113 Adaptations to the National Diabetes Prevention Program: A Case Study

Faculty Mentor: Katherine J.W. Baucom (Psychology, University of Utah)

Abstract

While 11.6 % of the U.S. population has Type 2 diabetes, Latine adults are 60% more likely than non-Hispanic whites to be diagnosed with Type 2 diabetes. Efforts to combat the issue of Type 2 diabetes can be illustrated in the CDC’s National Diabetes Prevention Program (National DPP), a lifestyle-based intervention. However, Latine participants have been less likely to achieve program goals than white participants. Cultural adaptations to the National DPP’s curriculum, such as the incorporation of family members, could improve program outcomes. To meet the needs of the Latine community more adequately, the Adapting Diabetes Interventions to improve Outcomes and Stop Type 2 Diabetes in Hispanic Communities in Utah (ADIOS T2D) project used a community-based approach by working with participants, family members, and community members to adapt the curriculum. The current research project aims to evaluate and describe the revisions made to the original National DPP manual, specifically focusing on the diversity of Latin American cuisine represented and the incorporation of relevant mental health content. Methods included the review of community advisory board meetings, the original National DPP curriculum, the adapted curriculum guide, and coded feedback from involved community members. Data analysis involved the deductive coding of photos and descriptions of foods deductively for culinary origin represented in the adapted participant guide based on broad geographical regions in Latin America. Results find that community feedback was well incorporated into the adapted curriculum when examining the diversity of Latin American cuisine and mental health content changes. Results also support the use of community collaboration within research for increasing cultural responsiveness.

Introduction

In the United States, it is estimated that 11.6 % of the population or 38.4 million people have Type 2 diabetes.^[1] While this national prevalence is a major public health concern, Type 2 diabetes disproportionately affects minoritized communities in the United States. This is especially true for Latine communities, as the prevalence of Type 2 diabetes is the highest of all major racial/ethnic groups.^[2] Specifically, Latine adults are two times more likely than non-Hispanic whites to be diagnosed with Type 2 diabetes.^[3] To combat this prevalence, the Centers for Disease Control and Prevention began the lifestyle-focused National Diabetes Prevention Program in 2010 – releasing program manuals in both English and Spanish.^[4]

Despite the launch of the National Diabetes Prevention Program (National DPP) in both English and Spanish, the engagement of Latine participants has been considerably lower than that of white participants. Within the first four years of the National DPP only 10% of participants were Latine.^[5] Given the rates at which Latine communities experience Type 2 diabetes, this is especially concerning. When aiming to improve outcomes amongst specific populations, culturally relevant adaptations are important. Previous cultural adaptations to the National DPP have increased attendance rates amongst Latines.^[6] To better meet the needs of Latine communities, methods to make the National DPP more culturally responsive must be explored.

Background

To increase the cultural responsiveness for Latine communities, the Adapting Diabetes Interventions to improve Outcomes and Stop Type 2 Diabetes in Hispanic Communities in Utah (ADIOS T2D) project used a community-based participatory research approach to adapt a National DPP curriculum. The community-academic ADIOS T2D research team included leaders from a local non-profit, Alliance Community Services, and researchers from the University of Utah. Further, the team recruited eight community members with personal and/or professional experience with Type 2 diabetes management and prevention to be part of a community advisory board. These community advisory board members made recommendations about questions in the focus group guides used to obtain qualitative feedback from participants and how to adapt the curriculum based on results of the mixed methods data.

In the first phase of the project, Latine individuals at risk for Type 2 diabetes were recruited along with one adult family member with whom they lived. These participants received the “core curriculum” of the Centers for Disease Control and Prevention (CDC) Spanish version of the National DPP, PrevengaT2. Following each class, participants provided mixed methods feedback. The research team summarized this feedback and shared it with the community advisory board, which recommended specific steps for the adaptation. Upon completion of the adaptation, PrevenganT2, another set of participants were recruited for the second phase of the project, a pilot trial of the adapted intervention. Ultimately, the ADIOS T2D project lasted from 2022 to 2025 with the adapted National DPP curriculum being completed in June 2025.

Objectives

The purpose of this case study is to evaluate and describe adaptations made to the CDC’s National Diabetes Prevention Program curriculum during the ADIOS T2D project in relation to (a) the diversity of Latin American cuisine represented and (b) mental health content incorporated.

Methods

Demographics

Participants included Latine community members (N=46) aged 18 years or older. For feedback on PrevengaT2 (Phase 1), participants included individuals at high risk for Type 2 diabetes (n=16), adult family members who attended the program along with the individual at risk (n=16), and community health workers (CHWs) who were trained to deliver PrevengaT2 as lifestyle coaches (n=6). Phase 1 participants were recruited from each of three counties in the Salt Lake Valley. Finally, eight community advisory board members provided feedback on PrevengaT2 as well as recommendations for the adapted curriculum. Figure 1 details the countries of origin for the members of the community advisory board. Two CHW participants made recommendations for the adapted manual, as well.

Of the eight community advisory board members, five (62.5%) listed Mexico as their country of origin. These five would be categorized as Central American. One (12.5%) of the community advisory board members listed Honduras as their country of origin and would also be categorized as Central American. One member (12.5%) would list their country of origin as Colombia and would be categorized as South American. Finally, one member (12.5%) would list their country of origin as the United States and be categorized as North American.

Data Analysis

Data analysis involved reviewing community advisory board meetings, the PrevengaT2 curriculum, the adapted participant guide, and coded feedback from involved community members. Coding of the present research was completed by two members of the HEART Lab at the University of Utah. The first HEART Lab research assistant coded feedback (a total of 166 separate documents) deductively then inductively. The second HEART Lab research assistant later identified the most common feedback in relation to cultural relevance, mental health content, and food content.

Additionally, the second HEART Lab research assistant coded photos and descriptions of foods deductively for culinary origin represented in the adapted participant guide based on broad geographical regions in Latin America. Namely, the culinary origins were grouped as Central America (e.g. Mexico, Guatemala, and Costa Rica), the Caribbean (e.g. Cuba, Puerto Rico, and the Dominican Republic), and South America (e.g. Ecuador, Peru, and Argentina). The participant guide for the adapted curriculum, PrevenganT2, was a 171-page document.

Results

Diversity of Latin American Cuisine Represented

Involved community members identified a need for more culturally relevant food in the adapted curriculum. For example, there were concerns about the demonization of cultural food and unfamiliarity with the manual-recommended meals or ingredients in PrevengaT2. For example, one participant gave their feedback about the lack of cultural consideration in the participant guide’s substitutions recommendations, noting, “…en la comida tres, por ejemplo, están los tacos y en la otra esta el espagueti o las pastas, pero causalmente cuando camian no camb, o sea, en el de tacos le quitan las tortillas, pero en el otro no le quita el espagueti” [in the third meal, for example, coincidentally when they change, in the taco one they take away the tortillas, but in the other one they don’t take away the spaghetti because it’s the pasta].

Figure 2 details the number of photos and descriptions of food within the adapted curriculum. Of the 87 photos with identifiable ingredients and/or meals, 85% were coded as representative of Central America, 60% of the Caribbean region and South America respectively, and 14% that did not have an identifiable origin to the knowledge of the researcher. Of the 437 descriptions of food, 95% were coded as representative of Central American cuisine, 90% of Caribbean region cuisine, and 91% of South American cuisine. Finally, 3% of descriptions were classified as not having an identifiable to the knowledge of the researcher.

Adaptations Relating to Mental Health Content

Another major theme of community feedback on the original CDC PrevengaT2 program was the need for tools for coping with stress and anxiety, specifically in relation to food and weight. Dealing with changes in diet or thinking about weight and health can be challenging. Specifically, participants alluded to stress, anxiety, and obsessive thoughts. One participant spoke saying, “Y lo que me ataca el éstres” [Stress attacks me]. Recognizing a need for more support, involved community members requested more material related to mental health and coping skills within the National DPP curriculum.

In comparison to the original National DPP curriculum, the adapted manual contained a condensed but more varied amount of material relating to mental health. While the original manual had content spread between two modules respectively named “Supere el Estrés” [Overcome Stress] and “Hágarse Cargo de Sus Pensamientos” [Take Charge of Your Thoughts], the adapted manual combined the modules into one named, “Trabajemos el Estrés y Nuestros Pensamientos” [Let’s Work on Stress and Our Thoughts]. While both manuals included examples of and recommendations for managing stress and harmful thoughts, the adapted manual allowed more instances for participants to actively learn coping skills. For example, activities included space for participants to explore the causes of their stress and also work through negative thoughts they may have. It also provided directions for progressive muscle relaxation. Finally, the adapted manual included links to outside resources on dealing with depression and anxiety.

Discussion

Using a community-based participatory research approach appears to be a viable method for incorporating community input into interventions. The adapted manual not only contained more culturally relevant material but also incorporated specific concerns introduced by participants. As described above, the pictures and descriptions of food in the adapted program represented a variety of Latin American cuisines. Additionally, the adapted manual included diversified and more interactive material related to mental health.

Despite the many culturally responsive adaptations made to PrevenganT2, areas for development and refinement persist. Photos and descriptions of food included in the adapted manual clearly skew towards a Central American population. While the U.S. Latine population is heavily composed of Central Americas, immigration and heritage are found from many other countries and regions within Latinidad. When aiming to attune the manual for the diverse Latine community, it is important to recruit participants from varied cultural heritage. Additionally, the external resources included in the adapted manual were minimal and unable to speak to more serious mental health concerns. Further external mental health information, possibly linking to national or statewide resource databases, may be beneficial for both participants and lifestyle coaches seeking information and support.

While there is always room for improvement within research and intervention development, future intervention adaptations should consider using a community-based participatory research approach to increase their cultural responsiveness.

Limitations

Despite the strengths of this study, there are several important limitations to note. First, the coders on this project lacked diversity in terms of cultural knowledge of Latin American cuisine. Specifically, the food descriptions were coded by a second-generation Ecuadorian American. While this coder clearly has applicable cultural knowledge, the lack of researchers from other regions may have limited correct identification of the diet represented throughout Latinidad. Second, codes representing Latin American cuisine were broad. While there are some historical culinary similarities across countries, the diversity between countries–and even within one country–must be acknowledged. Finally, the ADIOS T2D project and the PrevenganT2 manual were developed alongside members of Latine communities in the Salt Lake Valley. For this reason, recommendations and adaptations may not generalize to communities in other regions of the United States.