Background: Among adults with diabetes, 19-34% will develop a diabetic foot ulcer (DFU), which increases amputation risk and health care costs, and worsens quality of life. Regular physical activity, when increased gradually, may help prevent DFUs. In this mixed-methods study, we examined the feasibility of a low-intensity, technology-based behavioral intervention to increase activity in adults at risk for DFUs. Method: Participants at risk for a DFU (n = 12; 66% female; mean age = 59.9 years) received four in-person exercise and behavioral counseling sessions over 2-3 weeks, supplemented with use of an activity monitor (to track steps) and text messages (to reinforce behavioral strategies) for an added 8 weeks. Pre- and postintervention assessments of accelerometer measured activity, daily mobility, and glycemic control (A1C) were completed. Treatment acceptability was assessed by questionnaire and via key informant interview. Results: The program appears feasible since all but one participant attended all four sessions, all used the activity monitor and all responded to text messages. Treatment acceptability (scale: 1 = very dissatisfied, 5 = extremely satisfied) was high; average item ratings were 4.79 (SD = 0.24). Participants increased their steps by an average of 881.89 steps/day ( d = 0.66). A1C decreased on average by 0.33% ( d = 0.23). Daily mobility did not change. Interview results suggest that participants perceived benefits from the intervention. Participant recommended improvements included providing more physical activity information, addressing pain, and intervention delivery in a podiatry clinic. Conclusion: Individuals at risk for a DFU might benefit from a minimally intensive, technology-based intervention to increase their physical activity. Future research comparing the intervention to usual care is warranted.

Objective The Make Better Choices 1 trial demonstrated that participants with unhealthy diet and activity behaviors who were randomized to increase fruits/vegetables and decrease sedentary leisure achieved greater diet and activity improvement than those randomized to change other pairs of eating and activity behaviors. Participants randomized to decrease saturated fat and increase physical activity achieved the least diet-activity improvement. This study examined which psychological mechanisms mediated the effects of the study treatments on healthy behavior change. Methods Participants (n=204) were randomized to one of four treatments: increase fruits/vegetables and physical activity; decrease saturated fat and sedentary leisure; decrease saturated fat and increase physical activity; increase fruits/vegetables and decrease sedentary leisure. Treatments provided three weeks of remote coaching supported by mobile decision support technology and financial incentives. Mediational analyses were performed to examine whether changes in positive and negative affect, and self-efficacy, stages of readiness to change, liking, craving and attentional bias for fruit/vegetable intake, saturated fat intake, physical activity and sedentary leisure, explained the impact of the treatments on diet-activity improvement. Results Greater diet-activity improvement in those randomized to increase fruits/vegetables and decrease sedentary leisure was mediated by increased self-efficacy (indirect effect estimate=0.04; 95% bias corrected CI: 0.003, 0.11). All treatments improved craving, stage of change and positive affect. Conclusion Accomplishing healthy lifestyle changes for 3 weeks improves positive affect, increases cravings for healthy foods and activities and enhances readiness to make healthy behavior changes. Maximal diet and activity improvement occurs when interventions enhance self-efficacy to make multiple healthy behavior changes.

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Integrated care is increasingly recognized as an ideal treatment model for a variety of medical conditions, including pediatric gastroenterology. The current study aims to better understand the impact of psychology integration into a subspecialty gastroenterology clinic on referral patterns and psychology utilization. A retrospective chart review evaluated 504 unique referrals over a period of two years, including the 12-month period immediately pre and post integration of psychology services. The impact of integrated psychology and medical services included a large increase in the overall number of referrals placed, a significant increase in the rate of follow-through of these referrals, and a significant decrease in elapsed time from the referral to initial psychology appointment for referrals placed following the integration of psychology services. Utilization was not significantly affected by demographic characteristics (i.e., age, gender, distance from the hospital, insurance type). Referral characteristics, including referring physician and presenting problem, had varying impacts on patient follow-through depending on the time period studied, highlighting the complexity of integrated care's impact on referral patterns and psychology utilization. Results add to existing literature on the benefits of integrated care and accentuate the need for better understanding and ultimately reducing the barriers to utilization of psychology services.