# Integrated Community-Clinical Linkage Model to Promote Weight Loss among South Asians with Pre-Diabetes

> **NIH NIH R01** · NEW YORK UNIVERSITY SCHOOL OF MEDICINE · 2021 · $706,081

## Abstract

PROJECT SUMMARY
The proposed project will build on a well-established collaboration between researchers at the NYU School of
Medicine, HealthFirst (largest Medicaid insurer in NYC), New York City Department of Health and Mental
Hygiene, clinical practices, and community partners to promote diabetes prevention among NYC South Asians.
The goal of this study is to test the effectiveness and assess the implementation process of an integrated
intervention to support weight loss for South Asian patients at risk for Type 2 Diabetes Mellitus (T2DM) in
primary care settings. The integrated intervention has two components: an electronic health record (EHR)-
based component to increase screening and identification of South Asian patients who are at-risk of T2DM;
and 2) A registry-driven community health worker (CHW)-led health coaching component. Using a stepped-
wedge design, we will implement the study in 25 NYC primary care practice (PCPs) sites enrolling 2,840 South
Asian patients at- risk for T2DM. The project has two specific aims. First, we will test the effectiveness of an
integrated EHR-based intervention (ie. an alert to screen at-risk patients and a registry function to track
outcomes) plus CHW-led coaching of registered patients compared with usual care. The primary outcome is
>5% weight loss among South Asian patients at-risk for T2DM. Second, using a mixed-methods approach and
the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance) evaluation framework, we
will systematically assess the implementation process and delineate factors that influence adoption,
sustainability, and scalability of an integrated EHR-CHW intervention within applied practice settings. The
integrated EHR-CHW protocol will support team-based care by allowing for feedback between providers and
CHWs, who will be providing health education to participants while actively participating in patient management
with providers.

## Key facts

- **NIH application ID:** 10133630
- **Project number:** 5R01DK110048-05
- **Recipient organization:** NEW YORK UNIVERSITY SCHOOL OF MEDICINE
- **Principal Investigator:** NADIA S ISLAM
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2021
- **Award amount:** $706,081
- **Award type:** 5
- **Project period:** 2017-04-04 → 2024-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10133630

## Citation

> US National Institutes of Health, RePORTER application 10133630, Integrated Community-Clinical Linkage Model to Promote Weight Loss among South Asians with Pre-Diabetes (5R01DK110048-05). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10133630. Licensed CC0.

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