Diabetes Management In Physical Therapy: Developing A Nutrition, Exercise, And Lifestyle Program With Rupal M Patel, PT, PhD

Welcome back to the Healing Pain Podcast with With Rupal M Patel, PT, PhD

Diabetes is one of the fastest-growing chronic conditions affecting physical health, physical function, mental health and mental well-being. In the United States, most Americans are either prediabetic or diabetic, and most of them go undiagnosed. In this episode, Dr. Joe Tatta is joined by diabetes researcher and diabetes management expert Rupal M Patel, PT, PhD to discuss who a group-based culturally-tailored lifestyle intervention program can help in addressing the diabetes epidemic in the country. She discusses who she developed and tested a 12-week community-based group diabetes management program, which uses nutrition, exercise and other lifestyle interventions. Join in and learn about the results of Dr. Patel’s inquiry and how it can change the way diabetes is addressed by the healthcare system.

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Diabetes Management In Physical Therapy: Developing A Nutrition, Exercise, And Lifestyle Program With Rupal M Patel, PT, PhD

Addressing Diabetes Through Community Based Lifestyle Programs

Thanks for joining me for this episode. In this episode, we’re discussing how to treat, manage and reverse diabetes through a combination of nutrition, exercise and lifestyle medicine interventions. Diabetes is one of the fastest-growing chronic conditions affecting physical health, physical function, mental health and mental well-being. In the United States, most Americans are either prediabetic or diabetic.

According to the latest CDC data in 2020, at least 38% of US adults have prediabetes. Most of these conditions go undiagnosed or often missed and many go on to develop full diabetes. Diabetes majorly increases the risk of cardiovascular disease. If you have diabetes, you’re more than likely to have heart disease or stroke. It also affects muscle tissue and nerves, especially peripheral nerves in the feet and hands causing painful diabetic neuropathy. It can damage the brain and the central nervous system causing early cognitive decline and increasing the risk for conditions such as Alzheimer’s and dementia.

My guest is Dr. Rupal Patel. She is at the forefront of diabetes research and management approaching it from a comprehensive, integrative and lifestyle approach. Her PhD studies and dissertation work culminated in a randomized controlled trial of the effectiveness of a group-based culturally-tailored lifestyle intervention program on changes in risk factors for Type 2 diabetes.

In this episode, we discussed how Dr. Patel created and tested a twelve-week community-based group diabetes management program, which uses nutrition, exercise and other lifestyle interventions. The participants of her group maintain positive lifestyles and biomarker changes past the six-month period, which demonstrates that her intervention was useful for the long-term management of not only glucose regulation but also diabetes care and prevention. Diabetes is a condition that impacts physical therapy care and rehabilitation across all physical therapy specialties as well as subspecialties.

We discussed the risk factors for diabetes, why lifestyle medicine is the first defense even before medication for the treatment of prediabetes, how to screen and intervene for diabetes in your clinic and free online resources you can use in your practice for diabetes education. We also discussed the chapter that Dr. Patel wrote in the upcoming book, Integrative and Lifestyle Medicine in Physical Therapy. This text is available for purchase. You can find it on Amazon or by going directly to the publisher’s website at OPTP.com.

This evidence-based text shows physical therapists how to use a biopsychosocial systems-based integrative approach to physical therapy practice. Dr. Patel contributed to the section on diabetes care. If you read this, purchase the textbook and read her section on diabetes, you will be ahead of the curve in how to manage, treat and reverse diabetes.

I had the opportunity to co-edit this textbook with my colleague and physical therapist, Dr. Ginger Garner. We’re fortunate enough to have the contribution of over 40 other physical therapy researchers, educators and clinicians that significantly contributed to this textbook. I would like to thank everyone for their dedication and contribution to this great text and especially thank our publisher OPTP for all of their editorial support. Without further ado, let’s begin and meet Dr. Rupal Patel and learn about managing diabetes from an integrative and lifestyle medicine perspective.

Rupal, welcome to the show. It’s great to have you here to talk about diabetes.

Thank you for having me, Joe. I’m excited to be here.

I’m going to point people right away at the top of this episode to the book Integrative and Lifestyle Medicine in Physical Therapy because you penned a whole big section of a chapter on the care of diabetes and prevention and how we can use integrative and lifestyle medicine interventions as physical therapists. Everyone can find that book on the OPTP website. That’s OPTP.com. We’re going to talk a lot about diabetes, which I’m excited about.

HPP 28 | Diabetes Management
Integrative and Lifestyle Medicine in Physical Therapy: A guide for primary care, health promotion, and disease prevention

I love the stance that you’re taking on this topic because it fits well within the PT scope of practice with regard to prevention, health and wellness promotion, treatment and disease management and primary care physical therapy. Those are all important topics that we are discussing in our practice, field and profession as DPTs and physiotherapists across the globe. How did you get started in diabetes? I know a little bit of your backstory but when you first got started, this wasn’t a topic that PTs were talking about.

It was not even a topic that I was thinking about as a physical therapist. Accept it as a sidebar because so many of the patients that I saw had diabetes as a condition but it wasn’t until I started my PhD work in health promotion and wellness that we started taking classes and looking at primary prevention and the big things that contribute to mortality in our country. Heart disease, diabetes and obesity are big factors. It made me think about looking upstream.

As a physical therapist in clinical care, here I am. I’m seeing people that already have diabetes. Sometimes by then, it may be too late to do anything except more tertiary prevention or management but if we can curtail this earlier, then we will improve our population’s health. That’s what we’re about as a profession. Our vision is transforming society. We can transform society by going more upstream and thinking about primordial and primary prevention.

That switch flipped in my brain when I was doing my PhD work in the didactic classes I was taking. Diabetes particularly was of interest to me because my father-in-law had been a lifelong diabetic. Around the time when I was starting my PhD, he moved to Dallas to be closer to us because he was getting significantly ill. He had to stop working at the early age of 62 before he was even eligible for Medicare. Here he is, an educated man and an engineer.

He was an immigrant but had been in the United States for at least 25-plus years, yet still. He had health insurance and all these things that we think of as factors that are determinants of getting diabetes but he didn’t have those things that were barriers. It got me interested. He’s already getting sick. We need to manage him and his diabetes but what could have been done?

It’s that personal connection. Everything that I started learning about prevention, I always reflected on my father-in-law’s experience, thinking back, “I wonder if he had this. Could this have been different?” That’s how I got started in looking at it from having a family member who had it and seeing what he was going through as well as learning about the importance of prevention and how we can mitigate some of the mortality.

The seed was planted early with you in your PhD program.

Yes. In PT curricula, we don’t tend to focus on it as much as primary prevention. In my curriculum, where I teach at Texas Woman’s University in Houston, we do have two courses on health promotion and wellness. One of them has an individual health focus and one has a community health focus. We do talk about prevention from that perspective but I still feel like it’s an area that we could do better in terms of education, practice and having physical therapists take on that more upstream approach and look at it from a prevention lens with their patients, even orthopedic clients that have sports issues or young adults that have potentially Fatty Liver disease that is going to end up with diabetes if nothing gets done in terms of their nutrition, weight and other things. We have some work to do in that area.

How deep did you go into your PhD with regard to this topic of diabetes?

On diabetes, not particularly. In the assignments that we did as part of different courses, we have the choice of digging deeper into an area. I focused on that area but we learned about things like primordial primary prevention and what are different ways to do that. I took it as, “How can I apply this to a patient with diabetes or a patient with risk factors for diabetes, whether they are genetic, behavioral, lifestyle or environmental?”

When we talk about health behavior change and utilization of health coaching and motivational interviewing, “How can I apply that to a person with diabetes to help them with self-management or someone who’s prediabetic and help them with self-management and lifestyle medicine?” That’s the approach. We were given the different foundations of lifestyle medicine. We could apply it to whatever patient population we chose. Diabetes was the population I chose.

You ran some trials on a diabetic population.

That was my dissertation work. At the end of our didactic coursework as a PhD student, you do a dissertation. I chose to focus on community-based lifestyle modification for people that were at risk for diabetes. I chose the South Asian or Asian Indian population because one of the things that I found through research when I was going through my PhD is the aggregation of data, meaning that putting everybody together in one grouping of Asian Americans dilutes the data.

It doesn’t show the disparities in terms of diabetes as a diagnosis and heart disease within subpopulations because Asians are very wide. You have Southeast Asians, South Asians, Chinese, Filipino, Vietnamese, Indian and Bangladeshi. Every ethnicity and cohort is different in their lifestyle, practices, religion, culture and acculturation in terms of how long they have been in America and what type of lifestyle practices they have.

The aggregate data was diluting the population. There were a few disaggregated articles when I started. I chose to focus on Asian Indians because they have the highest rates of heart disease next to Latinos in America. That was my focus for my RCT. I decided that it was best to go where the people are because we know the determinants of health happen not in our clinical walls but in places where we live, work and worship.

It’s best to go where the people are because the determinants of health happen not in our clinical walls but in places where we live, work and worship. Click To Tweet

I chose to partner with a Hindu temple and held my program at the temple before the services happened on Sundays so that I could run my twelve-week program there. I made sure that the model I was using from the CDC and the National Diabetes Education Program was designed for community-based. The original program was Power to Prevent, which was for use in African American communities.

I went into the Asian literature and tailored each session to the cultural and linguistic practices of the Asian Indians that I was working with. We had a control arm of folks that got usual care, which was, “Eat right and exercise. See you in twelve weeks.” The weekly sessions were with the people that were in the intervention arm and we went through the modules, which included nutrition, physical activity, stress and lots of different topics in more of a group-based model.

It was powerful because we looked at outcomes. A1C is one. That’s the gold standard in terms of, “Do you make a difference?” We had significant changes, not just from pre to post but also at six months. I went back and tested the folks again at six months in both the control and the intervention arm. The intervention group retained the changes they had made in their A1C because of the lifestyle changes they learned to do gradually over time in that twelve-week program.

That was cool. Even now, years later, if I go to that temple for different festivals and services, I still see some of the participants from my trial. They will still come, approach me and say, “We’re still doing our exercise, using this cooking technique, measuring this or doing that.” That’s heartening to see that. They have gotten their friends and family involved in also making lifestyle changes. There’s that snowball effect, which is always cool to see.

You’re one of the few PTs that I know that have created and tested, which is the big part too, community-based intervention for diabetes management and prevention.

It wasn’t easy. As a PT, I’ll be honest and say when I was trying to do the dissertation work, you need funding for testing people for A1C. You have to send the test samples to an independent lab that’s certified and all that good stuff when you’re doing an RCT.

Tell people what A1C is and why that’s so important for that population.

A1C is the acronym we use for looking at the blood glucose level on average over three months. Typically, for prediabetes, it’s 5.7% to 6.4%. Most Americans fall in that prediabetic range. Diabetes is 6.4% and above. It’s looking at your average blood sugar over 2 to 3 months. That’s what A1C detects in the blood. It’s a good measure because if you do fasting blood glucose, that tells you fast from the past twelve hours. We could all cheat, do good, not carb-load and be good the day or two before. Our fasting blood glucose would be fairly normal. You can’t cheat on A1C because that’s your average blood glucose over 2 to 3 months.

Your fasting is a snapshot of what happened within the last 12 to 24 hours. Your A1C is important because it gives you an average look at what your blood sugar has been over a three-month period. Oftentimes the A1C is looked upon as the more important one. We want to track that one because we’re hoping that people make these lifestyle changes over the course of the long-term of their health. We should see that A1C decreases. It’s incredible for those that understand research. Most research will go back and look at those three months but you’ve continued into six months and have shown positive improvements from the intervention.

From a research perspective, there are a lot of trials that do pre and post. Anyone who goes through any modification program or even a physical therapy intervention program is going to see changes pre and post but where the rubber meets the road is sustainability. When we’re talking about lifestyle intervention and lifestyle modification, sustainability to me is the key because if a clinician or a researcher is not looking at that, then I’m not sure if what you’re doing is effective in the long-term. That was important.

HPP 28 | Diabetes Management
Anyone who goes through any modification program or even a physical therapy intervention program is going to see changes pre and post, but where the rubber meets the road is sustainability.


The community-based programs that the diabetes prevention program offers are year-long. In the CDC one, which is Medicare-approved, if you as a provider want to have one in your clinic, it needs to be a year-long program. The first three months are intense, whether it’s weekly or biweekly, in terms of education and sessions. Taper it down to once every two weeks or once a month and make sure you have that follow-up. In terms of your A1C and some other markers, you’re making sure that you’re also keeping track of that.

That long-term is important. I wanted to build that into my RCT but funding for physical therapist researchers to do that is very limited. There are a couple of smaller funding agencies that were specifically PT-related at the state level and even nationally. When I put in my proposal to help me to fund that RCT, it’s like, “It’s a great study, great design and all this great stuff. I’m not sure how this applies to PT.” I was like, “Seriously?”

I’m glad to see years later that this book that you and Ginger are leading the effort as editors. We will hopefully get this information out as this is important for the health of our population. If we’re going to be doctors or physical therapists that are going to be out there in our communities with the vision of transforming society, we need to pay attention to lifestyle medicine.

Diabetes is largely preventable. We need more providers. Physical therapists are in a perfect place because we see our patients and clients over time. It’s not a one-and-done visit for most of us in any setting, whether it’s in acute care, a skilled nursing facility or outpatient and inpatient rehab. We see our patients. We develop those relationships and trust. That therapeutic alliance is huge when you’re talking about lifestyle modification with your clients and patients.

We’re in the perfect place to do it. What we’re missing is our self-efficacy to be able to do it. That’s why as an educator, I want to be able to empower my students to have the skillsets to be able to have those conversations and if they don’t have programs within their clinical environments, then plug them into where in the community can your patient or client go for the help that they need.

I’ve recorded almost 400 episodes and talked a lot about self-efficacy on this show. Most of the time, we’re talking about helping patients access or improve their self-efficacy. I’ve spoken about this probably on the show. I’ve mentioned it in the inner circles when I’m hanging out with colleagues at a conference. You’re the first person who mentioned on the show that, as PTs, we have to work on our own or what I consider our professional self-advocacy.

That’s huge, especially in this. I don’t consider this an emerging area anymore.

Say that again 100 times because the challenge is that people are like, “PTs, what do you mean they’re treating diabetes?” First of all, if we wipe away sleep, nutrition and all that stuff, exercise alone is effective to manage diabetes. You add in all the other lifestyle components that you speak about in your chapter in the textbook, which are well within our scope of practice.

We talk about them in the book. You are teaching them in your health and wellness promotion classes from an individual and a community perspective. You have an RCT to support that. You went in and counseled on all these lifestyle interventions and have positive outcomes. People are like, “I don’t see how this fits into PT. Why should a PT do this?” I think, “Let’s go to the bar, have a drink and talk about this for four hours. I’ll tell you how this squarely fits into our scope and how it helps with population health.”

I talk about this with my faculty. Over time, we have come around to thinking about introducing these concepts of lifestyle management and factors that impact health in general early in the curriculum. That way, we start with a big picture in terms of what is health, wellness, prevention and all those things early on and what are the big killers in terms of our people and population. Heart disease is the number one killer. We start there. We get into our siloed mode of neuromuscular PT, musculoskeletal PT, integumentary, cardiopulmonary and all the different practice patterns.

If we start after we introduce them to the broad what is health, health promotion and what makes us healthy, then they would have self-efficacy. We teach them those skills. That’s why as an educator, I’m very passionate about increasing the self-efficacy of my graduates so that when they get out there, they will have it to some extent. The challenge still is they learn these tricks and tools in school. I even have them go and do a full-on annual wellness visit with a Medicare-age patient. Physical therapists are not reimbursed for that but we should be.

I always tell my students, “I’m training you for the future of physical therapy. I want you to find a grandma, a grandpa, an uncle or an aunt who’s Medicare age. Here’s what CMS requires for an annual wellness visit. I want you to do it. Here’s how you do it.” They work on it in groups but they learn. Initially, they’re like, “What are we doing?” They do it and I have them write a reflection along with their report. They’re like, “I would have never thought I could do this unless I was made to do it. This was a great experience.” It’s building that.

When they go to the clinic though, they have clinical instructors that don’t have that self-efficacy. They’re hesitant, “If my CI is not doing it, I’m not sure if I should be or could be. Can I?” That’s the conversations we have are like, “Can you level up your CI and share some of the information that you have with them to help them improve their self-efficacy in that? Together, if they’re willing, can you try some of these things in terms of lifestyle medicine and whatnot with your patient or client?”

It’s very refreshing. This is one of the reasons why I invited you to write on this chapter and speak on this show. I remember reaching out to you a while back. We wound up on the topic of nutrition. To be honest with you, I speak to educators who are like, “What are you teaching? Can you teach us? Can we do this?” You and I spoke years ago. You were like, “I’ve been counseling and teaching PTs about nutrition for almost a decade.” For you, it’s like, “This is second nature. This is what we’re doing.”

It wasn’t always. I credit it to having a focus on my PhD in health promotion and wellness. We had nutrition classes and health behavior change classes. We learned about how nutrition is so important. As a physical therapist, if you only focus on the physical aspect and the movement aspect, you’re doing your patient or client to disservice because that’s only half the equation. Energy-in is as important as energy-out to me and the quality of the energy-in and energy-out.

We focus a lot on the quantity, the quality, the prescription and what the patient can do from an exercise or movement perspective but that’s just one half. This is one of the things I tell my students because they have a very low self-efficacy for nutrition. That’s why we have four hours of that in our curriculum, plus assignments and stuff that they do. That’s one of the things that they struggle with, “I don’t know enough.” It’s like, “Here’s what you need to know, what’s within our scope of practice and then how you can utilize that.” I didn’t always have that lens but I realized, especially with diabetes.

When I say it’s a lifestyle disease, most of it is nutrition. In the US diabetes prevention trials that occurred in the mid-’90s, they showed that people did 30 minutes of moderate-intensity exercise. 5 days equal 150 minutes total but it was the change in their diet that was a key factor. If they change their diet, that helps them lose weight. It’s that weight loss. 5% to 7% of body weight loss has a huge impact in terms of your hemoglobin A1C and your blood glucose level and bringing those down or controlling those. Much of it is nutrition. It’s something we should be focusing on.

In my PhD program, it was a PhD already registered dietician who was teaching those nutrition courses. She had a good perspective. She always told us this because we were all from different disciplines. As a dietician, she makes it a point to counsel her patients not just on the diet but also on physical activity and movement because she sees the importance of that. As physical therapists or other healthcare professionals, we should all be doing the same thing. What is within our scope, we should counsel on nutrition and then certainly physical activities within our scope. We should do it.

When we say, “Counseling on nutrition affects blood sugar,” you first think, “That applies to diabetes,” but then we also know through the evidence, which is building rapidly, that when you regulate blood sugar, it also helps with things like regulating hormones, modulating pain and improving mental well-being. It’s not just the diabetes piece. We’re not treating single conditions. We’re treating the whole person. It’s counseling on those things.

Someone may come to you with diabetes. You start counseling them on how nutrition impacts their blood sugar but it winds up taking a holistic approach and helps that person with their overall physical and mental well-being. On that note, if we bring this full circle, PTs are seeing patients in their practice who are prediabetic. Probably about 2/3 of Americans are at least prediabetic and another 1/3 at least are diabetic. How can a PT begin to screen and intervene with regard to prediabetes or diabetes?

A very quick and easy tool is questions. The ADA, which is the American Diabetes Association, has a diabetes risk tool. On their website, you can find it online. It’s seven questions. You can open up your browser in the clinic and have your patient go through it right then and there on a computer or on your tablet. If they have a smartphone, they can do it there.

You can see what the risk factors for diabetes that your patient has, whether they have diabetes or not are. If they score five or more on that ADA risk tool, then you probably need to refer them to a primary care physician, have them checked for prediabetes if they haven’t had A1C or a blood test done and see where they’re at so that they can get that baseline. Most prediabetes is undiagnosed in our country because most of us don’t have that tested regularly unless we have a lifestyle factor.

That’s a quick and easy tool. There are seven questions that ask people about their lifestyle. Their weight is one of them. Whether they have a family history, gestational diabetes or hypertension, those are all things that increase the risk for diabetes. It’s doing a quick screen, documenting it, not just asking the questions on intake because a lot of times, we have intake forms in a lot of our settings. We have checkboxes where we ask that but we don’t do anything with it, whereas a risk tool is one where there’s a score and a cutoff.

You can say, “My patient scored more than five. They’re at higher risk. Here’s what I need to do about it.” Refer them to get tested. If the test comes back and they are prediabetic, their A1C is 5.7% to 6.4% range. Lifestyle medicine is the most evidence-based thing you can do. That’s the first line of defense for prediabetes. It’s a matter of, “In your setting as a physical therapist, do you counsel them on nutrition and physical activity and how to titrate that up in terms of physical activity to get to that 150 minutes moderate intensity with whatever function and activity limitations they have?”

On the nutrition side, they’re not diabetic, so they may not need a registered dietician to give them a “diabetic diet” but they’re prediabetic. We can from a lifestyle management perspective, counsel them on eating more complex carbohydrates, fruits, vegetables, lean meats and those things. There are wonderful tools that I teach my students to access through my plate and even through the ADA that they can use as part of their general counseling.

Motivational interviewing and health coaching are huge aspects of that. Instead of telling people what to do and thinking about all the things they’re missing and not doing, it’s making it more of an asset-based approach. Let’s focus on what you are doing and what can you add to what you’re doing versus not doing. That’s a key piece because as physical therapists, we have these white coats on. We’re the experts. We’re going to tell people what to do.

Another big thing I learned as a physical therapist going through my PhD program is how to take off your white coat and look at the worldview the patient has, sitting alongside them and helping them navigate and modify their lifestyle based on the factors in their life that are contributing to their health, the barriers and how can I help them navigate those barriers and empower them to navigate those barriers.

Take off your white coat and look at the worldview the patient has. Sit alongside them and help them navigate and modify their lifestyle based on the factors in their life that are contributing to their health. Click To Tweet

It’s not me doing it for them or to them but them doing that for themselves. As PTs, those are big things we can do. We do that for the physical activity piece. It’s a matter of flipping our switch and saying, “I need to do that for sleep and nutrition because that’s as important to the immune system and their prediabetic state as the physical activity is.”

You’re a full-time professor in a DPT program. You’re in contact not only with your colleagues in the program but also colleagues in other programs across the US and globally. How would you like to see your colleagues take the information that you’ve written in this chapter and use it to inform DPT education?

It would be wonderful if they used our textbook as part of education. You’ve amassed a great group of clinicians as well as educators for this particular book. I’ll propose to my faculty to utilize the book in terms of their education and others but having textbook-level knowledge in this field is important because it signals that we have arrived in terms of lifestyle medicine and population health management. This is part of our scope of practice. This is not an emerging thing but here it is. This is what it is. It needs to be at the forefront.

I hope that people will get the book and incorporate it in DPT education either as standalone courses or they could have it threaded throughout. That would be the biggest thing. These are the things that impact the health of our society, not just in the US but everywhere. Heart disease is the number one killer in the world. Diabetes either occurs in tandem. Who knows what comes first, heart disease, diabetes or vice versa? The studies show both.

HPP 28 | Diabetes Management
Heart disease is the number one killer in the world. Diabetes occurs in tandem. Who knows what comes first, heart disease or diabetes? The studies show both.


This textbook and the chapters within it are a great way for people to realize that there is a role for physical therapy and that we could play a big role in this because we see our patients over time. When you think about chronic pain patients, which I know is your area of expertise, they’re patients and clients for life. They come and go with us in physical therapy. When we talk about diabetes and heart disease prevention, what a perfect opportunity to start that conversation when they first come into your clinical realm.

Follow with them over time and be that person for them in terms of helping them navigate through those changes. If they’re in a prediabetic state or a diabetic state, it’s like, “Here’s how that’s going to affect your chronic pain and musculoskeletal health. Here are some things that I can work with you on to help you reduce or minimize those factors. That’s not going to only help you improve your pain and musculoskeletal health but the big thing or this big disease process that we want to stop because we know the outcome of that is not going to be good for some of the other things that are going on with you.”

It’s interesting because I do some adjunct work at DPT programs. I’ve spoken to you before. In your program, you have two health and wellness promotion courses. One is more on the individual that lives on the community health. I love that because it gives people a more specific under-the-microscope, “How do I treat the patient?” but in a broader, “I can also stretch this out and weave it into community health as you did.” Not every program has that, as you mentioned. Sometimes there are weeds within the curricula in different parts and pieces.

When we designed our DPT curriculum, I was finishing my PhD. I was like, “We’ve got to have this.” The faculty threw me about and said, “As long as you’re to teach it, you can have it.” It has been great. Whether it’s good or bad, it’s towards the end of the curriculum. We’re still thinking about that as we think about restructuring our curriculum, “Do we want to put it in the second year and make it a longer stream for the course?”

What we do is we have community partners and different organizations that are mainly organizations that don’t have a lot of resources. We partner with them to do a community needs assessment. We take the white coat off, go in, do our needs assessment, listen to the people, go into the literature, look at the evidence of what’s changeable based on what the people tell us and then develop whatever program that has to do with health promotion prevention as our loose topic for that population.

We have developed programs like an increasing water or hydration program for people with mild Alzheimer’s or early memory loss at a community-based center for mild memory loss with a social model because they weren’t hydrating enough. We have done things like nutrition programs, lots of those, for parents of kids that are in early head-start programs or head-start programs. The head-start schools had to abide by Federal guidelines to get funding for their schools.

The kid is eating two meals a day in school but then the parents feeding them junk food is not healthy in building sustainable behavior change. We had to get to the parents. It’s the same thing. We have done physical activity programming with parents of children because the kids were not active. During school, they have PE but it’s very limited. We’re working with parents, “How do you take your kids to the park and play?” We’re working with a lot of Latino immigrant families in that organization.

They took their kids to play but then they sat on benches and chatted while the kids played. How do you emulate physical activity? There’s a lot of that community-based stuff. None of those things we dreamed up on our own. We had to go into the population, listen, go in with open minds and then think about what’s changeable in terms of some of those risk factors and what’s sustainable. Those are the things.

We have done movement and memory programs for people with early memory loss and Parkinson’s clients that are in community-based exercise classes. We have worked with people with stroke. We’re empowering them to do more things on their own and some of the mental health issues, depression and those things. Lifestyle, when we talk about community health, is going in there without preconceived notions of what you, as the professional, feel like they need. It’s something you have to leave at the door.

It’s a group-based thing. You’re not working with people individually. You’re working with the whole population or that whole community. How you tackle that is going to be different from the one-on-one thing that you’re used to doing in your clinic. They learn that skill. Your outcomes are knowledge. Sometimes it’s self-efficacy. Does the group have the skills, knowledge and efficacy? Social support is a huge aspect of community health. In my diabetes prevention trial, that was one of the factors that I didn’t study but as I was going through the intervention and leading the intervention in my trial, I noticed how powerful that was.

That’s something that we do need to study more in that community group-based model. Having that social support and a group going through it together makes a big difference, especially when you’re looking at lifestyle modification because if you’re trying to eat well or better but the group you’re with, whether it’s your work, family or friends are not the folks that are supportive of that, not intentionally or unintentionally but the environment that’s created, then you’re not going to be as successful.

Having a group to go do that together with is important. One of the last sessions that we did as a wrap-up session for my lifestyle modification program was having everyone do a potluck. Throughout the twelve weeks, I had done different ways they can modify traditional recipes and still make them taste good but modify it, “What does a South Asian MyPlate look like? I’m making that my plate.”

I had given them lots of different resources and recipe modifications. Everybody was doing their thing. In the last session, we had a potluck where everybody brought something that they had modified that was their favorite dish or family dish to make it healthier with the parameters of what we talked about. That was so empowering. Everybody was like, “I love this. Can I have that recipe? That’s so great.”

That social support was powerful. Community-based stuff is so important. I’m all for us as researchers and clinicians getting out of our white walls in a clinic and going to where the people are, doing some of our programming there and being immersed in our community so that they see that we are there to support and help them rather than coming in and telling them what to do. Communities are tired of that.

It’s important for clinicians and researchers to get out of the white halls of the clinic and immerse themselves in the community. We should be there to help and support them rather than coming in and telling them what to do. Communities… Click To Tweet

We’re very fortunate to have you in the PT profession. I do believe that you’re leading this aspect of diabetes care in PT management, which is important. Few people can straddle everything you’ve talked about, which is the individual factors and then the more community-based factors that you ended with. People are going to want to learn more about you, especially educators, what are you doing in the program, how are you weaving this in, what courses you’re teaching and how you even have diabetes. How can people learn more about you and the work you’re doing?

They can always contact me by email. I’m on the Texas Woman’s University School of Physical Therapy website as one of the faculty. My email address is [email protected]. That’s probably the best way. The RCT that I did is published in the Journal of Diabetes Research, which is an open-access journal. You can google Journal of Diabetes Research and put my name in it. You will come up with my study there.

In terms of community-based health promotion, there was a method model paper a long time ago that my colleague Dr. Tapley and I wrote in the process. The model we used to teach is the Precede-Proceed model for community health promotion program planning, delivery and evaluation. We wrote a method model paper in the Journal of PT Education on the use of that model.

I’ve presented that quite a bit. Every year, students use that model with these community-based projects. I usually have students that are willing to submit a poster or a platform for it. Every year, they get accepted. Even at CSM, you will see my students that are presenting that work on how to utilize the evidence-based model to do community health promotion programming. It’s doable.

What has been cool is some of our graduates that have gone through our curriculum get out there and want to do more community-based stuff. They have then developed their programs. One of our graduates who’s an adjunct in our program, his wife, has MS and contracted MS when they were in undergraduate school together.

They have a program that they lead called MSFit for people in our community that have MS. They do strength training social support, empowerment and even advocacy work in terms of contacting legislatures and that kind of thing. It has been cool to see that. We have had others develop other programs. We have partnered with our graduates to help us become partners and do more. That’s always cool.

You can go to her website at the university. You will find information about her there. I ask you to share this episode with your friends, family and colleagues who are interested in learning more about addressing disparities in diabetes through community-based lifestyle modification programs because it’s a big topic in integrative and lifestyle medicine that we address the well-being of people with prediabetes and diabetes. Make sure to share this on Facebook, LinkedIn and Twitter. If you’re on Instagram, take a picture of this episode and tag me. I’ll make sure to tag you back. I want to thank Dr. Patel for being here. We will see you.

Thank you, Joe. You were a great host.


Important Links


About Rupal M Patel, PT, PhD

HPP 28 | Diabetes ManagementRupal M Patel, PT, PhD is an Associate Professor in the School of Physical Therapy at Texas Woman’s University (TWU) in Houston, Texas. She received her Bachelor of Science degree in biology and physical therapy and an advanced clinical Master of Science degree in physical therapy from TWU. Dr. Patel has a PhD in Health Promotion and Wellness from Rocky Mountain University of Health Professions in Provo, UT. She is a founding member of the American Physical Therapy Association’s Council on Prevention, Health Promotion and Wellness. Dr. Patel’s research and community-based practice focuses on reducing risk factors for diabetes among disparate populations using a group-based lifestyle medicine approach. Dr. Patel also serves in varied volunteer service roles in the APTA, TPTA, and various sections and academies related to diversity, equity, inclusion (DEI), advocacy, and governance/policy making.


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