The Pure Prairie Living Program for Type 2 Diabetes: Evaluation and Steps to Optimize and Enhance Participant Success

  • Author / Creator
    Archundia-Herrera, Martha C.
  • Background: Given the complex etiology of type 2 diabetes (T2D), the Diabetes Canada
    Clinical Practice Guidelines recommend a multidisciplinary approach for its management, in
    which self-management education and support, nutrition therapy, physical activity and
    pharmaceutical therapy play major role. However, people with T2D face difficulties in following
    these guidelines especially in regards to nutrition therapy. Consequently, lifestyle intervention
    (LI) programs help guide participants through the overwhelming process of acquiring necessary
    knowledge and skills. The goal of the work presented in this thesis was to provide strategies that
    enhance participants’ successful adherence to the guidelines through the evaluation and
    optimization of the Pure Prairie Living Program (PPLP), a LI developed previously. Thus, the
    primary objective of this thesis was to evaluate the effectiveness of the PPLP in a primary care
    setting. Guided by results obtained from this randomized controlled trial (RCT), two additional
    objectives were examined:
    i) To analyze to what extent LI programs align with the cornerstones of T2D
    management and to compare their effect sizes when moving through the scale-up
    process (efficacy trials to effectiveness trials)
    ii) To understand the lived experience of people with T2D when managing their disease,
    in order to identify optimization strategies for the PPLP and other LI programs.
    Methods: The PPLP intervention was a 2-arm, parallel group, RCT. Participants were blinded to
    group assignment through concealment of allocation until assignment occurred. The program
    spanned 6 months from recruitment to the final participant visit. Baseline, 3- and 6-month
    assessments were carried out in the PPLP intervention group (n = 25) and wait-listed controls
    (CON, n = 24) to assess anthropometric, metabolic and demographic information. In the
    intervention arm participants attended and participated in 5 weekly nutrition education session (~
    90 min each). They received the PPLP resource pack that consisted of a copy of the nutrition
    education presentations each week and a copy of the PPLP workbook to guide them though the
    educational sessions and provide support, positive reinforcement of concepts and the opportunity
    for skill acquisition. Lastly, a copy of the Pure Prairie Eating Plan was provided to facilitate and guide participants towards healthy eating options. A detailed summary of intervention activity
    content, educational sessions and support materials can be found at During
    the 3-month evaluation, two focus groups with the intervention group were carried out. After the
    6-month evaluation, the waited listed control group started the education sessions.
    For the analysis of LI alignment with the guidelines, a systematic review methodology was
    adopted guided by PRISMA guidelines. Studies reporting on real-world LI that included at least
    two of the main pillars of T2D management in accordance with the Diabetes Canada Clinical
    Practice Guidelines, had gone through scale-up process (efficacy (research setting) to
    effectiveness (real-world setting)), and reported HbA1c were included. Multiple databases were
    searched and titles and abstracts, then full texts were reviewed based on the predetermined
    inclusion and exclusion criteria. For studies meeting the inclusion criteria, research setting pairs
    were retrieved. Risk of bias components were assessed using the Joanna Briggs Institute
    To understand the lived experience of people with T2D an explorative qualitative study design
    was undertaken guided by COREQ checklist. Purposeful sampling was used to recruit 15
    participants who had participated in LI programs and/or had past consultations with any health
    care provider (HCP) regarding their T2D. One-on-one, semi-structured, open-ended, in-depth
    interviews were conducted. An essentialist paradigm was adopted to report experiences, meaning
    and the reality of participants. An inductive approach was used to analyse the data.
    Results: The RCT intervention yielded no significant within-group changes in HbA1c at 3-
    month (-0.04 (-0.27 to 0.17)) and -0.15 (-0.38 to 0.08)) or 6-month (-0.09 (-0.41 to 0.22)) and
    (0.06 (-0.26 to 0.38)) follow up in either CON or PPLP groups, respectively. Dietary adherence
    scores improved in the PPLP group (p < 0.05) at 3 and 6 months but were not different in the
    between-group comparison. No changes in diabetes self-efficacy scores were detected.
    Participants described the program as clear and easy to understand. Knowledge acquired
    influenced their everyday decision-making but participants faced barriers that prevented them
    from fully applying what they learned. Healthcare professionals enjoyed delivering the program
    but described the “back-stage” workload as detrimental.
    The main results of the systematic review found that all the studies analyzed reported a decrease in HbA1c values in the intervention group and that a scale-up penalty was detected ranging from
    22 to 35%. Furthermore, comprehensive LI that incorporated most of the cornerstones of T2D
    management reduced HbA1c in research settings and generally sustained those benefits in realworld
    setting, albeit with a scale-up penalty under some circumstances.
    Findings from the qualitative study reflect 5 important results. First, participants’ reality of
    living with and managing T2D can be overwhelming; effective T2D management address
    individuals’ context. Second, T2D management is influenced by and forms part of a complex,
    evolving system in which a person’s behaviour is influenced not only by their personal health
    background and history, but also by their external environment where work, family and HCP
    influence their behaviour towards more positive or negative outcomes. Third, participants cycled
    through good behaviour and bad behaviour with social factors, resources, the food environment
    and competing priorities influencing these cycles. Fourth, people with T2D indicated that all the
    cornerstones of T2D management should be integrated into LI including foot, eye and dental
    care. Several program characteristics including active learning and hands-on approach were
    desired for all of the knowledge being taught; furthermore, close follow up and intervention
    maintenance strategies should be incorporated. Lastly, HCP and researchers should understand
    who each individual participant is, because through this understanding they can provide
    appropriate, directed advice that will be effective for each individual context.
    Conclusion: While some positive effects of the PPLP intervention were observed, they were not
    comparable to those previously attained by our group in an academic setting or to what the
    guidelines recommend, which reflects the challenge of translating LI programs to real-world
    settings. However, the finding of a modest scale-up penalty does not negate that real-world
    application of LI programs can result in clinically relevant improvements in T2D outcomes,
    particularly if interventions support and promote the importance of each cornerstone of T2D
    management and work with patients to help them increase or maintain their focus or inclusion of
    each behaviour over the long term. Including input from participants’ context, experiences and
    needs, will provide more sustainable and realistic LI programs. People living with T2D request a
    more extensive and comprehensive treatment to address the multifaceted etiology of this chronic
    disease. Shifting of program content, delivery and long-term maintenance is required to address
    participants’ needs.

  • Subjects / Keywords
  • Graduation date
    Spring 2021
  • Type of Item
  • Degree
    Doctor of Philosophy
  • DOI
  • License
    This thesis is made available by the University of Alberta Libraries with permission of the copyright owner solely for non-commercial purposes. This thesis, or any portion thereof, may not otherwise be copied or reproduced without the written consent of the copyright owner, except to the extent permitted by Canadian copyright law.