Models of Diabetes Care in PHC Dr Nabil

Models of Diabetes Care in PHC Dr Nabil Sulaiman The University of Sharjah The University Melbourne

This Presentation Trends in diabetes l Lifestyle interventions- evidence l Models of interventions in PHC: l Diabetes Nurse Educator (DNE) l COACH model l Chronic Disease Self management l

Diabetes in UAE High prevalence in the Gulf Countries. In the UAE the prevalence is: 24% of adults 40% with diabetes and IGT Diabetes is occurring in younger age

Environmental and behavioral changes New dietary habits (what and how we eat), Lack of physical activity, Overweight/ obesity, and Stresses of urbanization and working condition will lead to further rise of CVD and diabetes, and their risk factors.

Evidence RCT in Finland the USA have demonstrated that the incidence of diabetes can be reduced by about 57% by modifying: Physical activity and Diet (Tuomilehto et al 2001, Knowler et al 2002)

Lifestyle Changes However, uptake of such lifestyle changes has been poor Programs developed to enhance the uptake, such as: Ø Diabetes Nurse Educator Ø Coach program Ø Chronic Disease Self- management Ø Others

In Primary Health Care In Australia, people with T 2 D have 80% of their care in General Practice Diabetes requires the GP to practise biomedical, anticipatory and psychosocial care using evidencebased and patient-centred medicine and Patient to engage actively in managing their illness.

Diabetes Nurse Educator Trained nurse Engage, educate and empower patient to manage diabetes and impact of disease on patient and family Based on trust and partnership between PHC centre- Diabetes nurse educator and patient Patient determines agreed targets Continuity and access

Diabetes Coach Program Tested in Melbourne using RCTs for CVD Trained nurse or dietitian to do COACH Following diagnosis or after discharge from hospital Education and empowerment Patient determines agreed targets Follow up consultation or phone calls Showed benefit in several outcomes

Chronic disease self management Is an effective way in which patients are empowered to become more active and effective in managing their disease. Patient engages in “activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes”

Chronic Disease Self Management (CDSM) Stanford University Kate Lorig Director of the Stanford Patient Education Research Center

Stanford CDSM Program Is a workshop where people with different chronic diseases attend Teaches the skills needed in the day-to-day management of treatment and to maintain and/or increase life’s activities. The Program has been adopted by NHS, the Diabetes Society of British Columbia in Canada, Kaiser Permanente, etc It has been translated into Chinese, Vietnamese, Norwegian, and Italian. The patient book is available in Japanese

Stanford Program Small-group workshops, Generally 6 weeks long, Meeting once a week for about 2 hours, Led by a pair of lay leaders with health problems of their own, The meetings are highly interactive, focusing on building skills, sharing experiences and support.

One Step Ahead Seminars for people with pre diabetes Evidence of reduction of 0. 5% Hb. A 1 C

Patient empowerment through CDSM Patient empowerment has a crucial role in the treatment of chronic disease: knowledge and skill development to understand manage one’s condition and the confidence to use that training for better self care and greater compliance Feeling of control and skill development to achieve a more interactive relationship with health care professionals, with the capacity to demand good quality care The patient becomes a better self advocate/agent, more able to get from the health system what they need in particular.

Uptake of lifestyle However, uptake of such lifestyle changes has been poor Programs developed to enhance the uptake, such as: Ø Diabetes Nurse Educator Ø Coach program Ø Chronic Disease Self- management Ø Others

Projected prevalence of diabetes in 2025 Number of people < 5, 000– 74, 000 75, 000– 349, 000 350, 000– 1, 500, 000 > 1, 500, 000 No data available Total cases = 300 million adults Adapted from World Health Organization. The World Health Report: life in the 21 st century, a vision for all. Geneva: WHO, 1998.

The increasing global prevalence of diabetes Patients (millions) 250 200 150 Type 1 Type 2 100 50 1994 Estimates from Mc. Carty and Zimmet, 1994 2000 Year 2010

Projected growth of Type 2 diabetes by region Type 2 diabetes prevalence (millions) 120 1997 120 100 80 80 60 60 40 40 20 20 0 ica a a r Asi eric rope ani f e u ce A Am Am E O rth atin o L N Amos et al. 1997 2010 0 ca sia ica pe nia A er er uro ea c Am Am E O h n rt ti No La ri Af

Lifestyle modification Diet Exercise Weight loss Smoking cessation If a 1% reduction in Hb. A 1 c is achieved, you could expect a reduction in risk of: • • • 21% for any diabetesrelated endpoint 37% for microvascular complications 14% for myocardial infarction However, compliance is poor and most patients will require oral pharmacotherapy within a few years of diagnosis Stratton IM et al. BMJ 2000; 321: 405– 412.

Type 2 diabetes in different populations Lowest rates Highest rates (Rural India) Asian Indian (Fijian Indian) (Rural Kiribati) Micronesian (Urban Kiribati) (Rural Tunisia) Arab (Oman & UAE) (Central Mexico) Hispanic (US Mexican) (Rural China) Chinese (Mauritian Chinese) (Rural W. Samoa) (Urban W. Samoa) Polynesian (Rural Tanzania) African (US Afr. Amer. ) (Poland) European (Laurino, Italy) (Rural Fiji) Melanesian (Urban Fiji) 0 5 10 15 20 Prevalence of Type 2 diabetes (%) Amos et al. 1997 25

Diabetes Australia Facts 2008 T 2 DM in CALD populations: 1. 2. 3. 4. 5. Prevalence of diabetes Prevalence of risk factors Complications Hospitalisations due to non-treatable diabetes Death rates due to diabetes

Diabetes Australia Facts 2008 1. Prevalence of diabetes is increasing over time 2. Reduces quality of life 3. Preventable via lifestyle modifications 4. Some population groups are at higher risk including CALD

Meta-analysis of 11 trials in CALD 1. 2. 3. 4. 5. Improved Hb. A 1 c after culturally at 3 M Weight Mean Difference -0. 3% at 3 M and 0. 6% at 6 M Knowledge scores improved at 3 M Healthy life style improvement at No difference in secondary outcomes: lipid levels, qo. L, selfefficacy, BP, Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health education for type 2 diabetes in ethnic minority groups. Cochrane Database of Systematic Revies 2008 (3)

What are the main reasons for not taking any actions to lower your risks? PRE Practices No time to cook own meal Like to eat fast food Too busy to follow a routine POST n % n 35 37. 2 18 % p-value 20 0. 004* 23 24. 5 10 11. 1 0. 029* 23 24. 5 34 37. 8 0. 053**

Time in minutes you spent walking for recreation/exercise in the last week (mean) Exercise PRE n POST n 180 258 pvalue 0. 007*

2. Qualitative Study Qualitative focus groups to investigate feasibility and cultural appropriateness, barriers and facilitators of known interventions in Sharjah

Aims The target setting is primary health care centers. People visiting all primary health care centers/ Hospitals in Sharjah will be targeted. Risk factors are: Diabetes Physical activity High cholesterol Unhealthy eating (poor diet) Smoking

Interventions

Interventions Case-finding/ screening for prediabetes and diabetes in PHC Consultation with doctors, nurses and patients to identify appropriate diabetes intervention Engaging people with diabetes/ pre-diabetes in CDSM programs and the COACH Family study to look at the genetic profile CME for doctors and nurses in EB diabetes management Training nurses to be diabetes nurse educators (DNE) to provide the interventions in PHC centres.