Community-based diabetes prevention randomized controlled trial in refugees with depression: effects on metabolic outcomes and depression

Abstract

Depression and antidepressant medications increase risk for type 2 diabetes. Cambodian-Americans have exceedingly high rates of both depression and diabetes. This paper reports outcomes of a diabetes prevention trial for Cambodian-Americans with depression. Primary outcomes were HbA1c, insulin resistance and depressive symptoms. Participants were aged 35–75, Khmer speaking, at risk for diabetes, and met study criteria for likely depression by either (a) antidepressant medication and/or (b) prolonged elevated depressive symptoms. Participants were randomized to one of three community health worker (CHW) interventions: (1) lifestyle intervention called Eat, Walk, Sleep (EWS), (2) EWS plus medication therapy management sessions with a pharmacist/CHW team to resolve drug therapy problems (EWS + MTM), or, (3) social services (SS; control). Assessments were at baseline, post-treatment (12 months), and follow-up (15 months). The n = 188 participants were 78% female, average age of 55 years, half had a household income < $20,000, and modal educational attainment was 7.0 years. Compared to the other arms, EWS + MTM showed a significant decrease in HbA1c and a trend for reduced inflammation and stress hormones. Depressive symptoms improved for EWS and EWS + MTM relative to SS. There was no change in insulin resistance. Cardiometabolic and mental health can be improved in tandem among immigrant and refugee groups.

Secondary analysis of a randomized trial testing community health educator interventions for diabetes prevention among refugees with depression: effects on nutrition, physical activity and sleep

“…We were surprised that no health behavior changes were associated with improved depression or change in insulin resistance. We hypothesize that the improvements in depression experienced by the intervention groups, previously reported [ 21 ], were caused by other intervention factors such as behavioral activation and increased socialization. We were also surprised, and disappointed, that no participants in the EWS + MTM group initiated metformin, despite the fact that their providers received laboratory results and accompanying recommendations from study pharmacists.…”

“…In exploratory analyses, we examined how changes in health behaviors were associated with changes that we have previously reported in our primary outcomes, i.e., HbA1c, depressive symptoms, and insulin resistance [ 21 , 46 ]. Findings show that changes to all three health behaviors – nutrition, physical activity, and sleep – may promote lowering HbA1c.…”

“…Exclusion criteria were: type 2 diabetes; seeing or hearing problems that would interfere with group sessions; major medical problems requiring intensive treatment; pregnancy or planning pregnancy; serious thinking or memory problems (e.g., schizophrenia or dementia); and 3 or more days in a psychiatric hospital or self-harm in the past 2 years. Sample size was determined using a power calculation to detect an effect on the primary outcomes at endpoint (12 months) as previously described [ 21 ]. Recruitment began in March 2016 and data collection ended in September 2020.…”

“…Participants were paid $10 USD in gift cards to a local pharmacy for completing the surveys. CHWs obtained anthropometrics and blood pressures according to standard practice as previously described [ 21 , 27 ]. Participants were asked to wear accelerometers on their non-dominant wrist (for sleep measurement) and hip (for physical activity measurement) for seven consecutive days.…”

“…In a previous report of our primary outcomes, we showed that, relative to social services (SS), EWS + MTM improved HbA1c while both EWS and EWS + MTM decreased depression [ 21 ]. Below we report planned analyses of our secondary outcomes, i.e., key lifestyle behaviors including 1) daily grams of carbohydrate from rice, 2) physical activity and sedentary behavior per actigraphy, and, 3) sleep per actigraphy.…”