SPECIFIC AIMS In the U.S. it is estimated that 20.8 million people (7% of the population) have diabetes, and of these, 14.6 million are diagnosed and an estimated 6.2 million remain undiagnosed (National Diabetes Information Clearinghouse [NDIC], 2005a). In addition to the millions of people in this country who have been diagnosed with diabetes or who have it but don't yet know that they do, the prevalence of pre-diabetics among U.S. adults has been increasing and is now about 30.5% (Ford et al., 2004). Pre-diabetics have blood glucose levels that are higher than normal but have not yet risen to the level at which they would indicate a diagnosis of diabetes. Therefore, people who are at risk for diabetes are an important group to target for interventions that prevent or delay the onset of diabetes. Type 2 diabetes, the most common type, is expected to increase by 165% between 2000 and 2050 (Boyle et al., 2001). Diabetes and its complications (heart disease, stroke, and hypertension, kidney disease, blindness, and distal neuropathy and amputation) are leading causes of morbidity and mortality in the U.S. (Centers for Disease Control and Prevention [CDC], 2004;National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2004). In addition to the loss of quality of life, diabetes is one of the more economically costly chronic diseases (CDC, 2005a;Nichols &Brown, 2005). In 2002, the nation spent $132 billion on direct medical and indirect expenditures related to diabetes, or $13,243 on each patient with diabetes compared to $2,560 per person for people who do not have diabetes (Hogan et al., 2003). Even persons with elevated glucose who are not yet diabetics (i.e., pre-diabeticj incur a 31% higher rate ($4,977) in health care costs compared to $3,799 in health care costs of persons with normal glucose levels (Beckley, 2005). Non-Hispanic Blacks aged 20 years or older are 1.8 times more likely to have diabetes as non-Hispanic whites (CDC, 2005b), and diabetes is one of the leading causes of disease burden and disability in African-Americans (McKenna et al., 2005). For example, compared to whites, African Americans with diabetes are more likely to develop heart disease, peripheral vascular disease leading to lower limb amputation, blindness, kidney disease, and neuropathy, and death as a result of these complications (Lanting et al., 2005). The finding that African Americans compared with Whites have higher Hemoglobin A1C (HgA1c) levels (a marker for diabetes control) may be one explanation why African Americans with diabetes are more likely to develop diabetes complications and experience greater disability from the complications than white Americans with diabetes (Kirk et al., 2006). Thus, primary prevention of diabetes is an essential public health goal (U. S. Department of Health and Human Services [USDHHS], 2000), and it is especially important for African Americans. The primary modifiable risk factors for type 2 diabetes are physical inactivity and a high fat, high carbohydrate diet (American Diabetes Association [ADA], 2004;Gross et al., 2004;Swinburn et al., 2001), which often results in overweight and obesity. Although rates for overweight and obesity are a problem for all racial and ethnic groups, 69.6% of African Americans are overweight and 39.9% are obese, and among women, the black population has the highest prevalence of overweight (78%) and obesity (50.8%) (CDC, 2006a). Strong evidence indicates that modifying lifestyle to increase physical activity and improve diet can prevent or delay diabetes in people who are at risk (Diabetes Prevention Program Research Group, 2002;Hamman et al., 2006;Laaksonen et al, 2005;Pan et al., 1997). The Diabetes Prevention Program used an intensive lifestyle intervention that included individual and group sessions with a lifestyle coach (Diabetes Prevention Program, 2006). An important finding from this study was that diabetes can be prevented or delayed by losing a modest amount of weight and increasing physical activity with modification of lifestyle behaviors--30 minutes of physical activity 5 days a week and eating healthier. The National Diabetes Education Program launched the Small Steps. Big Rewards. Prevent Type 2 Diabetes campaign, the first-ever national diabetes prevention campaign, to encourage the millions of Americans with pre-diabetes to make modest lifestyle changes that could delay and possibly prevent the onset of the disease. By losing 5%-7% of their body weight and getting just 2 1/2 hours of physical activity a week, people with pre- diabetes can reduce their risk for developing type 2 diabetes by more than half (CDC, 2005). While there are many types of interventions to assist people in making these lifestyle changes, changing physical activity and dietary behaviors even for short durations has been difficult and has required complex and systematic activities to ensure successful outcomes (Blue &Black, 2005). Interventions that are designed to address the unique needs and concerns of individuals have shown promise in changing a number of health-promoting behaviors (Holtgrave et al., 1995). For example, Clark et al. (2004) found that a brief, tailored lifestyle self-management intervention for patients with diabetes helped them to reduce fat intake and improve their physical activity. Ryan and Lauver's (2002) integrative review of tailored interventions revealed that 1) people preferred tailored to standard informational interventions because they were personal and they could remember and discuss the content more often, 2) tailored interventions had better outcomes than standard interventions, 3) tailored interventions were more effective when past behavior feedback was provided, and 4) tailored interventions were more effective than standard interventions in changing dietary behaviors, but there were mixed results in changing physical activity behaviors. Traditional health promotion programs, including national campaigns, are based on the premise that clients are ready to change their behaviors, which includes only about 20% of the population (Prochaska, 1997). The other 80% either is not considering the behavior change or is considering the behavior change but have not acted on it. Research has shown that people resist messages of behavior change even when a health risk is apparent (Dowd, 2002;Whitehead &Russell, 2004). Even people who want to change a behavior often are ambivalent to the change?on the one hand, they want to change, but on the other hand, they do not want to give up the behavior that may be more comfortable for them (Miller &Rollnick, 2002). It is this ambivalence to change that can be alleviated with interpersonal, motivating interaction (Rollnick &Miller, 2002). For example, diet and physical activity interventions for African Americans have been more successful with frequent positive motivating feedback (Racette et al., 2001) and the addition of motivational interview counseling (Resnicow et al., 2005). Although educational materials for the Small Steps. Big Rewards. Prevent Type 2 Diabetes campaign have been tailored to high risk groups, including African Americans, one of the goals for the campaign is to identify delivery strategies that are appealing to special populations (National Diabetes Education Program, 2006). For some people, receiving the Small Steps. Big Rewards. Prevent Type 2 Diabetes educational materials may be enough to change behaviors, while other people may need help with interpersonal motivation in addition to the printed materials to help them overcome their resistance to behavior change. Strategies for enhancing intrinsic motivation to follow the physical activity and dietary recommendations may strengthen the outcomes of the Small Steps. Big Rewards. Prevent Type 2 Diabetes campaign. If we are to reach the at-risk people who need to change their behaviors to reduce their risk, we need to create health promotion and prevention programs that match the needs of the people (Prochaska, 1997). DiClemente and Velasques (2002) have recommended that a motivational interviewing intervention be combined with an individual's readiness for change to enhance intrinsic motivation to change behaviors. Following these recommendations may result in improving behaviors in the 20% of the people at risk for diabetes who are ready to change their behavior as well as the 80% who may increase their intrinsic motivation to change the physical activity and dietary behaviors addressed in the Small Steps. Big Rewards. Prevent Type 2 Diabetes. The purpose of this study is to test a motivational interviewing intervention for African Americans at risk for diabetes and evaluate the efficacy of this intervention in improving their physical activity and diet. Motivational interviewing (Ml) is a client-centered counseling technique that is focused on individual decision making and results in enhanced motivation for behavior change (Miller &Rollnick, 2002). The client-centered, individualized nature of Ml recognizes the individual as central to the success of the intervention. Goal setting by the individual is a key element of Ml (Miller &Rollnick, 2002), and goal attainment scaling (GAS) is a measurement strategy for evaluating individual progress toward goals that the individual determines (Kiresuk et al., 1994). Therefore, GAS will be used to monitor individual behavior change, provide feedback to the Ml participants, and to focus the motivational interview intervention.
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