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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
We know that the prevention of diabetes
mellitus is effective, feasible, evaluated
but difficult, time consuming, challenging
How to get it to practice
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
We need
Plan
Concept
Action
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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).
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Concept
Detection
of
increased
diabetes
risk
Timely limited
intervention to
prevent diabetes
Continuous intervention
and quality management
3 Steps of a Diabetes prevention program
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Action
Take Action to prevent Diabetes
A toolkit for the prevention of type 2 diabetes
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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.
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
• 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”):
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
What is necessary
SMART Goals
F.I.T.T. Principles
EAT CLEVER strategy
START
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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.
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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)
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
1000 additional steps a day
reduces postprandial glucose by 1,5 mmol/l
Yates et al. 2011, Diabet Med
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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.
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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.
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Take Action to prevent Diabetes
A curriculum for Prevention managers for the prevention of type 2 diabetes
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
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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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Number of users in the network „Active in diabetes prevention“
2 months after start - 1085
north america: 247 south america: 60 europe: 583
africa: 49 asia: 102 australia: 44
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Number of users in the network „Active in diabetes prevention“
6 months after start - 2016 user
north america: 470 south america: 101 europe: 1063
africa: 76 asia: 235 australia: 71
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Number of users in the network „Active in diabetes prevention“
Today - 3888 user
north america: 681 south america: 135 europe: 1444
africa: 130 asia: 415 australia: 111
Users per country
in the network „Active in diabetes prevention“
www.activeindiabetesprevention.com
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Become a
„Volunteer“
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Diabetes Index?
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
• 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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
• 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
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Imagine…….
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
We are the Social Network
www.activeindiabetesprevention.com
www.virtualpreventioncenter.com
www.globaldiabetessurvey.com
Let‘s act
Upper Egypt Diabetes Association Conference
8. February 2012, Aswan, Egypt
Network – who are active in diabetes prevention
www.activeindiabetesprevention.com
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