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

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 Lorig Director of the Stanford Patient Education Research Center

13. 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 CDSM Program

14. 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. Stanford Program

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. Total cases = 300 million adults Projected prevalence of diabetes in 2025 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 50 100 150 200 250 199420002010 Year Patients (millions) Type 1 Type 2 McCarty and Zimmet, 1994 Estimates from

20. Projected growth of Type 2 diabetes by region Amos et al. 1997 Type 2 diabetes prevalence (millions) Africa Asia North America Latin America 0 120 Europe Oceania 100 80 60 40 20 0 120 100 80 60 40 20 Africa Asia North America Latin America Europe Oceania 19972010

21. Lifestyle modification Diet Exercise Weight loss Smoking cessation If a 1% reduction in HbA 1c 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 Amos et al. 1997 Melanesian European African Polynesian 05101520 Prevalence of Type 2 diabetes (%) 25 Chinese Hispanic Lowest rates Highest rates Arab Micronesian Asian Indian (Rural India) (Fijian Indian) (Rural Kiribati) (Urban Kiribati) (Rural Tunisia) (Oman & UAE) (Central Mexico) (US Mexican) (Rural China) (Mauritian Chinese) (Rural W. Samoa) (Urban W. Samoa) (Rural Tanzania) (US Afr. Amer.) (Poland) (Laurino, Italy) (Rural Fiji) (Urban Fiji)

23. Diabetes Australia Facts 2008 T2DM in CALD populations: 1. Prevalence of diabetes 2. Prevalence of risk factors 3. Complications 4. Hospitalisations due to non- treatable diabetes 5. Death rates due to diabetes

24. 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

25. Meta-analysis of 11 trials in CALD 1. Improved HbA1c after culturally at 3M 2. Weight Mean Difference -0.3% at 3M and 0.6% at 6M 3. Knowledge scores improved at 3M 4. Healthy life style improvement at 5. 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? PREPOST Practicesn%n%p-value No time to cook own meal 3537.218200.004* Like to eat fast food 2324.51011.10.029* Too busy to follow a routine 2324.53437.80.053**

27. Time in minutes you spent walking for recreation/exercise in the last week (mean) PREPOST n np- value Exercise 1802580.007*

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. 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.