA1c (P value for change over time <.001).

Conclusions: The use of the I-ACE software in a 6-month, 4-session dietician-delivered lifestyle counseling intervention improved the efficiency of lifestyle education, compared with SLA, among low-SES, ethnic minority patients with T2DM. This pilot trial provides justification for conducting a large-scale trial to evaluate its effectiveness and applicability in routine clinical care among ethnically diverse populations.

Trial registration: ClinicalTrials.gov NCT01858506; https://ichgcp.net/clinical-trials-registry/NCT01858506.

Keywords: culturally congruent care; diabetes mellitus, type 2; diabetes-related dietary knowledge; ethnic minorities; lifestyle; software.

Conflict of interest statement

Conflicts of Interest: None declared.

©Kathleen Abu-Saad, Havi Murad, Rivka Barid, Liraz Olmer, Arnona Ziv, Nuha Younis-Zeidan, Vered Kaufman-Shriqui, Michal Gillon-Keren, Shmuel Rigler, Yakir Berchenko, Ofra Kalter-Leibovici. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 16.10.2019.

Figures

Figure 1
Figure 1
Screening, randomization, and completion of follow-up flow chart for the pilot trial of a culturally-adapted lifestyle counseling software among Arab adults with T2DM. T2DM: Type 2 diabetes mellitus; I-ACE: Interactive lifestyle Assessment, Counseling and Education; SLA: Standard Lifestyle Advice.
Figure 2
Figure 2
Change in DM-related lifestyle knowledge score during intervention (up to 6 months) and follow-up (up to 12 months) among 50 Arab patients with type 2 diabetes mellitus in the I-ACE pilot trial by study arm. Results of a linear mixed regression model for repeated measures with a time*study arm interaction, controlling for sex, educational level, and number of study dietary counseling visits. DM: diabetes mellitus; I-ACE: Interactive lifestyle Assessment.
Figure 3
Figure 3
Expected HbA1c values over time among 50 Arab patients with type 2 diabetes mellitus in the I-ACE pilot trial by study arm. Results from a linear mixed regression model for repeated measures, controlling for sex. HbA1c: hemoglobin A1c; I-ACE: Interactive lifestyle Assessment.
Figure 4
Figure 4
Participant responses to counseling utility questions regarding their ability to understand material and/or adhere to recommendations in the I-ACE pilot trial by study arm. Abbreviations: I-ACE Interactive lifestyle Assessment, Counseling, and Education; SLA Standard Lifestyle Advice.

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