4.1. Principal Findings
This study aimed to demonstrate that a DPP using synchronous distance technology is an effective delivery mode to help participants adopt healthy behaviors, increase physical activity levels, and achieve the weight loss recommended to prevent or delay the onset of type 2 diabetes. Our findings support this aim. The average weight loss for those who completed the program was 5.66% and the average weekly minutes of physical activity was 127 min. Most importantly, our findings found a statistically significant decrease in A1C (−0.24 p < 0.0001). Based on the Wilcoxon signed-rank test, there were statistically significant changes in participants’ self-reported confidence in their ability to perform all 18 health-promoting behaviors assessed (p < 0.0001). By demonstrating the overall effectiveness of a large-scale distance learning DPP, this study contributes to the existing literature on the CDC NDPP delivery mode options.
The findings of the study provide further support for the effectiveness of the distance learning delivery of the NDPP [
23,
24,
25]. This study is novel in its analysis of a community based not-for-profit program serving over 2000 participants with a distance learning DPP. A previous study looking at cumulative enrollment in the NDPP by delivery mode between January 2012 and December 2019 showed that online and distance learning participants were overwhelmingly enrolled in programs run by organizations classified as for-profit businesses or insurers [
26]. Additionally, the findings highlight the importance of program completion on weight loss and A1C reduction, aligning with previous research emphasizing the importance of longer program engagement for weight loss and diabetes prevention [
27,
28,
29,
30].
In developing the ESMMPD program, the ability to scale the monthly class offerings based on demand was a driving factor. The program is able to offer and launch a new set of yearlong classes 9 months out of the year (excluding the months of July, November, and December). As a community-based program, ESMMPD’s primary aim was to serve program participants. None of the participants were enrolled specifically for research. The study sample consisted of 2390 program participants who enrolled between January 2019 and June 2022 and provided their consent to use their data for research purposes. The study participants were 89.2% (2132) female and 10.8% (257) male. Previous studies have shown men are underrepresented in weight maintenance and weight loss programs for which there are many theories, but it is believed to be in part due to the different societal norms and pressures to lose weight between the sexes [
29,
31].
Participants often face challenging constraints that affect retention, yet success in the NDPP lifestyle change program is strongly associated with retention [
32]. ESMMPD defines program completion as attending at least 9 out of 18 Phase 1 and 5 out of 8 Phase 2 classes. Of the 2390 study participants, 74.0% (1768) completed Phase 1 and 46.9% (1120) completed both Phase 1 and Phase 2. The program completion rates did not differ across race and ethnicity categories as outlined in the 2021 DPRP Standards.
There were statistically detectable differences in completion rates across levels of education for Phase 1; however, the difference at the program completion-level was not statistically significant. Nearly 65% of those with a high school education completed Phase 1, compared with 40% for those with “some high school” education. The Phase 1 completion rate for college graduates was 75.5%. The program completion rates are similar across education levels compared with the Phase 1 completion rates, but with smaller differences. Only 30% of those who completed “some high school” completed the program, while more than 40% of those with a high school education or equivalent completed the program. There was a 57% completion rate among those who graduated from college.
Program completers lost on average 12.56 pounds or 5.66% of their body weight during the program. Previous papers have highlighted that longer engagement in a DPP is associated with larger weight loss [
27,
28,
29,
30]. Participants of the ESMMPD program reached the weight loss goal set by the NDPP lifestyle change program which states that if individuals with pre-diabetes achieve a moderate 5–7% weight loss (along with 150 weekly minutes of physical activity), they can prevent the onset of type 2 diabetes by 58%. A study that examined predictors of long-term weight loss among DPP participants found that greater weight loss at the end of 12 months predicted long-term weight loss in all treatment groups. Further, incidence of type 2 diabetes over a 15-year period was lower among those who achieved ≥5% weight loss than those achieving <5% weight loss at Year 1 [
33].
Unless an organization is a MDPP supplier, participants are not required to report an A1C when enrolling in a CDC-recognized program. Organizations with full recognition status from the DPRP must show at least 35% of completers in the evaluation cohort are eligible for the program based on either a blood test that indicates prediabetes or a history of gestational diabetes mellitus. For the study participants that voluntarily reported pre- and post-program changes in A1C values (n = 482) a detectable reduction in A1C of −0.24 units (SD = 0.45,
p < 0.001) was found. This finding compares favorably with past research on technology-driven DPPs that have reported reductions in A1c ranging from −0.1% to −0.4% [
17,
34,
35,
36,
37]. Though the A1C test is a powerful diagnostic tool, it does have limitations due to genetic differences in erythrocyte metabolism, as medical evidence suggests. Despite the fact that their plasma glucose levels may be similar, African American, Hispanic, and Asian populations may have higher A1C levels when compared to White Caucasian individuals [
38]. Strategies to increase the accessibility and affordability of A1C testing are needed to allow more robust analysis of reductions in A1C based on DPP participation.
One of the two main goals of the NDPP is to increase weekly physical activity to at least 150 min. Our findings suggest there is a need for improvement in achieving the weekly physical activity recommendations. For the study participants who completed the program (n = 1120), the average weekly minutes of physical activity was 127 min. Program completers, on average, reported 93 more minutes of weekly physical activity than of participants who did not complete the program. Interestingly, participants reported high levels of confidence in their ability to be physically active for at least 30 min most days. Participants also reported that as a result of the program, they are more mindful of getting physical activity each day. Being confident in one’s ability to perform the recommended amount of physical activity and mindful of the physical activity recommendations does not appear to result in engaging in 150 min of weekly physical activity. Future studies should investigate factors that increase physical activity levels to meet the recommendations set by the Physical Activity Guidelines for Americans.
The goal of ESMMPD is to not only help participants achieve specific weight, A1C, and physical activity NDPP benchmarks, but to also provide knowledge and tools that empower participants to adopt and sustain health-promoting behaviors throughout their lifetime. Our findings showed statistically significant changes in participants’ self-reported confidence in their ability to perform each assessed health-promoting behavior pre-program and post-program, listed in
Table 5. This demonstrates significant participant learning and comprehension in distance learning lessons, pointing to the overall effectiveness of synchronous distance learning as an NDPP delivery mode.
Participants also reported high rates of adoption of health-promoting behaviors as a result of participating in ESMMPD, as shown in
Table 6. To highlight behaviors directly pertaining to NDPP goals, 98% of participants reported being more mindful of what and how much they eat. A total of 96% reported being more mindful of getting physical activity every day, with 87% reporting being physically active at least 30 min most days. Participants not only gained confidence in their ability to perform health-promoting behaviors shown to prevent diabetes onset, but also gained tools to adopt and implement these behaviors into their lives. Notably, as a result of the program, 92% of participants said they were able to better plan for holidays and travel, 85% reported they were able to manage stress, and 80% reported sleeping better. ESMMPD’s distance learning delivery mode helps participants adopt specific behaviors to reach NDPP benchmarks proven to prevent diabetes, as well as adopt other behaviors that promote overall health and sustained behavior change.