Behavioral research at the National Institute of Diabetes and Digestive and Kidney Diseases
By Christine Hunter
The mission of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is to conduct and support research and research training and to disseminate science-based information on diabetes and other endocrine and metabolic diseases; digestive diseases, nutritional disorders and obesity; and kidney, urologic and hematologic diseases, to improve people’s health and quality of life. Behavioral and social science research is important across the NIDDK as many of the diseases within its mission have behavioral, psychological or lifestyle factors that contribute to the onset, maintenance or exacerbation of the condition. This article focuses on obesity and diabetes research to illustrate the range of research opportunities at the NIDDK that would benefit from the expertise of the psychological sciences.
Diabetes is a common chronic disease that imposes considerable demands on the individual as well as the U.S. healthcare system. People with diabetes have a higher rate of cardiovascular disease than those without diabetes and are at increased risk for kidney failure, lower limb amputation and blindness. Obesity is a significant risk factor for diabetes and the prevalence of obesity in children and adults in the United States has dramatically increased in the past four decades. Diabetes currently affects an estimated 25.8 million people in the United States. Another 79 million Americans are estimated to be at greatly increased risk of developing diabetes in the next several years. Type 1 and type 2 diabetes in youth are also on the rise. Overweight, obesity and/or excessive weight gain during pregnancy are also contributing to rising rates of gestational diabetes mellitus which in turn increases risk of future type 2 diabetes in the mother and child. The Centers for Disease Control and Prevention estimate that one in three American children born in 2000 will develop diabetes at some point in their lives. In addition to the considerable impairments to health and quality of life with these conditions, there are also serious economic consequences. The estimated current annual cost of diabetes in the U.S. is $245 billion dollars per year, with $176 billion in direct medical costs and the remainder related to reduced productivity.
Large clinical trials have demonstrated that glycemic control and cardiovascular risk factor modification can reduce the risk of diabetes complications. Many of these successful interventions have behavioral components that include lifestyle modification, adherence to medications and self-management tasks. Although there have been considerable improvements in diabetes treatment and in risk-factor control over the past three decades, recent research demonstrates that most U.S. adults with diabetes do not meet the recommended goals for diabetes care. Further, NIDDK sponsored research has established that behavioral lifestyle interventions, with modest (5-7 percent) weight loss, can prevent or delay development of type 2 diabetes in individuals at high risk for the disorder and, in individuals who already have type 2 diabetes, can decrease sleep apnea, reduce the need for diabetes medications, help maintain physical mobility and improve quality of life. Despite these findings, behavioral adherence and lifestyle interventions are not offered as a part of routine care for most individuals with or at risk for diabetes.
To tackle the growing challenges of obesity and diabetes and improve the quantity and quality of life for Americans, behavioral research is needed to identify drivers of poor health outcomes and test efficient ways to close the gap between outcomes achieved in clinical trials and the outcomes achieved in routine healthcare practice. To address these needs the NIDDK supports studies across the research continuum including basic behavioral and social science, studies testing the efficacy of behavioral interventions, translational research and dissemination and implementation science. The NIDDK also supports research across the lifespan and in diverse and underserved populations. Although diabetes and obesity occur in all populations in the U.S., many minority racial and ethnic groups and individuals with low education and income are at higher risk for these conditions and their associated complications. Given these health disparities, research including low income/resource and diverse populations at disproportionate risk for obesity, diabetes and diabetes complications is encouraged (see, for example PA-13-183).
Basic behavioral and social sciences research (b-BSSR) at the National Institutes of Health is focused on improving health and well-being by understanding the fundamental mechanisms and patterns of behavioral and social functioning including how they interact with each other, with biology and the environment. NIDDK encourages b-BSSR research to understand the mechanisms of behaviors such as adherence, self-management, energy intake and energy expenditure with the goal of using those finding to develop and test novel, improved or more appropriately tailored behavioral approaches to preventing and treating obesity and diabetes. For example, in obesity research there is general agreement that a permissive food environment contributes to obesity but, within similar environments, there remains considerable individual variability in body weight and weight gain. Understanding those differences can point to better ways to prevent or treat excess weight gain. In diabetes treatment research, understanding how people process and make use of medical recommendations and make adherence decisions could enhance the quality and type of doctor-patient or patient-family communication or identify important individual factors that influence self-management and adherence behavior.
Just as with basic biomedical research, the NIDDK encourages b-BSSR to identify behavioral phenotypes, help us understand treatment responders and non-responders, inform new treatment pathways and allow for more targeted intervention. Areas of b-BSSR research at NIDDK include, but are not limited to, understanding the influence of cognition or affect, communication science, decision-making and choice, the formation of habits, the psychophysiology of stress and behavior, reward processing, models of learning, behavioral economics, the nature and impact of social networks and the influence of diabetes or obesity on the brain and behavioral/psychological consequences such as depression, learning and cognitive processing.
The NIDDK is interested in recruiting an individual with a background in basic behavioral science relevant to diabetes and obesity to work as a program officer. Interested psychologists should contact Christine Hunter, PhD, for more information about the potential position and upcoming job announcements.
In addition to b-BSSR, the NIDDK is committed to supporting research that translates these basic science findings into applied approaches to prevention and treatment of obesity and diabetes. NIDDK has been a key partner in PA-11-063 and also recently published RFA-DK-13-022. The goal for these funding opportunities is to support research to translate b-BSSR discoveries into novel interventions by iteratively developing, refining and pilot testing innovative strategies to improve prevention or treatment strategies.
The NIDDK also supports behavioral efficacy and effectiveness research. Areas of focus might include testing novel adaptations to lifestyle interventions for weight management, interventions to improve adherence to diabetes medications and self-management regimens, or interventions that focus on co-morbid treatment of diabetes and other mental health conditions such as depression as a means to improve diabetes outcomes. Additionally, sustaining behavior change over time remains a challenge. For example, even with successful weight loss, many individuals gain back most or all of the lost weight in few years. As such, the NIDDK encourages researchers to test approaches that promote maintenance of behavior change.
Pragmatic research to test practical, sustainable and cost efficient adaptations of evidence based strategies or approaches in real-world healthcare settings and communities is also an important focus of behavioral research at the NIDDK (PAR-13-366, PAR-13-367, PA-13-352). Research that develops and refines effective and efficient methods for successful dissemination and implementation of evidence based research findings/approaches is supported through PAR-13-055. Research that evaluates “natural experiments” in policy or programs in healthcare or at the local, state or federal level is another important piece of NIDDK's efforts at the level of public health and practice. Many of the changes in policy or healthcare practice are made with the intent of improving health but often little is known about the effectiveness of these policies and programs. Rigorous scientific evaluation of such natural experiments can help to more rapidly build an evidence base to inform obesity and diabetes prevention and treatment. The NIDDK supports several funding announcements in this area (PAR-12-257, PA-13-110, PAR-13-365). The NIDDK's Centers for Diabetes Translation Research provide resources and technical expertise to enhance the efficiency, productivity and multidisciplinary nature of translational research at the NIDDK.
The NIDDK also leads or participates in many trans-NIH and trans-agency committees with activities relevant to behavioral researchers. Below are some illustrative examples:
- The Diabetes Mellitus Interagency Coordinating Committee (DMICC) is chaired by NIDDK and facilitates cooperation, communication and collaboration on diabetes among these government entities. See Advances and Emerging Opportunities in Diabetes Research: A Strategic Planning Report of the DMICC for diabetes research priorities.
- The NIH Obesity Research Task Force is co-chaired by the director of the NIDDK and its Strategic Plan for NIH Obesity Research serves as a guide to obesity research priorities.
- The NIH Adherence Research Network develops opportunities to strengthen adherence research at the NIH such as through PA-12-022 and offers a Distinguished Speaker Webinar series.
- Communication and outreach through the National Diabetes Education Program, Diabetes HealthSense and the Weight-control Information Network.
Although this article focused on behavioral diabetes and obesity research, the range of activities and resources hopes to demonstrate the commitment to and breadth of behavioral priorities at the NIDDK.
Christine Hunter, PhD, a clinical psychologist, is director of Behavioral Research in the Division of Diabetes, Endocrinology and Metabolic Diseases at the National Institute of Diabetes and Digestive and Kidney Diseases.