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

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Models of Diabetes Care in PHC Dr Nabil
SulaimanThe University of Sharjah The
University Melbourne
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This Presentation

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

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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

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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.

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Evidence

• RCT in Finland and 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)

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Lifestyle Changes

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

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In Primary Health Care

• In Australia, people with T2D have 80 of their
  care in General Practice
• Diabetes requires the GP to practise biomedical,
  anticipatory and psychosocial care using
  evidence-based and patient-centred medicine and
• Patient to engage actively in managing their
  illness.

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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

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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

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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

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

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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.

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One Step Ahead

• Seminars for people with pre diabetes
• Evidence of reduction of 0.5 HbA1C

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Patient empowerment through CDSM

• Patient empowerment has a crucial role in the
  treatment of chronic disease
• knowledge and skill development to understand and
  manage ones 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.

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Uptake of lifestyle

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

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Adapted from World Health Organization. The World
Health Report life in the 21st century, a vision
for all. Geneva WHO, 1998.
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The increasing global prevalence of diabetes
Patients (millions)
250
200
150
Type 1
Type 2
100
50
1994
2000
2010
Year
Estimates from
McCarty and Zimmet, 1994
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Projected growth of Type 2 diabetes by region
1997
2010
Type 2 diabetes prevalence (millions)
Amos et al. 1997
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Lifestyle modification

• If a 1 reduction in HbA1c is achieved, you could
  expect a reduction in risk of
• 21 for any diabetes-related endpoint
• 37 for microvascular complications
• 14 for myocardial infarction

• Diet
• Exercise
• Weight loss
• Smoking cessation

However, compliance is poor and most patients
will require oral pharmacotherapy within a few
years of diagnosis
Stratton IM et al. BMJ 2000 321 405412.
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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)
Polynesian
(Urban W. Samoa)
(Rural Tanzania)
African
(US Afr. Amer.)
(Poland)
European
(Laurino, Italy)
(Rural Fiji)
Melanesian
(Urban Fiji)
0
5
10
15
20
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Prevalence of Type 2 diabetes ()
Amos et al. 1997
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Diabetes Australia Facts 2008

• T2DM in CALD populations
• Prevalence of diabetes
• Prevalence of risk factors
• Complications
• Hospitalisations due to non-treatable diabetes
• Death rates due to diabetes

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Diabetes Australia Facts 2008

• Prevalence of diabetes is increasing over time
• Reduces quality of life
• Preventable via lifestyle modifications
• Some population groups are at higher risk
  including CALD

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Meta-analysis of 11 trials in CALD

• Improved HbA1c after culturally at 3M
• Weight Mean Difference -0.3 at 3M and 0.6 at
  6M
• Knowledge scores improved at 3M
• Healthy life style improvement at
• No difference in secondary outcomes lipid
  levels, qoL, self-efficacy, 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)

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What are the main reasons for not taking any
actions to lower your risks?
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Time in minutes you spent walking for
recreation/exercise in the last week (mean)
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2. Qualitative Study

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

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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

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Interventions
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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.

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