Pathway From Type 2 Diabetes Diagnosis to Action: How to Move People Forward.

Seven self-care behaviors-healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem-solving-are recommended for individuals with diabetes to achieve optimal health and quality of life. People newly diagnosed with type 2 diabetes may find it challenging to learn and properly incorporate all of these self-care behaviors into their life. This qualitative study explored the experiences and perceived immediate self-management and psychosocial support needs in individuals newly diagnosed with type 2 diabetes. Data analysis revealed the significant challenges individuals encounter after a type 2 diabetes diagnosis. Five main themes were identified: 1) type 2 diabetes diagnosis competes with other complex life challenges, 2) difficulty in performing behavior modification actions, 3) lack of support, 4) emergence of emotional and psychological issues, and 5) need for planned individualized follow-up support after a type 2 diabetes diagnosis. This study revealed a gap in care after type 2 diabetes diagnosis. Individualized support is needed to assist people in moving successfully from diagnosis to being well equipped with the knowledge and skills necessary to properly manage the condition.

Hispanic Diabetes Peer Facilitator Training Needs and Connections to Hispanics With Type 2 Diabetes.

Introduction: There is a gap in the literature on the role of Hispanic peer facilitators (PFs) in online peer-support communities for Hispanics with diabetes. This paper explores bilingual Hispanic PFs' training experiences and their perspectives on their role in a continuous glucose monitoring and online peer support intervention for people with type 2 diabetes. Methods: We conducted semi-structured interviews with five PFs. A three-stage triangulation of qualitative data using inductive and deductive reasoning was used for the data analysis. Results: We grouped emerging themes into three categories: (a) technical and practical training needs and experiences, (b) building connections through shared diabetes experience, and (c) challenges and benefits of being a PF, such as helplessness, to further support participants and find motivation for their diabetes management. Conclusion: Successful peer facilitation requires more than technical knowledge. PFs need additional communication skills and psychosocial training on diabetes distress, anxiety, and depression. PFs may derive personal benefits in managing their own diabetes and making positive lifestyle changes from participating in an online peer support community.

Remodeling Type 2 Diabetes Diagnosis: What Individuals Need for Success.

The diagnosis of type 2 diabetes initiates a new health-illness transition. However, little is known about the immediate support that people need to successfully cope with this diagnosis. This qualitative study explored the experiences and immediate support needed at the point of diagnosis among individuals with type 2 diabetes. The findings suggest the need for health care professionals to render immediate emotional support in the form of reassurance and partnership to manage the condition together. Pre- and post-counseling sessions can minimize the emotional and psychological strain associated with the new diagnosis. Individuals should be given information on available resources, as well as an immediate connection with a health care partner who can provide guidance and help with the transition.

Continuous Glucose Monitoring Plus an Online Peer Support Community Reinforces Healthy Behaviors in Hispanic Adults With Type 2 Diabetes.

Background: Previous research has suggested beneficial glycemic outcomes for people with type 2 diabetes with the use of continuous glucose monitoring (CGM); yet, there is a dearth of data examining CGM in diverse populations. Additionally, the use of online peer support communities (OPSCs) can further support the application of CGM information to improve health behaviors. The purpose of this qualitative study was to assess participant experiences with a CGM+OPSC intervention. Methods: Semi-structured interviews were conducted after a 12-week combined CGM+OPSC intervention with Hispanic, Spanish-speaking people with type 2 diabetes not using insulin. The OPSC was managed by five trained bilingual peer facilitators. Interviews were conducted in Spanish. Audio recordings were translated and transcribed and then reviewed by the interviewer for accuracy. Emergent themes were identified through inductive thematic analysis. Results: Twenty-six participants completed interviews. Three main themes emerged from the data: 1) CGM supports participants' understanding of the relationship between glucose levels and health behaviors such as healthy eating, being active, taking medication, stress reduction, and improving sleep; 2) the OPSC reinforced how to make healthy choices through personal experiments, collective learning, and social support; and 3) CGM+OPSC supports behavior change and increases confidence. Conclusion: When combined, CGM+OPSC interventions appear to create a positive feedback loop to reinforce and optimize healthy behaviors for diabetes self-management in individuals with type 2 diabetes who are not on insulin. The provision of such an intervention tailored to Hispanic, Spanish-speaking individuals has the potential to address the health care disparity seen in this population.

Examining a Continuous Glucose Monitoring Plus Online Peer Support Community Intervention to Support Hispanic Adults With Type 2 Diabetes: Protocol for a Mixed Methods Feasibility Study.

BACKGROUND: Type 2 diabetes is twice as likely to affect Hispanic people than their White counterparts. Technology and social support may be an important part of behavior change. In this study, we address gaps in diabetes care for Hispanic Spanish-speaking people with diabetes through an online peer support community (OPSC) pilot intervention using Hispanic Spanish-speaking peer facilitators with diabetes to enhance the use of continuous glucose monitoring (CGM) for diabetes management. OBJECTIVE: This study aims to address gaps in diabetes care for Hispanic Spanish-speaking people with diabetes through an OPSC pilot intervention using Hispanic Spanish-speaking peer facilitators with diabetes to enhance the use of CGM for diabetes management. METHODS: A mixed-methods, pre-post test design will be used in this feasibility study. A total of 50 Hispanic participants with type 2 diabetes willing to wear a continuous glucose monitor for 13 weeks will be recruited. Hispanic Spanish-speaking peer facilitators with diabetes and experience wearing a continuous glucose monitor will be employed and undergo training. Peer facilitators will help participants learn how CGM data can inform behavior changes via an OPSC. Participants will interact with the private OPSC at least three times a week. Weekly questions and prompts derived from the Association of Diabetes Care and Education Specialists, previously American Association of Diabetes Educators, and seven self-care behaviors will be delivered by peer facilitators to engage participants. Measures of feasibility and acceptability will be determined by the percentage of participants who enroll, complete the study, and use CGM (number of scans) and objective metrics from the OPSC. Efficacy potential outcomes include change in time in range of 70 to 180 mg/dL from baseline to 12 weeks, A1c, diabetes online community engagement, self-efficacy, and quality of life. Additionally, semistructured exit interviews will be conducted. RESULTS: Funding for this project was secured in November 2018 and approved by the institutional review board in April 2019. Peer facilitator recruitment and training were undertaken in the second half of 2019, with participant recruitment and data collection conducted in January and April 2020. The study has now concluded. CONCLUSIONS: This study will generate new evidence about the use of an OPSC for Hispanic Spanish-speaking patients with diabetes to make behavior changes incorporating feedback from CGM. TRIAL REGISTRATION: ClinicalTrials.gov NCT03799796; https://clinicaltrials.gov/ct2/show/NCT03799796. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/31595.

Navigating Diabetes Online Communities in Clinical Practice.

OBJECTIVE: This purpose of this study was to conduct a rapid review and environmental scan of diabetes online communities (DOCs) to highlight the clinical impact of DOC engagement and provide guidance to health care providers for navigating and prescribing DOCs. METHODS: This two-phase review included a rapid review of clinical outcomes and an assessment of DOC content. We conducted a literature search for studies evaluating DOC use and glucometric (glycated hemoglobin [A1C], time-in-range, hypoglycemia), behavioral, and psychosocial outcomes. The environmental scan of current DOC sites established key features, including available platforms, target population, content areas, and reach. RESULTS: Twelve papers were included-eight reported DOC use within a context of do-it-yourself (DIY) noncommercial, opensource hybrid closed loop systems community and four were non-DYI related. In latter, all studies were cross-sectional, describing patient-reported outcomes. Two studies reported A1C lowering with DOC use, two DOC use was associated with high self-efficacy, one showed association with higher self-care levels, and one showed higher quality of life scores when compared with population norms. All DIY studies showed improvement in glucometrics after initiation of sensor augmented pump technology with DOC support. Of 54 DOC sites reviewed in the environmental scan, 29 were included. Diabetes online community sites were heterogenous in social media platform and type of diabetes targeted. CONCLUSION: Diabetes online communities have the potential to improve clinical, behavioral, and psychosocial outcomes. Randomized control trials and/or longitudinal prospective studies evaluating outcomes are needed to further examine the potential benefits of DOC use. Diabetes online communities are diverse and span a variety of social media platforms, providing clinicians opportunities to individualize recommendations for DOC use.

What Individuals Want to Hear at the Point of Type 2 Diabetes Diagnosis.

Recent studies have shown that the time of diagnosis with type 2 diabetes is often not a teachable moment because of heightened emotions. Yet, research also shows that individuals who are newly diagnosed with type 2 diabetes need reassurance and a clear pathway to obtain the education and support needed to self-manage the condition. This article reports on qualitative research exploring the experiences of individuals with type 2 diabetes at the time of diagnosis, including information they wanted to hear and learn at diagnosis. The findings suggest that initial communication should offer reassurance and establish a partnership between the diagnosed individual and the health care provider to identify next steps toward self-management success.

Combining CGM and an Online Peer Support Community for Hispanic Adults with T2D: A Feasibility Study.

BACKGROUND: Previous research has identified that people with type 2 diabetes (T2D) within the Hispanic community would benefit from an online peer support community (OPSC) and continuous glucose monitoring (CGM) data to facilitate diabetes self-management. METHODS: A mixed-methods feasibility study enrolled Hispanic, Spanish-speaking adults with T2D, not on insulin. Participants were provided with CGM and access to an OPSC for 12 weeks. Feasibility was assessed by number of eligible participants who enrolled, attrition, quantity of CGM data, validated clinical measures of self-efficacy, quality of life and adverse events. Engagement in the OPSC was measured using objective metrics on the online platform. Qualitative interviews were conducted upon conclusion of the intervention to assess feasibility, acceptability, participant satisfaction, and key recommendations for improvement. RESULTS: Of 46 participants screened, 39 were eligible and 26 completed the study. Participants significantly improved self-efficacy scores. Posts in the OPSC related to goal setting had the highest engagement followed by mid-week and end of week check-in posts respectively. Participant interviews described challenges accessing the OPSC platform as a barrier to engagement. Despite this, all participants were satisfied with the intervention. Key recommendations for improvement included providing greater variety of and individualized education and the use of a peer support platform that is easily accessible. CONCLUSIONS: The CGM + OPSC intervention tailored to the Hispanic community with T2D was feasible, acceptable and satisfactory and improved participant self-efficacy for diabetes management which may lead to improved clinical outcomes.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review.

BACKGROUND: A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature. METHODS: We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias. RESULTS: The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C. CONCLUSIONS: Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

2017 National Standards for Diabetes Self-Management Education and Support.

PURPOSE: The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. METHODS: The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. RESULTS: Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. CONCLUSION: Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Healthcare Professional Perceptions of Blood Glucose Meter Features That Support Achievement of Self-Management Goals Recommended by Clinical Practice Guidelines.

BACKGROUND: Blood glucose meters remain an effective tool for blood glucose monitoring (BGM) but not all meters provide the same level of insight beyond the numerical glucose result. OBJECTIVE: To investigate healthcare professional (HCP) perceptions of four meters and how these meters support the achievement of self-management goals recommended by diabetes clinical practice guidelines. METHODS: Three hundred and fifty-three HCPs from five countries reviewed the features and benefits of four meters using interactive webpages and then responded to statements about the utility of each meter and ranked each meter in terms of clinical value. RESULTS: Meter D ranked significantly higher in terms of clinical utility for all 13 guideline questions (70%-84%, P < .05) compared to other meters. Endocrinologists (69%-85%), primary care physicians (PCP; 63%-80%), and diabetes nurses (DN; 80%-89%) consistently ranked meter D highest for all guideline questions. DNs ranked selected questions significantly higher compared to PCPs (8 of 13) or endocrinologists (3 of 13; P < .05). Meter D achieved strong endorsement from HCPs in France and Germany, followed by the United States and Canada, with comparatively lower responses from Italian HCPs (P < 0.05). With respect to self-management, 80% of HCPs selected meter D as their first choice for patients with type 1 diabetes to help patients improve diabetes management or understand their numbers to help them stay in range. CONCLUSIONS: HCPs had strong preference for a meter providing additional insights, messages, and guidance direct to the patient to support achievement of self-management goals recommended by diabetes clinical practice guidelines.

A Framework for Optimizing Technology-Enabled Diabetes and Cardiometabolic Care and Education: The Role of the Diabetes Care and Education Specialist.

PURPOSE: The purpose of this article is to present a framework for optimizing technology-enabled diabetes and cardiometabolic care and education using a standardized approach. This approach leverages the expertise of the diabetes care and education specialist, the multiplicity of technologies, and integration with the care team. Technology can offer increased opportunity to improve health outcomes while also offering conveniences for people with diabetes and cardiometabolic conditions. The adoption and acceptance of technology is crucial to recognize the full potential for improving care. Understanding and incorporating the perceptions and behaviors associated with technology use can prevent a fragmented health care experience. CONCLUSION: Diabetes care and education specialists (DCES) have a history of utilizing technology and data to deliver care and education when managing chronic conditions. With this unique skill set, DCES are strategically positioned to provide leadership to develop and deliver technology-enabled diabetes and cardiometabolic health services in the rapidly changing healthcare environment.

Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice.

PURPOSE: Technology is rapidly evolving and has become an integral component of diabetes care. People with diabetes and clinicians are harnessing a variety of technologies, including connected blood glucose meters, continuous glucose monitors, insulin pumps, automated insulin delivery systems, data-sharing platforms, telehealth, remote monitoring, and smartphone mobile applications to improve clinical outcomes and quality of life. Although diabetes technology use is associated with improved outcomes, this is enhanced when the person using it is knowledgeable and actively engaged; simply wearing the device or downloading an app may not automatically translate into health benefits. The diabetes care and education specialist (DCES) has a central role in defining and establishing a technology-enabled practice setting that is efficient and sustainable. The purpose of this article is to describe the role of the DCES in technology implementation and to demonstrate the value of diabetes technology in both the care of the individual and as a tool to support population-level health improvements. CONCLUSION: By following the recommendations in this article, DCESs can serve as technology champions in their respective practices and work to reduce therapeutic inertia while improving health outcomes and providing patient-centered care for the populations they serve.

Applying a Solution-Focused Approach to Life With Diabetes: Insights Gleaned via Twitter.

PURPOSE: The purpose of this study was to explore responses of people with diabetes (PWD) when exposed to a solution-focused brief therapy (SFBT) approach. This approach focuses on solutions rather than the problems and what is desired in life rather than what will not occur. METHODS: Ten SFBT questions were presented for discussion during 1 hour of a Twitter chat on November 14, 2018, during a World Diabetes Day multiple-hour chat. Verbatim transcripts of Twitter data were downloaded from Symplur Signals LLC. Thirty-two participants from 4 countries created 358 tweets, 118 retweets, and 1.5 million impressions. A qualitative content analysis was then completed. RESULTS: Five themes emerged regarding the desired future state: more living life, laughter and humor, self-compassion, resilience, and support. There was an overwhelming sense of burden associated with diabetes yet a global feeling of hope, acceptance, and being "capable" to manage diabetes. CONCLUSION: Employing SFBT, asking future-directed questions with a focus on solutions and the desired state, generated impactful insights around life with diabetes. Diabetes care and education specialists can incorporate SFBT as a tool to focus diabetes care, education, and support in partnership with PWD. Use of SFBT in diabetes demonstrates potential to strengthen resilience and confidence needed to manage this challenging condition.

Using the RE-AIM framework to evaluate internal and external validity of mobile phone-based interventions in diabetes self-management education and support.

OBJECTIVE: We evaluated the extent to which studies that tested short message service (SMS)- and application (app)-based interventions for diabetes self-management education and support (DSMES) report on factors that inform both internal and external validity as measured by the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework. MATERIALS AND METHODS: We systematically searched PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), and IEEE Xplore Digital Library for articles from January 1, 2009, to February 28, 2019. We carried out a multistage screening process followed by email communications with study authors for missing or discrepant information. Two independent coders coded eligible articles using a 23-item validated data extraction tool based on the RE-AIM framework. RESULTS: Twenty studies (21 articles) were included in the analysis. The comprehensiveness of reporting on the RE-AIM criteria across the SMS- and app-based DSMES studies was low. With respect to internal validity, most interventions were well described and primary clinical or behavioral outcomes were measured and reported. However, gaps exist in areas of attrition, measures of potential negative outcomes, the extent to which the protocol was delivered as intended, and description on delivery agents. Likewise, we found limited information on external validity indicators across adoption, implementation, and maintenance domains. CONCLUSIONS: Reporting gaps were found in internal validity but more so in external validity in the current SMS- and app-based DSMES literature. Because most studies in this review were efficacy studies, the generalizability of these interventions cannot be determined. Future research should adopt the RE-AIM dimensions to improve the quality of reporting and enhance the likelihood of translating research to practice.

Defining Usual Care in Clinical Trials.

Pragmatic trials occur within the complexity of real-world care delivery, and when effective, contribute to more rapid translation into practice because of their greater generalizability. Research with older adults is complex when participants have chronic conditions and multiple comorbidities. Often pragmatic trials introduce a novel intervention and try to determine whether it offers a benefit beyond the usual or routine care provided. Researchers commonly focus attention on describing the intervention, yet the comparator condition of usual or routine care can be anything but standard, reducing the effect size of the intervention and introducing threats to the overall validity of the study. The current article describes clinical trial guidelines, then illustrates the complexity of characterizing usual care for interventions addressing type 2 diabetes. The authors provide recommendations for improving description of usual care and discuss implications for gerontological nursing research. [Research in Gerontological Nursing, 13(3), 125-129.].

Short-term weight trajectories and long-term weight outcomes from a lifestyle intervention in real-world clinical practice.

Centers for Disease Control and Prevention aligned lifestyle change programs are effective in promoting weight loss among those with elevated cardiometabolic risk; yet, variability in weight outcomes among participants is high. Little is known about heterogeneity of short-term weight changes among participants in real-world clinical practice. We sought to identify short-term weight trajectory clusters among lifestyle change program participants in real-world clinical practice and to examine the relationship between cluster membership and long-term weight outcomes. We identified participants from the electronic health records (2010-2017) with weight measured ≤30 days prior to program initiation (baseline) and in four intervals (3-week segments) in the 12 weeks after baseline. Clustering analysis was performed to identify distinct trajectories in percent weight change over 12 weeks. Cluster-specific differences in weight change at 12 and 52 weeks were assessed. Among 1,148 participants, across 18 clinic sites, three clusters were identified: minimal-to-no weight loss (MWL), delayed-minimal weight loss (DWL), and steady-moderate weight loss (SWL), corresponding to mean weight changes of 0.4%, -2.3%, and -4.8% at 12 weeks follow-up, respectively. Mean weight changes were 0.4%, -1.8%, and -5.1% for MWL, DWL, and SWL clusters, respectively, at 52 weeks follow-up, which correlated in direction and magnitude with short-term weight changes. Clustering analysis reveals heterogeneous, short-term weight trajectories among lifestyle change program participants in real-world clinical practice. Given the relationship between the magnitudes of short- and long-term weight change, individual participant weight trajectories may be useful in identifying potential non-responders in need of adjunctive or alternative therapy.

2017 National Standards for Diabetes Self-Management Education and Support.

PURPOSE: The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. METHODS: The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. RESULTS: Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. CONCLUSION: Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Empowering Diabetes Self-Management Through Technology and Nurse Health Coaching.

PURPOSE: This research explores the impact of mobile health (mHealth) technology and nurse health coaching on views of diabetes self-management (DSM) for persons living with diabetes. METHODS: Three focus groups (N = 24) were conducted with individuals living with type 2 diabetes who participated in a nurse health coaching and mHealth technology intervention study. Qualitative thematic analysis was used to identify overarching themes in each group. RESULTS: Major themes identified following intervention participation included enhanced perspectives about living with diabetes, increased awareness of how health behaviors influence DSM, improved support, and increased ownership of DSM. CONCLUSIONS: The themes identified suggest that the mHealth technology and health coaching intervention together may have had an empowering effect on participants' DSM. These results suggest that providing nurse health coaching with mHealth technology may help individuals ameliorate some of the challenges of living with and managing diabetes.

Implementation of a group-based diabetes prevention program within a healthcare delivery system.

BACKGROUND: Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, promote clinically significant weight loss and reduce cardio-metabolic risks. Studies have examined implementation of the DPP in community settings, but less is known about its integration in healthcare systems. In 2010, a group-based DPP known as the Group Lifestyle Balance (GLB) was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. We leveraged this natural experiment to qualitatively assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions. METHODS: Using purposive sampling, we conducted semi-structured interviews with DPP lifestyle coaches. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. RESULTS: We conducted 33 interviews at 20 clinics across the three regional administrative divisions. Consistencies in implementation of the program were found across regions in terms of satisfaction with the evidence base (acceptability), referral methods (adoption), eligibility criteria (fidelity), and strategies to increase retention and effectiveness (sustainability). Heterogeneity in implementation across regions were found in all categories, including: the number and frequency of sessions (fidelity); program branding (adoption); lifestyle coach training (adoption), and patient-facing cost (cost). Lifestyle coaches expressed differing attitudes about curriculum content (acceptability) and suitability of educational level (appropriateness). While difficulties with recruitment were common across regions (feasibility), strategies used to address these challenges differed (sustainability). CONCLUSIONS: Variation exists in the implementation of the DPP within a large multi-site healthcare system, revealing a dynamic and important tension between retaining fidelity to the original program and tailoring the program to meet the local needs. Moreover, certain challenges across sites may represent opportunities for considering alternative implementation to anticipate these barriers. Further research is needed to explore how differences in implementation domains impact program effectiveness.