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

1. Models of Diabetes Care in PHCDr Nabil SulaimanThe University of SharjahTheUniversityMelbourne

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

3. 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

4. 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.

5. 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)

6. 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

7. 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.

8. 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

9. 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

10. 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”

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

13. 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

14. 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.

15. One Step Ahead • Seminars for people with pre diabetes • Evidence of reduction of 0.5% HbA1C

16. Patient empowerment through CDSM • Patient empowerment has a crucial role in the treatment of chronic disease: • knowledge and skill development to understand and 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.

17. 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

18. Projected prevalence of diabetes in 2025 Number of people < 5,000 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 21st century, a vision for all. Geneva: WHO, 1998.

19. 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

20. Projected growth of Type 2 diabetes by region 120 120 100 100 80 80 60 60 40 40 20 20 0 0 Asia Asia Africa Africa Europe Europe Oceania Oceania Latin America North America North America Latin America 1997 2010 Type 2 diabetes prevalence (millions) Amos et al. 1997

21. Lifestyle modification Diet Exercise Weight loss Smoking cessation 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 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.

22. 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 25 Prevalence of Type 2 diabetes (%) Amos et al. 1997

23. 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

24. 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

25. 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)

26. What are the main reasons for not taking any actions to lower your risks?

27. Time in minutes you spent walking for recreation/exercise in the last week (mean)

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

29. 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

30. Interventions

31. 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.