Diabetes Education вЂ¦ Educology The magic capsule for primary and secondary prevention W e I g h t l o s s H e a l t h y пѓї P o s t e r d I e t E x e r c I s e V I d e o - t a p e L o w p r e v a l e n c e S c r e e n I n g P r o c u r e l e s s L e c t u r e c o m p l I c a t I o n Diabetes Education The magic capsule for primary and secondary prevention W e I g h t l o s s H eIS a l tAN h y EPEDEMIC d I e t E x e DISEASE r c I s e DIABETES ! S c r e e n I n g IS IT A PREVENTABLE DISEASE ? o s t e r V I d e o - t a p e WHAT ARE PTHE WAYS OF PREVENTION ? P r o c u r e L e c t u r e WHICH METHOD TO USE ? WHERE DO WE GO NOW ?L o w p r e v a l e n c e l e s s c o m p l I c a t I o n Historical story of diabetes prevention Ancient Greek scientist 500 B.C. Polyuria ? : W e I g h t l o s s H e a l t h y d I e t E x e r c I s e вЂў He described a disease characterized by: вЂў Polyuria. P o s t e r V I d e o - t a p e вЂў Lack of pain. вЂў Weakness. вЂў Fluid output greater than fluid intake. L o w p r e v a l e n c e вЂў Treat by: вЂў Diet containing a minimum amount of food. вЂў Regulated mode of life. De Medicina ( English translation). S c r e e n I n g P r o c u r e l e s s Celsus L e c t u r e c o m p l I c a t I o n Diabetes is preventable disease The proven methods in prevention of diabetes are: W e I g h t l o s s 1. H e a l t h y d I e t E x e r c I s e S c r e e n I n g Lifestyle modification. P o s t e r 2. Drug use. 3. Future methods: V I d e o - t a p e P r o c u r e L e c t u r e Vaccine Genetic ? L o w p r e v a l e n c e l e s s c o m p l I c a t I o n Historical story of diabetes prevention Two early studies suggested that changes in life style can prevent l o s s H e a l t h y d I e t E x e r c I s e S c r e e n I n g diabetes: W e I g h t 1. 2. Prevention of type 2 diabetes mellitus by diet and physical 1991 V I d e o P o s t e exercise r Diabetologia 34, - t a p e Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes study 1997. L o w p r e v a l e n c e P r o c u r e L e c t u r e Diabetes care 20, l e s s c o m p l I c a t I o n Historical story of diabetes prevention Four recent well designed randomized controlled trails: 1. W e I g h t l o s s 2. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired H e a l t hglucose y d I e tolerance t E x2001 e r c I N Engl J Med 344, s e Diabetes prevention research group: Reduction in the evidence of type 2 diabetes with lifestyle intervention or Metformin 2002 P o s t e r V I d e o - t a p Diabetes prevention research group: The diabetes prevention program: baseline characteristics of the randomized cohort 2000 3. 4. S c r e e n I n g Diabetes prevention program: Design and methods for a clinical trial in the prevention in type 2 diabetes L o1999 w p r N Engl J Med 346, e P rDiabetes o c u r e care 23, L e c t u r e Diabetes care e v a l e n c e Prevention of pancreatic пЃў cell function and prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high risk Hispanic women 2002 l e s s c o m p l I c a t I o n Diabetes 51, 2002 The Finnish Study 2001 Number Age (mean) BMI (mean) Clinical condition W e I g h t l o s s H e a l t h y 522 55 years 31 kg/m2 IGT d I e t E x e r c I s e Control group: Received brief diet and Exercise counseling Intervention group: ReceivedP intensive individualized o s t e r V I d e instruction on weight reduction, Food intake, and guidance on increasing physical activity Duration (mean) 3.2 years L o w o - t a p e p r e v a l e n c e S c r e e n I n g P r o c u r e L e c t u r e Lifestyle 58% l e s s c o m p l I c a t I o n Diabetes Prevention Program (DPP) Number Age (mean) BMI (mean) Clinical condition W e I g h t l o s s H e a l t h y 3,234 51 years 34 kg/m2 IGT d I e t E x e r c I s e Lifestyle group: Intensive nutrition and exercise counseling Treatment group: Two masked P o s tmedications: e r V I d 1. Biguanide Metformin. 2. Placebo. Duration (mean) 2.8 years L o w S c r e e n I n g e o - t a p e Lifestyle 58% p r e v a l e n c e P r o c u r e L e c t u r e Metformin 31% l e s s c o m p l I c a t I o n The Troglitazone in Prevention of Diabetes (TRIPOD) Number Age (mean) BMI (mean) Clinical condition W e I g h t l o s s H e a l t h y 235 Younger 28 kg/m2 GDM d I e t E x e r c I s e Placebo group: Received Placebo Tested group: Received Troglitazone which is Withdrawn P o sfrom t e r the group V I d Named Thiazolidinediones class Duration (mean) e o - t a p e P r o c u r e Troglitazone L e c t u r e 56% 2.5 years L o w S c r e e n I n g p r e v a l e n c e l e s s c o m p l I c a t I o n STOP-NIDDM trail Number Age (mean) BMI (mean) Clinical condition W e I g h t l o s s H e a l t h y 1,429 55 years 31 kg/m2 IGT d I e t E x e r c I s e Placebo group: Received Placebo Tested group: Received Acarbose from the group named пЃЎ-glucosidase inhibitor P o s t e r V I d e o Duration (mean) Acarbose - t a p e 25% P r o c u r e L e c t u r e To 3.3 years L o w S c r e e n I n g p r e v a l e n c e 36% l e s s c o m p l I c a t I o n Lifestyle in prevention of type 2 diabetes Cumulative probability of remaining free of Diabetes 1 Education pill: вЂў reduce weight >5%. вЂў Fat <30% of energy consumption. вЂў Fiber intake >15gm per 1000kcal. вЂў Moderate exercise for 30 min/day. 0.9 0.8 Intervention group 0.7 Education dosing: вЂў Seven sessions with nutritionist in 1st year then вЂў One session every three months. вЂў Individual guidance on physical activity. W e I g h t l o s s H e a l t h y d I e t Control group 0.6 0.5 E x e r c I s e 0 1 years 4 S c r e 2e n I nStudy g3 5 6 Self-reported change in dietary and exercise Habits during the first year Variable Decrease fat consumption Increase vegetables consumption P o s t e r Intervention group Control group Number 253 (%) Number 247 (%) 87 70 72 V I d e o - t a p e 62 P value 0.001 P r o c u r e L e c t u r e 0.01 Decrease sugar consumption 55 40 0.001 Increase exercise 36 16 0.001 Success in achieving the goals of the intervention by one year Variable Intervention L o w p r egroup v a l e n c e Control group Number 253 (%) Number 247 (%) Weight reduction >5% 43 13 0.001 Fat intake <30% 47 26 0.001 Saturated fat intake <10% 26 11 0.001 Fiber intake п‚і15g/1000 kcal 25 12 0.001 Exercise >4 hr/week 86 71 0.001 l e s s c o m P p value l I c a t I o n N Engl J Med,, Vol. 344 May 3, 2001 Public education W e I g h t The expected relation between: l o s s the level H of e public a l t h health y d I eeducation t E and the prevalence of diabetes. No data available to prove this because: 1. Public education standardization. 2. Multi-factorial disease. P o s t efactor. r 3. Ethnic and cultural 4. Long duration trials. 5. Life-style modification difficulty. Involvement level: Individual. Family. Community. Nation. Risk factors: Controllable vs non-controllable Health Education x e r c I s e S c r e e n I n g 125 Level of Education Degree of disease prevention 100 V I d e o - t a p e P r o c u r e L e c t u r e 75 50 L o w p r e v a l e n c e 25 0 l e s s c o m p l I c a t I o n Risk factors for type 2 Diabetes Which factorsвЂ¦? Education effect вЂў Uncontrollable: W e I g h t вЂў Age. вЂў Genetic. вЂў Ethnicity. l o s s H e a l t h вЂў Associated diseases: Individual conditions: y - Hypertension - Hyperlipidemia - Polycystic disease - Vaculopathy E n g Pre-diabetes conditions: вЂў Controllable: P o s вЂў Weight. вЂў Exercise. вЂў Associated disease: d I e t вЂў Age п‚і 45 years вЂў Overweight ( BMI п‚і25 kg/m2 ) relative with xвЂў eFirst r c Idegree s e S cdiabetes r e e n I вЂў Habitual physical inactivity вЂў Ethnic risk t e r вЂў IGF or IGT I d e o - t a p e c u r вЂў VHistory of GDM or big babyP>r 4o kgm Associated conditions: e вЂў Hypertension п‚і140/90 mmHg вЂў HDL п‚Ј0.9 mmol/l п‚± triglyceride 2.82 mmol/l вЂў Polycystic ovary disease (PCOS) L вЂўoHistory w p r of e vvascular a l e n cdisease e l e s s No Yes No Yes No Yes Yes L e c t u r e Yes/No Yes Yes cYes o m p l I c a t I o n Education 21% A share between doctors and patient W e I g h t 79% вЂў Patient share is an important issue that need special training for lthe o s streatingH physician. e a l t h y d I e t E x S c r e e n I n g Doctor Patient Before training вЂў Patient involvement in education is only 21% which change to 47% after training. P o s t e r вЂў Continuity and patient load was not tested which will affect the out-come. e r c I s e V I d e o - t a p e P r o c u r e 53% 47% L o w p r e v a l e n c e l e s s Doctor Therapeutic education of Patients Assal, 2000 L e c t u r e c o m p l I c a t I o n Patient After training Diabetes Education according to the source вЂў вЂў вЂў вЂў Physicians are the highest in providing patients with diabetes education but they are the least effective. The most effective method is the special training classes with >75% effect but not practical. The role of diabetes educator (nurse) is as effective >75% and more practical. Others ie; teachers, volunteersвЂ¦etc need to be evaluated. W e I g h t l o s s H e a l t h y % Receiving education d I e t E x e r c I s e % Effective education P o s t e r V I d e o - t a p e 100 100 75 75 50 50 L o w 25 0 0 Diatition Nurse Class Other P r o c u r e p r e v a l e n c e 25 Doctor S c r e e n I n g Doctor l e s s Diatition Massachusetts Results from the Behavioral Risk Factor Surveillance System (BRFSS) 1996 Nurse L e c t u r e c o m p l I c a t I o n Class Other Education of physicians vs patients: вЂў вЂў вЂў W e I g h t l o s s 401 intervention group focused on improving the skills and knowledge of general practitioners (EMC). 413 second intervention group focused on patients education and self management (DS). 105 reference group choosing patients from regular clinics (RG). H e a l t h y d I e t E x e r c I s e P o s t e r S c r e e n I n g V I d e o - t a p Change e P r o c(%) u r e in HbA1c 0.2 Patient education and self management decrease HbA1c by 0.51% comparing to the reference group. 0.1 0 Improving GPs skill and knowledge decrease HbA1c by 0.23% comparing to the reference group. L o w The patient involvement through education in their management give extra 0.28% decrease in the mean HbA1c. -0.1 DS EMC -0.2 p r e -0.3 v a l e n c e -0.4 -0.5 -0.6 Diabetic Medicine, 20, 846; 2003 L e c t u r e l e s s c o m p l I c a t I o n Model of Public Education Education program вЂў Reduce weight >5%. W e I g h t l o s s Knowledge Risk factors What to do H e a l t h y d I e t вЂў Fat <30% of energy consumption. вЂў Fiber intake >15gm per 1000kcal. P o s t e r E x e r c I s e Age distribution Problem size Illiteracy rate Cultural factor Health system Health beliefs V I d e o - t a p e Weight loss Healthy diet Physical activity P r o c u r e L e c t u r e Behavior вЂў Moderate exercise for 30 min/day. Eating less Healthy diet Exercise plan L o w Decrease costs S c r e e n I n g Factors: p r e v a l e n c e Decrease Prevalence l e s s c o m p l I c a t I o n Model of Diabetes Education Knowledge Education program W e I g h Patients вЂў Certified educator. t вЂў lEducation o s s H e a l t h y d I e system. вЂў Same language. вЂў Education materials. вЂў Support group. вЂў Integrated into lifestyle. P o shealth t e r вЂў Assisted by local care providers. Factors: t Diabetes general Diabetes management Age E x e r c I s e Sex Duration of DM Culture Education level Language Health system Health beliefs V I d e o - t a p e S c r e e n I n g Good control P r o c u r e Behavior Weight loss Skill performance Compliance/Adherence L o w Decrease medical costs p r e v a l e n c e Decrease complications HbA1c L e c t u r e Blood glucose l e s s c o m p l I c a t I o n Pharmacology Educology Definition: Definition: Material: Material: Science of drug effect on human body and its role in disease treatment. Using education as a tool for disease prevention or treatment. W e I g h t Large verity of methods. l o s s H e a l t h y d I e t E x e r c I s e Active compound. S c r e e n I n g Efficacy: Efficacy: Action: Action: Effective according to the dose. More effective than drugs. Long term. P o s t e r Short term. V I d e o - t a p e Side effect: Side effect: Cost: Cost: 4000 SR annually.* 50 SR annually.* Less accepted.** * ** The National Saudi Diabetes Registry 2004. Diabetic Medicine Vol 24, 1997. L e c t u r e May be. None. Acceptance: P r o c u r e L o w p r e v a l e n c e Acceptance: More accepted.** l e s s c o m p l I c a t I o n Factors related to each method Pharmacology Educology вЂў Age at education. вЂў Age. вЂў Literacy rate. вЂў Disease related. W e I g h t вЂў l o s s H e a l t h y Culture effect. d I e t E x e r c I s e S c r e e n I n g вЂў Indication. вЂў Different routes (bioavailability). вЂў Easy administration. вЂў Can be done by P oany s t e body. r вЂў No side effect. вЂў Side effect. вЂў Accumulative effect. вЂў Dose related. вЂў Effect loss with time. вЂў l e s s Effect with use only. V I d e o вЂў - t a p Prescribe e P by r o cphysician. u r e L o w p r e v a l e n c e L e c t u r e c o m p l I c a t I o n Is Physician Advice (patient education) effective? Weight loss Age: W e I g h t Sex: п‚і65 45-64 18-44 l o s s Male Female Ethnicity: White Black Hispanic Other 0.75 0.15 H e a l t h y 0.75 Reference group for age 1.21 0.96 d I e t E x e r c I s e Reference group for sex 0.89 P o s t e r 0.95 2.14 2.20 Exercise V I d e o - t a p e Reference group for race 1.19 1.30 L o1.14 w p r e v a l e n c e Effective Less effective Diabetes care, Volume 26, Number 3, 602-607; March 2003 Medication 0.88 0.31 Effective S c r e e n I n g Non-effective 1.30 P r o c u r e 1.16 0.80 0.88 L e c t u r e Non-effective l e s s Effective c o m p l I c a t I o n Physical activity % Insufficient activity W e I g h t вЂў l o s s H e a l t h y d I e t 100 E x e r c I s e There is no difference between adults with or without diabetes in the percentage of insufficient physical activity P o s t e r S c r e e n I n g 75 71 V I d e o - t a p e P r o c u r e 69 L e c t u r e 50 вЂў This data indicate that there is a large space for exercise in both primary and secondary L o prevention. 25 w p r e v a l e n c e l e s s c o m p l I c a t I o n 0 Diabetics Therapeutic education of Patients Assal, 2000 Non-Diabetics Education is Knowledge and behavior % Heard of HA1c Patient education: 100 97 Have you heard about HbA1c? - Age group: W e I g h t 18-30 31-64 >65 75 97% 31% 13% 50 patients l o- Younger s s H e ahave l t h better y d I education. e t E x e r c I 25 s e S c r e e n I n31g - Type of diabetes effect. - The target group 30-65 13 0 18-30 31-64 >65 Age Patient behavior: P o s t e r V I d e o - t a p e How many times did you check your feet? None 1-2 times 3-5 times > 5 times 15% 31% 17% 37% P r o c u r e L e c t u r e 15% 37% 31% L o w p r e v a l e n c e None 17% 1-2 times l e s s c o m p l I c a t I o n 3-5 times > 5 times Number of times feet were checked in one year Therapeutic education of Patients Assal, 2000 A Saudi twin families: W e I g h t вЂў вЂў вЂў вЂў l o s s H e a l t h y d I e t E x e r c I s e Mohamed and his twin Abdullah are76 years old, both have type 2 diabetes managed with V I P o s t ecurrently r insulin. Mohamed has 13 children while Abdullah has 17 children. Follow-up started 1989 with yearly OGTT. L o w MohamedвЂ™s family refused education on prevention but AbdullahвЂ™s family agree. S c r e e n I n g 15 d e o - t a p e P r o c u r e L e c t u r e 10 MohamedвЂ™s family 5 p r e v a l e n c e l e s s AbdullahвЂ™s family c o m p l I c a t I o n 0 0 5 10 15 Weight If you donвЂ™t know, you have to learnвЂ¦вЂ¦ W e I g h t l o s s H e a l t h y d I e t E x e r c I s e Diet S c r e e n I n g Activity If you learn, you have to implementвЂ¦вЂ¦ P o s t e r V I d e o - t a p e P r o c u r e If you implement, you have to do it right вЂ¦вЂ¦ If you do it right, it has to L o be w p ralways. e v a l e n c e l e s s L e c t u r e c o m p l I c a t I o n Eat healthyвЂ¦ Do exerciseвЂ¦ Watch your weight. Mass Education