Multi-Level Interventions in Obesity and Type 2 Diabetes Prevention and Management

Background and Purpose: Obesity and type 2 diabetes (OB-T2D) are multifactorial epidemic conditions. A prevailing misconception is that OB-T2D are result of personal health choices. However, socio-ecological factors are stronger drivers of OB-T2D outcomes. For example, chronic poverty initiates pathogenic metabolic sequelae (e.g., chronic inflammation, oxidative stress), and doubles the risk for OB-T2D. Such an endemic calls for interventions that address multiple levels of the social ecology (e.g., individual, interpersonal, organization, structural). Historically, OB-T2D interventions have focused on the individual-level (e.g., goal setting). While effective at improving, for example, glycemic control over the short term, they fail to address the socio-structural precipitants to OB-T2D metabolic sequelae, and worse disease management outcomes for low-income populations.

Multi-level interventions, which occur at multiple levels of the social ecology, are posited to improve OB-T2D clinical outcomes beyond individual-level interventions alone. Social workers, with their extensive training in ecological systems theory, are well-positioned to inform and implement multi-level interventions in transdisciplinary teams. To the author’s knowledge, there are no scoping reviews that assess how much, and what kinds of peer-reviewed literature examine the effectiveness of multi-level interventions for adults (18 and older) on OB-T2D clinical indicators. The aim of the current study is to conduct a scoping review of multi-level interventions on OB-T2D clinical outcomes (e.g., body mass index, hemoglobin A1C) for adults.

Methods: A scoping review was conducted in five large community health and psycho-social well-being databases: PubMed, CINAHL, PsycInfo, Scopus, and SocIndex. Inclusion criteria were peer-reviewed scholarly articles, published any year in any country, English, multi-level interventions, and OB-T2D clinical outcomes. The search yielded 1,160 peer-reviewed articles. After 474 duplicates were removed, 75 articles met the inclusion criteria. Emergent thematic analysis was used in the full-text review to identify themes.

Results: Multi-level interventions commonly included two levels of the social ecology. Individual-level components included: psycho-social counseling (e.g., solutions-focused therapy), diet management, physical activity (PA), PA education, T2D self-management education, goal setting, and PA aids (e.g., pedometer). Interpersonal-level: group psycho-social counseling (e.g., motivational interviewing), nutrition education, PA, PA education, OB-T2D prevention and management education, and social support. Organizational-level occurred within community health clinics and religious centers. Community clinic components included strengthening clinician and patient partnerships, training clinicians on diabetes empowerment, and care coordination between the clinical team and behavioral health providers (e.g., social workers). Religious congregates received T2D prevention training and delivered sermons and take-home faith activities geared toward health management. One intervention sought to address structural-level OB-T2D stigma through community educational activities. Multi-level interventions significantly reduced weight and hemoglobin A1C.

Conclusion and Implications: Though effective at reducing weight and hemoglobin A1C, improvements were not observed over time and differed by participant engagement. Notably, only one multi-level intervention involved the structural-level. The structural-level (e.g., policy), influences all other levels of the social ecology. Social Workers, as members of the care continuum, may like to advocate for multi-level interventions that intervene in structural drivers of OB-T2D. Such interventions may better maintain OB-T2D clinical improvements over the long term.