Diabetes Education … Educology The magic capsule for primary and secondary prevention W e I g h t...

Diabetes Education … Educology The magic capsule for primary and secondary preventionThe magic capsule for primary and secondary prevention

W e I g h t l o s s H e a l t h y d I e t E x e r c I s e S c r e e n I n g

P o s t e r V I d e o - t a p e P r o c u r e L e c t u r e

L o w p r e v a l e n c e l e s s c o m p l I c a t I o n

Diabetes Education The magic capsule for primary and secondary prevention




DIABETES IS AN EPEDEMIC DISEASE !DIABETES IS AN EPEDEMIC DISEASE !

IS IT A PREVENTABLE DISEASE ?IS IT A PREVENTABLE DISEASE ?

WHAT ARE THE WAYS OF PREVENTION ?WHAT ARE THE WAYS OF PREVENTION ?

WHICH METHOD TO USE ?WHICH METHOD TO USE ?

WHERE DO WE GO NOW ?WHERE DO WE GO NOW ?

Historical story of diabetes prevention




Celsus

Ancient Greek scientist500 B.C.

Polyuria ? :

• He described a disease characterized by:• Polyuria.• Lack of pain.• Weakness.• Fluid output greater than fluid intake.

• Treat by:• Diet containing a minimum amount of food.• Regulated mode of life.

De Medicina ( English translation).

Diabetes is preventable disease




The proven methods in prevention of The proven methods in prevention of diabetes are:diabetes are:

1.1. Lifestyle modification.Lifestyle modification.

2.2. Drug use.Drug use.

3.3. Future methods:Future methods: Vaccine Vaccine Genetic ?Genetic ?





Two early studies suggested that changes in life style can Two early studies suggested that changes in life style can prevent diabetes:prevent diabetes:

1.1. Prevention of type 2 diabetes mellitus by Prevention of type 2 diabetes mellitus by Diabetologia 34, Diabetologia 34, diet and physical exercise diet and physical exercise 19911991

2.2. Effects of diet and exercise in preventing Effects of diet and exercise in preventing Diabetes care 20, Diabetes care 20, NIDDM in people with impaired glucose NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes study tolerance: the Da Qing IGT and Diabetes study 19971997..





Four recent well designed randomized controlled trails:Four recent well designed randomized controlled trails:

1.1. Prevention of type 2 diabetes mellitus Prevention of type 2 diabetes mellitus N Engl J Med 344, N Engl J Med 344, by changes in lifestyle among subjects by changes in lifestyle among subjects with impaired glucose tolerance with impaired glucose tolerance 2001 2001

2.2. Diabetes prevention research group: Diabetes prevention research group: N Engl J Med 346, N Engl J Med 346, Reduction in the evidence of type 2 diabetes Reduction in the evidence of type 2 diabetes with lifestyle intervention or Metformin with lifestyle intervention or Metformin 20022002

Diabetes prevention research group: Diabetes prevention research group: Diabetes care 23, Diabetes care 23, The diabetes prevention program: baseline The diabetes prevention program: baseline characteristics of the randomized cohort 2000 characteristics of the randomized cohort 2000

3.3. Diabetes prevention program: Diabetes prevention program: Diabetes care Diabetes care Design and methods for a clinical trial in Design and methods for a clinical trial in the prevention in type 2 diabetes 1999the prevention in type 2 diabetes 1999

4.4. Prevention of pancreatic Prevention of pancreatic cell function and cell function and Diabetes 51, 2002Diabetes 51, 2002 prevention of type 2 diabetes by pharmacological prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high risk treatment of insulin resistance in high risk Hispanic women 2002Hispanic women 2002

The Finnish Study 2001




NumberNumber 522522Age (mean)Age (mean) 55 years55 yearsBMI (mean)BMI (mean) 31 kg/m31 kg/m22

Clinical conditionClinical condition IGTIGT

Control group:Control group:Received brief diet andReceived brief diet andExercise counselingExercise counseling

Intervention group:Intervention group:Received intensive individualized Received intensive individualized instruction on weight reduction, instruction on weight reduction, Food intake, and guidance on Food intake, and guidance on increasing physical activityincreasing physical activity

Duration (mean)Duration (mean) 3.2 years3.2 years

Lifestyle

58%

Diabetes Prevention Program (DPP) Diabetes Prevention Program (DPP)




NumberNumber 3,2343,234Age (mean)Age (mean) 51 years51 yearsBMI (mean)BMI (mean) 34 kg/m34 kg/m22


Lifestyle group:Lifestyle group:Intensive nutrition and exercise Intensive nutrition and exercise counselingcounseling

Treatment group:Treatment group:Two masked medications:Two masked medications:

1.1. Biguanide Metformin.Biguanide Metformin.2.2. Placebo.Placebo.


Lifestyle

58%Metformin

31%

The Troglitazone in Prevention of Diabetes (TRIPOD)The Troglitazone in Prevention of Diabetes (TRIPOD)




NumberNumber 235235Age (mean)Age (mean) YoungerYoungerBMI (mean)BMI (mean) 28 kg/m28 kg/m22

Clinical conditionClinical condition GDMGDM

Placebo group:Placebo group:Received PlaceboReceived Placebo

Tested group:Tested group:Received Troglitazone which is Received Troglitazone which is Withdrawn from the groupWithdrawn from the groupNamed Thiazolidinediones classNamed Thiazolidinediones class


Troglitazone

56%

STOP-NIDDM trailSTOP-NIDDM trail




NumberNumber 1,4291,429Age (mean)Age (mean) 55 years55 yearsBMI (mean)BMI (mean) 31 kg/m31 kg/m22


Placebo group:Placebo group:Received PlaceboReceived Placebo

Tested group:Tested group:Received Acarbose from the groupReceived Acarbose from the groupnamed named -glucosidase inhibitor-glucosidase inhibitor


Acarbose

25%To

36%




Lifestyle in prevention of type 2 diabetes

Education pill:• reduce weight >5%.• Fat <30% of energy consumption.• Fiber intake >15gm per 1000kcal.• Moderate exercise for 30 min/day.

Education dosing:• Seven sessions with nutritionist in 1st year then • One session every three months.• Individual guidance on physical activity.

0.5

0.6

0.7

0.8

0.9

1

0 1 2 3 4 5 6

Intervention group

Control group

Study years

Cumulative probability of remaining free of Diabetes

Self-reported change in dietary and exercise Habits during the first yearVariable Intervention group Control groupP value

Number 253 (%) Number 247 (%)

Decrease fat consumption 87 70 0.001

Increase vegetables consumption 72 62 0.01

Decrease sugar consumption 55 400.001

Increase exercise 36 16 0.001Success in achieving the goals of the intervention by one yearVariable Intervention group Control groupP value

Number 253 (%) Number 247 (%)

Weight reduction >5% 43 13 0.001

Fat intake <30% 47 26 0.001

Saturated fat intake <10% 26 11 0.001

Fiber intake 15g/1000 kcal 25 12 0.001

Exercise >4 hr/week 86 71 0.001N Engl J Med,, Vol. 344 May 3, 2001




Public education

The expected relation between: the level of public health education and the prevalence of diabetes.

No data available to prove this because:

1. Public education standardization.

2. Multi-factorial disease.3. Ethnic and cultural factor.4. Long duration trials.5. Life-style modification difficulty.

Involvement level:Individual.Family.Community.Nation.

Risk factors:Controllable vs non-controllable

Public education

The expected relation between: the level of public health education and the prevalence of diabetes.

No data available to prove this because:

1. Public education standardization.

2. Multi-factorial disease.3. Ethnic and cultural factor.4. Long duration trials.5. Life-style modification difficulty.

Involvement level:Individual.Family.Community.Nation.

Risk factors:Controllable vs non-controllable

Health Education Health Education

0

25

50

75

100

125 Level of Education

Degree of disease prevention




Which factors…?

• Uncontrollable:• Age.• Genetic.• Ethnicity.• Associated diseases:

- Hypertension

• Controllable:• Weight.• Exercise.• Associated disease:

- Hyperlipidemia- Polycystic disease- Vaculopathy

Risk factors for type 2 Diabetes

Education effect

Individual conditions:• Age 45 years No• Overweight ( BMI 25 kg/m2 ) Yes• First degree relative with diabetes No• Habitual physical inactivity Yes• Ethnic risk No

Pre-diabetes conditions:• IGF or IGT Yes• History of GDM or big baby > 4 kgm Yes

Associated conditions:• Hypertension 140/90 mmHg Yes/No• HDL 0.9 mmol/l triglyceride 2.82 mmol/l Yes• Polycystic ovary disease (PCOS) Yes• History of vascular disease Yes

Risk factors for type 2 Diabetes

Education effect

Individual conditions:• Age 45 years No• Overweight ( BMI 25 kg/m2 ) Yes• First degree relative with diabetes No• Habitual physical inactivity Yes• Ethnic risk No

Pre-diabetes conditions:• IGF or IGT Yes• History of GDM or big baby > 4 kgm Yes

Associated conditions:• Hypertension 140/90 mmHg Yes/No• HDL 0.9 mmol/l triglyceride 2.82 mmol/l Yes• Polycystic ovary disease (PCOS) Yes• History of vascular disease Yes




EducationA share between doctors and

patient

• Patient share is an important issue that need special training for the treating physician.

• Patient involvement in education is only 21% which change to 47% after training.

• Continuity and patient load was not tested which will affect the out-come.

Therapeutic education of Patients Assal, 2000

EducationA share between doctors and

patient

• Patient share is an important issue that need special training for the treating physician.

• Patient involvement in education is only 21% which change to 47% after training.

• Continuity and patient load was not tested which will affect the out-come.


21%79%

Doctor Patient

Before training

21%79%

Doctor Patient

Before training

47% 53%

Doctor Patient

After training

47% 53%

Doctor Patient

After training

Diabetes Education according to the source




• Physicians are the highest in providing patients with diabetes education but they are the least effective.

• The most effective method is the special training classes with >75% effect but not practical.• The role of diabetes educator (nurse) is as effective >75% and more practical.• Others ie; teachers, volunteers…etc need to be evaluated.

• Physicians are the highest in providing patients with diabetes education but they are the least effective.

• The most effective method is the special training classes with >75% effect but not practical.• The role of diabetes educator (nurse) is as effective >75% and more practical.• Others ie; teachers, volunteers…etc need to be evaluated.

0

25

50

75

100

Doctor Diatition Nurse Class Other

% Receiving education

0

25

50

75

100


% Receiving education

Massachusetts Results from the Behavioral Risk Factor Surveillance System (BRFSS) 1996

0

25

50

75

100


% Effective education

0

25

50

75

100


% Effective education

Education of physicians vs patients:




• 401 intervention group focused on improving the skills and knowledge of general practitioners (EMC).

• 413 second intervention group focused on patients education and self management (DS).• 105 reference group choosing patients from regular clinics (RG).

• 401 intervention group focused on improving the skills and knowledge of general practitioners (EMC).

• 413 second intervention group focused on patients education and self management (DS).• 105 reference group choosing patients from regular clinics (RG).

Diabetic Medicine, 20, 846; 2003

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

DS EMC

Change in HbA1c (%)

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

DS EMC

Change in HbA1c (%)

Patient education and self management decrease HbA1c by 0.51% comparing to the reference group.

Improving GPs skill and knowledge decrease HbA1c by 0.23% comparing to the reference group.

The patient involvement through education in their management give extra 0.28% decrease in the mean HbA1c.

Patient education and self management decrease HbA1c by 0.51% comparing to the reference group.

Improving GPs skill and knowledge decrease HbA1c by 0.23% comparing to the reference group.

The patient involvement through education in their management give extra 0.28% decrease in the mean HbA1c.




Education program

• Reduce weight >5%.

• Fat <30% of energy consumption.

• Fiber intake >15gm per 1000kcal.

• Moderate exercise for 30 min/day.

Education program

• Reduce weight >5%.

• Fat <30% of energy consumption.

• Fiber intake >15gm per 1000kcal.

• Moderate exercise for 30 min/day.

Knowledge

Risk factorsWhat to do

BehaviorEating less

Healthy dietExercise plan

Factors:Age distributionProblem sizeIlliteracy rateCultural factorHealth systemHealth beliefs

Weight loss

Healthy diet

Physical activity

Decrease Prevalence

Decrease costs

Model of Public EducationModel of Public Education




Education program

• Certified educator.• Education system.• Same language.• Education materials.• Support group.• Integrated into lifestyle.• Assisted by local health care providers.

Patients

Knowledge

Diabetes generalDiabetes

management

Behavior

Skill performanceCompliance/Adherence

Factors:AgeSexDuration of DMCultureEducation levelLanguageHealth systemHealth beliefs

Good control

HbA1cBlood glucose

Weight loss

Decrease complications

Decrease medical costs

Model of Diabetes Education




Definition:Definition:Science of drug effect on human body and Science of drug effect on human body and

its role in disease treatment.its role in disease treatment.

Material:Material:Active compound.Active compound.

Efficacy:Efficacy:Effective according to the dose.Effective according to the dose.

Action:Action:Short term.Short term.

Side effect:Side effect:May be.May be.

Cost:Cost:4000 SR annually.*4000 SR annually.*

Acceptance:Acceptance:More accepted.**More accepted.**

Definition:Definition:Using education as a tool for disease Using education as a tool for disease

prevention or treatment.prevention or treatment.

Material:Material:Large verity of methods.Large verity of methods.

Efficacy:Efficacy:More effective than drugs.More effective than drugs.

Action:Action:Long term.Long term.

Side effect:Side effect:None.None.

Cost:Cost:50 SR annually.*50 SR annually.*

Acceptance:Acceptance:Less accepted.**Less accepted.**

EducologyEducology PharmacologyPharmacology

* The National Saudi Diabetes Registry 2004.** Diabetic Medicine Vol 24, 1997.




• Age at education.Age at education.

• Literacy rate.Literacy rate.

• Culture effect.Culture effect.

• Easy administration.Easy administration.

• Can be done by any body.Can be done by any body.

• No side effect.No side effect.

• Accumulative effect.Accumulative effect.

• Effect loss with time.Effect loss with time.

EducologyEducology PharmacologyPharmacologyFactors related to each method

• Age.

• Disease related.

• Indication.

• Different routes (bioavailability).

• Prescribe by physician.

• Side effect.

• Dose related.

• Effect with use only.




Is Physician Advice (patient education) effective?Is Physician Advice (patient education) effective?

Weight loss ExerciseMedication

Age:65 Reference group for age45-64 0.75 1.21 0.8818-44 0.15 0.96 0.31

Sex:Male Reference group for sexFemale 0.75 0.89 1.30

Ethnicity:White Reference group for raceBlack 0.95 1.19 1.16Hispanic 2.14 1.30 0.80Other 2.20 1.14 0.88

Diabetes care, Volume 26, Number 3, 602-607; March 2003

Effective

Non-effective

Non-effective

Effective Less effective Effective

Physical activity




• There is no difference between adults with or without diabetes in the percentage of insufficient physical activity

• This data indicate that there is a large space for exercise in both primary and secondary prevention.

71 69

0

25

50

75

100

Diabetics Non-Diabetics

% Insufficient activity


Education is Knowledge and behavior




Patient education:

Have you heard about HbA1c?

- Age group: 18-3097%

31-6431%

>6513%

- Younger patients have better education.

- Type of diabetes effect.- The target group 30-65

Patient behavior:

How many times did you check your feet?

None 15%1-2 times 31%3-5 times 17%> 5 times 37%


13

97

31

0

25

50

75

100

18-30 31-64 >65

% Heard of HA1c

Age

15%

31%

37%

17%

None 1-2 times 3-5 times > 5 times

Number of times feet were checked in one year

A Saudi twin families:




• Mohamed and his twin Abdullah are76 years old, both have type 2 diabetes managed currently with insulin.

• Mohamed has 13 children while Abdullah has 17 children.

• Follow-up started 1989 with yearly OGTT.

• Mohamed’s family refused education on prevention but Abdullah’s family agree.

0

5

10

15

0 5 10 15

Mohamed’s family

Abdullah’s family




If you don’t know, you have to learn……

If you learn, you have to implement……

If you implement, you have to do it right ……

If you do it right, it has to be always.

ActivityDiet

Weight

Mass Education

Eat healthy… Do exercise… Watch your weight.

Diabetes Education … Educology The magic capsule for primary and secondary prevention W e I g h t...

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