Health Disparities

HD: Effectiveness of Nutrition Intervention Methods (2010)


Garvin CC, Cheadle A, Chrisman N, Chen R, Brunson E. A community-based approach to diabetes control in multiple cultural groups. Ethn Dis. 2004 Summer; 14 (3 Suppl 1): S83-S92

PubMed ID: 15682776
Study Design:
Trend Study
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:

To demonstrate the effectiveness of interventions to reduce the diabetes-related disparities among most of the racial/ethnic groups* in Seattle and King County though the Racial and Ethnic Approaches to Community Health (REACH) 2010 program.

*Racial/ethnic groups defined as Americans (AA), Cambodians, Chinese, Filipinos, Koreans, Vietnamese (Asian/Pacific Islanders - API) and Latinos/Hispanics (L/H)

Inclusion Criteria:
  •  Those living in Seattle and King County
  • Other specific inclusion criteria not explained in this paper.
Exclusion Criteria:

Not specified 

Description of Study Protocol:


Not explained


  • The REACH 2010 Coalition created a community action plan implemented by the following contracting agencies: The Center for MultiCultural Health (CMCH), African American Community Health Network (AACHN), International Community Health Services (ICHS), Sea Mar Community Health Centers (Sea Mar) and the Community Health Council of King County
  • This action plan included a number of interventions (listed below)
    • There was an evaluation of REACH classes and support groups 
      • Quantitative:
        • Pre- and post-surveys were used to assess the impact of support groups, education classes and self-management classes; subjects were given a closed-ended survey at the first session attended and again at the last session of the cycle
        • Support group surveys are administered at the first meeting attended and at six-month and one-year follow-ups
        • Surveys were administered by REACH evaluators, using translators, if necessary
        • Repeat participants are given a post-test survey at the end of each cycle of classes
        • Survey instruments were developed by the Evaluation Team to measure:              
          • Diabetes knowledge, social support level, attitudes, self-efficacy and health status
          • Three methods were used for in-class survey administration: Self-administration, one-on-one administration and group administration
          • Two additional methods were added in February 2003, mailed and administered at participants home.
      • Qualitative:
        • Focus groups were used to determine how REACH affected the lives of the group participants by asking about their experiences in REACH activities and living with diabetes following their REACH involvement
        • Trained moderators were used (one to facilitate and one to take notes)
        • Focus groups were conducted from July 2002 through August 2002 for each racial/ethnic group for participants of REACH classes anytime from September 2001 through June 2002
        • Grocery store gift cards ($25) were provided for focus group participants.


Interventions were directed to multiple societal levels, including individuals, families, communities and institutions:

  • Support Groups
    • Regularly-scheduled meeting for diabetes patients and their family members and friends
    • Tailored to meets the cultural needs of each of the three broad racial/ethnic groups (language and food preferences)
    • Formal and informal discussions led by a trained lay leader, peer educator or health professional
    • Getting what you need from the health care system, following medical, physical activity and healthy diet recommendations, managing discrimination, racism and other stressors, getting support from friends and family.
  • Peer Education
    • Lay leader with diabetes or with a friend or family member who has diabetes facilitates support groups and assists in education and self-management classes and arranges for the dissemination of diabetes materials in community settings 
    • Multiple bilingual peer educators address the need for multiple language capacity
  • Education Classes
    • Cover topics such as, diabetes education, how to check blood glucose levels, physical activity, healthy eating without losing taste or cultural significance, weight management/weight loss, psychosocial issues and social support and how to talk to your medical provider.
  • Self-Management Classes
    • Trained facilitators offer classes several times per year. These six-week classes assist patients to increase their confidence in their ability to manage their disease (following the Lorig Chronic Disease Self-Management model)
    • Topics covered: Cognitive symptoms and their management, how to formulate and personalize action plan, exercise, healthy eating, communication skills, problem-solving, medication usage and working with health care professionals. 
  • Enhanced Use of a Diabetes Registry
    • The use of the Chronic Disease Electronic Management System (CDEMS), software to create diabetes registries within each of the participating community clinics, so that individuals who have not received appropriate services can be identified and targeted for intervention.
  • Case Coordination for Appropriate Patients
    • Conducted in several settings, REACH 2010 case coordinators are health professionals who work in the selected settings to assist providers in using the diabetes registry to improve patient care
    • Alert providers of poor glycemic control, difficulty keeping appointments or adhering to medical regimen, making referrals for nutrition, physical activity and stress reduction or REACH classes or groups.

Statistical Analysis



Data Collection Summary:

Timing of Measurements

  • Support group surveys are administered at the first meeting attended and at six-month and one-year follow-ups
  • Focus groups were conducted from July 2002 through August 2002 for each racial/ethnic group for participants of REACH classes anytime from September 2001 through June 2002.

Dependent Variables

  • Behavior change
  • Knowledge.

Independent Variables

  • Pre-test
  • Post-test. 
Description of Actual Data Sample:
  • Initial N: 558 (59.7% female)
  • Attrition (final N): Quantitative Results:
  • Age: Range not specified in paper
    • AA mean 54.9
    • L/H mean 51.9
    • API mean 64.1.
  • Ethnicity:
    • 32.9% AA (N=184)
    • 29.5% L/H (N=165)
    • 37.5% API (N=209)
    • 29.5% L/H (N=165)
    • 37.5% API (N=209).
  • Other relevant demographics: Not applicable
  • Anthropometrics: 
    • L/H mean BMI 30.0
    • API mean BMI 24.3.
  • Location: Seattle and King County, Washington



Summary of Results:


Demographics of REACH participants
  AA Asian Latino
N 184 209 165
Female 63% 59.3% 56.8%
Mean age 54.9 64.1 51.9
Married 32% 64.2% 62.4%
High school graduate 78.3% 54.9% 42.9%
Income less than $10,000 32.3% 60.9% 59.4%
Mean number of people in household 2.1 1.9 2.8
Health status excellent, very good or good 48.1% 23.6% 25.6%
Doctor said to lose weight 65.4% 55.6% 63.4%

Participated in some physical activity

73.3% 76.3% 77.2%
Mean body mass index 33.3 24.3 30

Quantitative Results

  • As of December 2003 594 pre-tests and 410 matched post-tests were collected
    • CMCH: 187 pre-, 121 post-; ICHS 221 pre, 143 post-; Sea Mar 186 pre-, 146 post-
    • 168 lost to follow-up 
    • Expired, changed residences, had no interest, received diabetes information elsewhere.
  • Pre-and Post-health behavior changes
    • Increase in physical activity from 76% to 84% (P<0.05)
    • Improvements in dietary behaviors in 10 of 12 items from 76% to 85%
    • No change in tobacco or alcohol use.
  • Knowledge about diabetes increased significantly
    • More knew how often A1c should be checked from 54% to 69% (P>0.05)
    • More knew the best way to take care of their feet from 77% to 85% (P<0.05).
  • Changes in self-efficacy and social support increased significantly
    • Ability to keep blood sugar in good control from 48% to 58%  
    • Keep weight under control from 44% to 55%
    • Handle their feelings from 46% to 54%
    • No increases in confidence in their ability to quite smoking, limit alcohol, get health care when needed or ask a doctor for information.

Qualitative Results

  • Seven focus groups were conducted with a total of 48 participants
    • Two AA groups CMCH (six), AACHN (eight); one H/L group (seven); four Asian languages groups(18) 
    • Results for focus groups were quotes and stories from participants.


Author Conclusion:

The REACH evaluation results, to date, suggest that the program is being enthusiastically received and that the support groups and education classes are having significant impact on the way participants view and manage their diabetes. 

Funding Source:
Government: Centers for Disease Control and Prevention
Reviewer Comments:
  • Information was not clearly presented
  • Time frame of study was not clearly explained
  • Time frames of all interventions were not described; Were all class cycles six weeks? 
  • Researcher did not give reason for comparing REACH participants with Behavioral Risk Factor Surveillance Survey (BRFSS) in the results section (not presented in this work sheet)
  • The number of subjects in written results did not match those in tables
  • Focus group results were quotations and stories about participants. 
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? No
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? No
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) No
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) No
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? No
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) No
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? No
  4.4. Were reasons for withdrawals similar across groups? ???
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? N/A
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? Yes
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? ???
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? N/A
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? No
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes