Peter schwarz.prevention of type 2 diabetes

University Hospital
Carl Gustav Carus Dresden

Prevention of type 2 Diabetes
The challenge

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


What is the Evidence Story?
Lifestyle Metformin Life/Met Acarbose TZD Orlistat Absolut
(%) (%) (%) (%) (%) (%) (%
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
Life: lifestyle; Met: metformin; RR: risk reduction


We know that the prevention of diabetes
mellitus is effective, feasible, evaluated
but difficult, time consuming, challenging

How to get it to practice


Developing a prevention strategy
–– be structured – easy to understand
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

Diabetes in Asia Study Group (DASG)
Specific objectives 2nd DASG Conference March 26-27, 2010

Development of a European practice-oriented guideline for
1 prevention of type 2 diabetes

Development of a European curriculum for the training of
2 prevention managers

Development of European standards for continuous quality control
3 and evaluation of prevention programs for type 2 diabetes

Development of a European e-health training portal for
4 prevention managers

=> European standards applicable in all member states will help to reduce
inequalities in health

The IMAGE project – Partners involved
Thank you very much


We need

Plan
Concept
Action


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).


Concept 3 Steps of a Diabetes
prevention program

Detection
of
increased Timely limited
diabetes Continuous intervention
intervention to
risk and quality management
prevent diabetes


Action
Take Action to prevent Diabetes

A toolkit for the prevention of type 2
diabetes


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.


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


• 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”):


What is necessary

SMART Goals
F.I.T.T. Principles
EAT CLEVER strategy

START


EAT CLEVER
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
Estimation of the dietary the recommendations. Consider special needs, resources and readiness to change food habits.
pattern
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
Aims in the long and short proceed with small steps. Make a plan with your client.
term
Which kind of tools, guidance, support or skills are needed and available? Involving the family and friends and group counselling are all worth
Tools, guidance and considering.
support
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
Composition of the diet 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.

Diet is influenced by culture, religion, ethical, physiological, psychological, social and economical aspects, availability, and individual likes and
Lifestyle 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
for the whole life from these experiences to develop successful strategies over time.
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).
Energy 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.

Emphasise variety instead of restriction. A health-promoting diet provides satiety and pleasure as well as protective nutrients. Encourage clients to
Variety 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 and self-monitoring help in achieving and maintaining new food habits. Body weight and /or waist circumference should be measured
Evaluation regularly. Encourage your client to use a food diary (see Appendix) or some other methods to monitor eating habits:
Dietary guidance must be based on evidence from nutrition and behavioural sciences. Focus on the big picture: changing one aspect in the diet
Risks management 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.


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

(a) light to moderate
(40-60% VO2 max. / 50-70% HRmax)
(e.g. brisk walking – 5-6 km/h)
I ntensity How hard  slightly increased breathing rate
(b) vigorous
light to moderate
(slight muscular fatigue)
(e.g. jogging – 8-10 km/h)
 increased breathing rate and sweating

(a) light to moderate

T ime How long
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

about 8 different strength
exercises
 using the major muscles of the
T ype What kind
 walking, jogging, cycling, swimming, hiking,
skiing
body
(e.g. with fitness machines,
resistance-bands or just with your
own body weight)


Daily Step Recommendations

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 7500-9999
minutes per day of moderate intensity physical activity)

High (likely to incorporate the equivalent of around 45 minutes of 10,000-12499
moderate intensity physical activity)

Very High (likely to incorporate the equivalent of over 45 minutes >12500
of moderate intensity physical activity)


1000 additional steps a day

reduces postprandial glucose
by 1,5 mmol/l

Yates et al. 2011, Diabet Med


How to change behavior ?
Importance of Convenient Therapies
Low High

Consumer
Diabetes
Obesity
High

Cardiovascular
Disease Ultimate decision-
Required Behavior
maker concerning
Modification for
the nature and
effective therapy
Hypertension extent of therapy

Physician
Low

Cancer Asthma
Osteoporosis
Infections
Depression

Acute Chronic
Nature of Illness


Behaviour Change Model (Greaves etlinked to model
Behaviour change techniques (BCTS) al, 2011)

Greaves CJ et al. BMC Public Health. 2011 Feb 18;11(1):119.


Behaviour change techniques (BCTS) linked to model
Behaviour Change Techniques (Greaves et al, 2011)

Motivation Action Maintenance

Discuss
behaviour change
process (e-p-e)
SMART goals,
action plan, Revisit
Summary, coping plan Try out new
Motivational behaviour, self- motivation and
interviewing: Make (pre-empting
monitoring social support,
Importance, decisions barriers),
Expectations, Self- give feedback
social support /discuss
efficacy
plan progress, relapse
management
techniques, new
Identify social
plans
supporters
/their role

Greaves CJ et al. BMC Public Health. 2011 Feb 18;11(1):119.


Take Action to prevent Diabetes

A curriculum for Prevention managers for
the prevention of type 2 diabetes


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

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

29-31 October 2009


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


Overall Structure of the PM Training

PM alumni
Post-course network
Face-to-face part supervision
• local
Pre-course • 7 training modules • IMAGE e- national and
assignment • skills training learning international
• intermediate tests platform exchange of
•assisted self- • 1 year
• interactive program know how
studies supervision to •Quality
development
•Commented implement
• add. Module management
study material prevention
business planning
•Entrance program
• continuous skills
examination
and learning controls


Challenge Implementation
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


Risk assessment, Risk scores

Implementation
into practice Feedback and counseling to identify individual resources

Personal need for intervention – individual intervention plan

Occupational Health care Intervention material - newsletter

• Structured program Physical intervention – pedometer +
maintenance support
• Risk adjusted IMAGE PRAEDIAS TUMAINI
• quality management 4 +4 sessions
8+3 16 + 8
regular contact
sessions sessions
• structured intervention material
regular contact regular contact
• individual empowerment
• physical activity as basis
• self management as concept
• Reevaluation as outcome
individual risk evaluation after 1 year, quality management


Stepwise approach DISTRIBUTION
from basic science to
AVAILABILITY
Public Health
Diffusion of
Implementation EFFICIENCY interventions

Supply
EFFECTIVENESS
Biggest effect on
EFFICACY most people

Real world
BASIC SCIENCE settings

Ideal
settings

Molecular/
physiological


Prevention of Type 2 Diabetes The Community – Clinic Partnership Model

Community Clinic
Insurers
} Partnership Zone
Proactive Practice
Employers
Reimbursement Team
Informed Population Screening for Diagnosis of
High Risk Prediabetes Decision Support
Strong Community
Organizations
Structured Lifestyle Information Systems
Programs
Healthy Public Policy
Regular Glucose Informed, Activated
Monitoring Patients
Supportive
Environments

Total Population Pre-diabetes Diabetes Complications


4 level Public Health Model for the implementation of prevention programs

Easy to understand Personal feedback Easy healthy MY personal
Personal intervention material about intervention food choices in benefit from
(minorities, social progress daily life prevention
groups)

Intervention Management Targeted Quality Physician Secondary
structures for intervention in management education prevention
structures intervention high risk intervention programs
programs groups

Guidelines for Community Work site risk Intervention Community
diabetes screening reduction small manager based primary
Community prevention programs and big education prevention
practice business programs

National National Tax incentive in Health lifestyle Environmental City planning
Diabetes Plan Health private sector education at programs for
State insurance for screening school exercise
(reimbursement)

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

Info@activeindiabetesprevention.com

Titelmasterformat durch
Number of users in the network „Active in diabetes prevention“
1 month after start - 338

Klicken bearbeiten
north america: 21 south america: 10 europe: 263
africa: 14 asia: 24 australia: 6

24.03.2012 39

2 months after start - 1085

Klicken bearbeiten

24.03.2012 40

6 months after start - 2016 user

Klicken bearbeiten

24.03.2012 41

Users per country

in the network „Active in diabetes prevention“
Today - 3888 user

Klicken bearbeiten
africa: 130 www.activeindiabetesprevention.com
asia: 415 australia: 111

24.03.2012 42


Become a

„Volunteer“


Diabetes Index?

82
85

84
55

84 51 54
79
65
83
58 41

71 61
39 79 63
84 69 38
55 34
66 77 69
88
79 41
63 44 79
55
31
42


• 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


Objectives
• 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.
P. Schwarz, A. Albright, Horm Metab Res, Dec 2011


Imagine…….


We are the Social Network

www.activeindiabetesprevention.com
www.virtualpreventioncenter.com
www.globaldiabetessurvey.com

Let‘s act


Network –
who are active in

diabetes prevention

www.activeindiabetesprevention.com

Peter schwarz.prevention of type 2 diabetes

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