Peter schwarz.prevention of type 2 diabetes

Prevention of type 2 Diabetes

The challenge

University Hospital Carl Gustav Carus Dresden

Prof. Peter Schwarz

Department for Prevention and Care University Hospital „Carl Gustav Carus“ Dresden

Upper Egypt Diabetes Association Conference

8. February 2012, Aswan, Egypt

Global Development



Da Quing 47 – – –

DPS 58 – – – 22

DPP 58 31 – – Life 17

Met 8

TRIPOD 58 31

STOP-NIDDM – – – 25 7

XENDOS – – – – – 45 9

Chinese Study 43 77 88

Japanese Study 75

IDPP 31 29 28

ACTNOW 72

Lifestyle Metformin Life/Met Acarbose TZD Orlistat Absolute RR

(%) (%) (%) (%) (%) (%) (%)

What is the Evidence Story?

Life: lifestyle; Met: metformin; RR: risk reduction



We know that the prevention of diabetes

mellitus is effective, feasible, evaluated

but difficult, time consuming, challenging

How to get it to practice



Developing a prevention strategy

– be structured – easy to understand

– find people where they are – setting approach

– focus on the individual – empowerment

– involve regular contact with individuals with prediabetes

– recruit educated lifestyle managers

– continuously evaluate the success of prevention strategies

– use screening tools that are applicable in a population setting

– include quality management – prevention management

–be structured – easy to understand

Diabetes in Asia Study Group (DASG)

2nd DASG Conference March 26-27, 2010 Specific objectives

=> European standards applicable in all member states will help to reduce

inequalities in health

1 Development of a European practice-oriented guideline for prevention of type 2 diabetes

2 Development of a European curriculum for the training of prevention managers

3 Development of European standards for continuous quality control and evaluation of prevention programs for type 2 diabetes

4 Development of a European e-health training portal for prevention managers

The IMAGE project – Partners involved

Thank you very much



We need

Plan

Concept

Action



Plan

Development of an Global Action Plan - Diabetes Prevention The action plan should identify essential activities and available resources for diabetes

prevention and spell out the responsibilities of each stakeholder and their

involvement. In addition, the plan should recommend and outline action steps specific

to each involved cohort - (e.g. families, friends, health care providers, the media,

health insurance providers, employers, researchers, professional educators, ethnic and

cultural groups to name but a few).



Concept

Detection

of

increased

diabetes

risk

Timely limited

intervention to

prevent diabetes

Continuous intervention

and quality management

3 Steps of a Diabetes prevention program



Action

Take Action to prevent Diabetes

A toolkit for the prevention of type 2 diabetes



General aim

• To provide a credible, simplistic, concise, clear, pragmatic, accessible document with a positive message about health promotion

• Grounded on the IMAGE evidence-based guideline and training curriculum for prevention managers and should preferably be used alongside them

• Target group

– Politicians / policy makers (esp. executive summary)

– All service providers in the field of health care and promotion

• Background / education in health care – basic knowledge

– Information for “clients” will be included within the document and will be provided to them by the person delivering the intervention.



Toolkit - Contents

• Executive summary (“the problem&solution in a nutshell”)

• Why is it time to act? – Facts and Figures; Risk factors; Large number of unknown cases; Complications through late diagnosis;

Costs for health care system and the society; Prevention is possible: the evidence; Economic and social benefits of diabetes prevention

• How can I make a difference? – Prevention as joint effort; Why and how to involve societal framework partners; Practical tips for societal

support; How to build up multidisciplinary prevention team; Practical tips for networking

• How to budget and finance a prevention programme - Realistic budget; Possible sources of income

• How to identify people at risk – Diabetes risk factors; Risk assessment; Care pathway for healthcare provider; Strategy and practical tips

for encouraging participation in intervention activities

• How to change behaviour – Elements and targets of effective lifestyle intervention programmes; Supporting behaviour change;

Effective communication



• Physical activity to prevent diabetes – Why to increase physical activity; How to encourage to increase physical activity

– The FITT principle for training routine:

• Frequency - Intensity - Time - Type

• Nutrition & dietary guidance to prevent diabetes – Long-term dietary goals (in nutrient and food intake level)

– The EAT CLEVER principle for counselors

• Estimation of the dietary pattern, Aims in the long and short run, Tools, guidance, and support, Composition of the diet, Lifestyle for the whole life, Energy, Variety, Evaluation, Risks

• Other behaviours to consider – Stress and depression; Smoking; Sleeping patterns

• Evaluation / quality assurance – Quality criteria; Risks and adverse effects

• Join forces to make a difference! (“positive mission statement”):



What is necessary

SMART Goals

F.I.T.T. Principles

EAT CLEVER strategy

START



E A T C L E V E R Estimation of the dietary

pattern

Use the food diary, or interview to help your client to become aware of his/her dietary pattern and food consumption. Compare dietary intake to the recommendations. Consider special needs, resources and readiness to change food habits.

Aims in the long and short

term

Discuss both short and long term goals: what is your client willing and able to do at the moment? Help to set practical, achievable targets and proceed with small steps. Make a plan with your client.

Tools, guidance and

support

Which kind of tools, guidance, support or skills are needed and available? Involving the family and friends and group counselling are all worth considering.

Composition of the diet A diet with high sugar and other refined carbohydrates and low fibre content, or high saturated and trans fat content may increase the risk for diabetes and other related disorders. Whole grains and moderate amounts of coffee and alcohol may decrease the risk. Encourage the use of herbs and spices to reduce salt. Refer to your national nutrition recommendations but consider the special requirements of people with high diabetes risk, such as the improvement of the components of the metabolic syndrome. Take into account any additional disease your client may have.

Lifestyle

for the whole life

Diet is influenced by culture, religion, ethical, physiological, psychological, social and economical aspects, availability, and individual likes and dislikes. Help your client to find his/her own healthy way of life. Lifestyle change is a process and relapses are part of it. Help your client to learn from these experiences to develop successful strategies over time.

Energy Excessive energy intake causes weight gain. If the client is overweight, make a plan with her / him to support gradual weight loss (step by step). Focus on substituting foods with high saturated fat and/or refined carbohydrate content with lower-energy items. How many meals and snacks, beverages and alcohol included, does he/she have during a day and night? Some regularity in the daily meal plan helps to control over-eating.

Variety Emphasise variety instead of restriction. A health-promoting diet provides satiety and pleasure as well as protective nutrients. Encourage clients to try new foods. Give advice on how to read food labels. This can help your client to feel more confident and expand their healthy food choices.

Evaluation Evaluation and self-monitoring help in achieving and maintaining new food habits. Body weight and /or waist circumference should be measured regularly. Encourage your client to use a food diary (see Appendix) or some other methods to monitor eating habits:

Risks management Dietary guidance must be based on evidence from nutrition and behavioural sciences. Focus on the big picture: changing one aspect in the diet affects many others. Strict restrictions and ‘crash dieting’ may lead to an unhealthy diet, and can cause damage in the long term as well as psychological and social harm. A multi-disciplinary team, including a registered dietician and a psychologist, can give essential support to avoid these risks.



F.I.T.T. principle Aerobic Endurance Training Resistance Training

F requency How often 3x / week (minimum) Max. 2 days gap between training sessions

2-3x / week

I ntensity How hard

(a) light to moderate (40-60% VO2 max. / 50-70% HRmax) (e.g. brisk walking – 5-6 km/h) slightly increased breathing rate (b) vigorous (e.g. jogging – 8-10 km/h) increased breathing rate and sweating

light to moderate (slight muscular fatigue)

T ime How long

(a) light to moderate 45-60 min (in total > 150 min / week) (b) vigorous 30-40 min (in total > 90 min / week)

1-3 sets of 8-15 repetitions for each exercise

T ype What kind walking, jogging, cycling, swimming, hiking, skiing

about 8 different strength exercises using the major muscles of the body (e.g. with fitness machines, resistance-bands or just with your own body weight)



Category Steps per day

Sedentary <5000

Low (Typical of daily activity excluding volitional activity) 5000-7499

Moderate (likely to incorporate the equivalent of around 30

minutes per day of moderate intensity physical activity)

7500-9999

High (likely to incorporate the equivalent of around 45 minutes of

moderate intensity physical activity)

10,000-12499

Very High (likely to incorporate the equivalent of over 45 minutes

of moderate intensity physical activity)

>12500

Daily Step Recommendations



1000 additional steps a day

reduces postprandial glucose by 1,5 mmol/l

Yates et al. 2011, Diabet Med



How to change behavior ?

Hig

h

Low

High Low

Importance of Convenient Therapies C

on

sum

er

Ph

ysician

Chronic Acute

Required Behavior Modification for

effective therapy

Ultimate decision-maker concerning the nature and extent of therapy

Nature of Illness

Infections

Cancer

Hypertension

Asthma

Osteoporosis

Depression

Cardiovascular Disease

Diabetes Obesity



Behaviour change techniques (BCTS) linked to model Behaviour Change Model (Greaves et al, 2011)

Greaves CJ et al. BMC Public Health. 2011 Feb 18;11(1):119.



Motivation Maintenance Action

Behaviour change techniques (BCTS) linked to model

SMART goals, action plan, coping plan

(pre-empting barriers),

social support plan

Discuss behaviour change

process (e-p-e)

Summary, Make

decisions

Try out new behaviour, self-

monitoring

Revisit motivation and social support, give feedback

/discuss progress, relapse

management techniques, new

plans Identify social

supporters /their role

Behaviour Change Techniques (Greaves et al, 2011)

Motivational interviewing: Importance,

Expectations, Self-efficacy

Greaves CJ et al. BMC Public Health. 2011 Feb 18;11(1):119.



Take Action to prevent Diabetes

A curriculum for Prevention managers for the prevention of type 2 diabetes



29-31 October 2009

Tasks of the Prevention Manager (PM)

Management: Communication with other players (diab. prevention and society), networks

Motivation and recruitment of participants (persons at high risk)

Organization of the programme (time line, dates, places, coworkers*, reimbursement, ...)

Evaluation

Counselling and Training: Behaviour change & Motivation Lifestyle I – specific aspects of nutrition* Lifestyle II – specific aspects of physical activity*

*) in some countries the prevention manager will establish a „diabetes prevention team“ assuring to integrate experienced experts of the respective prevention areas



29-31 October 2009

Overall Structure of the PM Training

Pre-course assignment: supported by the e-learning platform (WP 7) about 4 weeks before the face-to-face-part the participants have to work on preparytory texts, book chapters, …

Face-to-face part of the PM-training (training course)

- Presentation of basic information to the participants (e.g. lecture)

- Group work (2 participants each): key questions of the respective module from every day practice have to be answered and prepared for the

- Presentation of group results

Post-course assignments: Transfer of results to own local prevention activities: documented organization and evaluated commence of the prevention programme (supported by the e-learning platform



Structure of the Training Curriculum PMT2Dm

The Training Curriculum PMT2Dm includes 8 modules (7x face-to-face plus 1x project report) Module 1: Problem, Evidence, and Tasks Module 2: Course Organization, Recruitment, Networking, Evaluation Management Modules 3 & 5: Behaviour Change I (Motivation) and Behaviour Change (II) (Action and Maintenance) Module 4: Specific Aspects of Physical Activity in Diabetes Prevention Module 6: Specific Aspects of Nutrition in Diabetes Prevention Modules 7 & 8: Longitudinal Project Report/Presentation of the Report



Overall Structure of the PM Training

Pre-course assignment

•assisted self- studies •Commented study material •Entrance examination

Face-to-face part

• 7 training modules • skills training • intermediate tests • interactive program development • add. Module business planning • continuous skills and learning controls

Post-course supervision

• IMAGE e-learning platform • 1 year supervision to implement prevention program

PM alumni network

• local national and international exchange of know how •Quality management



1. Evidence for diabetes prevention (guideline)

2. Evidence for diabetes prevention Practice (Implementation trial , Experience, practice guidelines)

3. Political support (Diabetes plan, Prevention plan, Educational activities, .....

4. Partners at different levels of care (stakeholder involvement, multidisciplinary team....)

5. Adequate intervention concepts and material (Exchange with others, know how transfer, networking..........)

6. Training of the trainer (license, reimbursement, work plan prevention)

7. Quality management in the process (comparable QM, benchmarking)

8. Business plan prevention including high risk and public health approach

Challenge Implementation



Physical intervention – pedometer +

maintenance support

Intervention material - newsletter

Risk assessment, Risk scores

Feedback and counseling to identify individual resources

Personal need for intervention – individual intervention plan

PRAEDIAS

8 + 3

sessions

regular contact

TUMAINI

16 + 8

sessions

regular contact

individual risk evaluation after 1 year, quality management

IMAGE

4 +4 sessions

regular contact

Implementation into practice Occupational Health care

• Structured program

• Risk adjusted

• quality management

• structured intervention material

• individual empowerment

• physical activity as basis

• self management as concept

• Reevaluation as outcome



BASIC SCIENCE

EFFICACY

EFFECTIVENESS

EFFICIENCY

AVAILABILITY

DISTRIBUTION

Molecular/

physiological

Ideal

settings

Real world

settings

Biggest effect on

most people

Supply

Diffusion of

interventions

Stepwise approach from basic science to Public Health Implementation



Prevention of Type 2 Diabetes The Community – Clinic Partnership Model

Community Clinic

Total Population Pre-diabetes Diabetes Complications

Informed Population

Strong Community

Organizations

Information Systems

Decision Support

Proactive Practice

Team

Screening for

High Risk

Diagnosis of

Prediabetes

Structured Lifestyle

Programs

Regular Glucose

Monitoring

Insurers

Employers Reimbursement

}

Healthy Public Policy

Supportive

Environments

Informed, Activated

Patients

Partnership Zone



National Diabetes Plan State

National Health

insurance (reimbursement)

Tax incentive in private sector for screening

Health lifestyle education at

school

Environmental programs for

exercise

City planning

Guidelines for diabetes

prevention practice

Community screening programs

Work site risk reduction small

and big business

Intervention manager education

Community based primary

prevention programs

Management structures for intervention

programs

Targeted intervention in

high risk groups

Quality management intervention

Physician education

Secondary prevention programs

Easy to understand intervention material

(minorities, social groups)

Personal feedback about intervention

progress

Easy healthy food choices in

daily life

MY personal benefit from prevention

Community

Intervention structures

Personal

4 level Public Health Model for the implementation of prevention programs

Schwarz PE, Med Clin North Am. 2011 Mar;95(2):397-407.

What is the situation today?

VPC

The Virtual Prevention Center

VPC

The Virtual Prevention Center

Diabetes in Asia Study Group (DASG)

2nd DASG Conference March 26-27, 2010

Do you think that Diabetes Prevention

is important?

Worldwide network of people active in Prevention of Diabetes

www.active-in-diabetes-prevention.com

[email protected]

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Number of users in the network „Active in diabetes prevention“

1 month after start - 338

north america: 21 south america: 10 europe: 263

africa: 14 asia: 24 australia: 6

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2 months after start - 1085



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6 months after start - 2016 user



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Today - 3888 user



Users per country

in the network „Active in diabetes prevention“

www.activeindiabetesprevention.com



Become a

„Volunteer“



Diabetes Index?



84

55

41

84

71

82

85

79

79

88

42

38

41

44

79

34

39

63

51

55

66

58

54

55

31

65

69

61

84

83

79

69

63

77



• To ask the people doing diabetes care about the perception of the

real situation, achievements, barriers and challenges

• To analyze this data in a standardized comparable way

• To report annually about the quality of diabetes care and the

degree of implementation National Diabetes Plans world wide

• To encourage stakeholders and National governments to engage

the implementation of National Diabetes Plans

• To improve the situation for people with diabetes



• to assess annually the quality of national diabetes care and the degree of implementation of NDP`s in each participating country (bottom up) by involving stakeholder representing different diabetes related

groups

• to identify gaps and barriers in diabetes management in the participating countries and combine inter- and intra-country comparisons as a best practice strategy to provide targeted evidence to decision-

makers in the planning, management and organisation of NDP`s.

• to analyze annually the changes of the quality of diabetes care, the progress for the implementation of NDP`s and policy development by using the follow-up GDS data to better allow decision makers to

plan and develop more effective and equitable health care systems.

Objectives

P. Schwarz, A. Albright, Horm Metab Res, Dec 2011



Imagine…….



We are the Social Network


www.virtualpreventioncenter.com

www.globaldiabetessurvey.com

Let‘s act



Network – who are active in diabetes prevention


Peter schwarz.prevention of type 2 diabetes

Health & Medicine

Transcript of Peter schwarz.prevention of type 2 diabetes