1. University HospitalCarl Gustav Carus Dresden Prevention of type 2 Diabetes The challenge Prof. Peter Schwarz Department for Prevention and Care University Hospital „Carl Gustav Carus“ Dresden
2. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptGlobal Development
3. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptWhat 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
4. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptWe know that the prevention of diabetesmellitus is effective, feasible, evaluatedbut difficult, time consuming, challenging How to get it to practice
5. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptDeveloping 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
6. 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
7. The IMAGE project – Partners involvedThank you very much
8. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptWe need Plan Concept Action
9. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt PlanDevelopment of an Global Action Plan - Diabetes PreventionThe action plan should identify essential activities and available resources for diabetesprevention and spell out the responsibilities of each stakeholder and theirinvolvement. In addition, the plan should recommend and outline action steps specificto each involved cohort - (e.g. families, friends, health care providers, the media,health insurance providers, employers, researchers, professional educators, ethnic andcultural groups to name but a few).
10. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptConcept 3 Steps of a Diabetes prevention programDetection ofincreased Timely limited diabetes Continuous intervention intervention to risk and quality management prevent diabetes
11. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptActionTake Action to prevent Diabetes A toolkit for the prevention of type 2 diabetes
12. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptGeneral 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.
13. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptToolkit - 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
14. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt• 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”):
15. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptWhat is necessary SMART Goals F.I.T.T. Principles EAT CLEVER strategy START
16. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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 toEstimation 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 andAims 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 worthTools, 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 forComposition 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 andLifestyle 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 learnfor 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 toVariety 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 measuredEvaluation 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 dietRisks 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.
17. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt F.I.T.T. principle Aerobic Endurance Training Resistance TrainingF 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 moderateT 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 theT ype What kind  walking, jogging, cycling, swimming, hiking, skiing body (e.g. with fitness machines, resistance-bands or just with your own body weight)
18. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptDaily Step RecommendationsCategory Steps per daySedentary <5000Low (Typical of daily activity excluding volitional activity) 5000-7499Moderate (likely to incorporate the equivalent of around 30 7500-9999minutes per day of moderate intensity physical activity)High (likely to incorporate the equivalent of around 45 minutes of 10,000-12499moderate intensity physical activity)Very High (likely to incorporate the equivalent of over 45 minutes >12500of moderate intensity physical activity)
19. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 1000 additional steps a day reduces postprandial glucose by 1,5 mmol/lYates et al. 2011, Diabet Med
20. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptHow 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
21. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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.
22. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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 roleGreaves CJ et al. BMC Public Health. 2011 Feb 18;11(1):119.
23. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptTake Action to prevent DiabetesA curriculum for Prevention managers for the prevention of type 2 diabetes
24. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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, ...) EvaluationCounselling 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
25. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt Overall Structure of the PM TrainingPre-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 resultsPost-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
26. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt Structure of the Training Curriculum PMT2DmThe Training Curriculum PMT2Dm includes 8 modules(7x face-to-face plus 1x project report)Module 1: Problem, Evidence, and TasksModule 2: Course Organization, Recruitment, Networking, Evaluation ManagementModules 3 & 5: Behaviour Change I (Motivation) and Behaviour Change (II) (Action and Maintenance)Module 4: Specific Aspects of Physical Activity in Diabetes PreventionModule 6: Specific Aspects of Nutrition in Diabetes PreventionModules 7 & 8: Longitudinal Project Report/Presentation of the Report
27. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptOverall 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
28. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptChallenge Implementation1. 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
29. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt Risk assessment, Risk scoresImplementationinto practice Feedback and counseling to identify individual resources Personal need for intervention – individual intervention planOccupational 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
30. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptStepwise approach DISTRIBUTIONfrom basic science to AVAILABILITYPublic Health Diffusion ofImplementation EFFICIENCY interventions Supply EFFECTIVENESS Biggest effect on EFFICACY most people Real world BASIC SCIENCE settings Ideal settings Molecular/ physiological
31. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptPrevention 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
32. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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.
33. What is the situation today?VPCThe Virtual Prevention Center
34. VPCThe Virtual Prevention Center
35. 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
36. 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: 624.03.2012 39
37. Titelmasterformat durch Number of users in the network „Active in diabetes prevention“ 2 months after start - 1085 Klicken bearbeiten north america: 247 south america: 60 europe: 583 africa: 49 asia: 102 australia: 4424.03.2012 40
38. Titelmasterformat durch Number of users in the network „Active in diabetes prevention“ 6 months after start - 2016 user Klicken bearbeiten north america: 470 south america: 101 europe: 1063 africa: 76 asia: 235 australia: 7124.03.2012 41
39. Users per country Titelmasterformat durch Number of users in the network „Active in diabetes prevention“ in the network „Active in diabetes prevention“ Today - 3888 user Klicken bearbeiten north america: 681 south america: 135 europe: 1444 africa: 130 www.activeindiabetesprevention.com asia: 415 australia: 11124.03.2012 42
40. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptBecome a „Volunteer“
41. Upper Egypt Diabetes Association Conference8. February 2012, Aswan, EgyptDiabetes Index?
43. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt• To ask the people doing diabetes care about the perception of thereal situation, achievements, barriers and challenges• To analyze this data in a standardized comparable way• To report annually about the quality of diabetes care and thedegree of implementation National Diabetes Plans world wide• To encourage stakeholders and National governments to engagethe implementation of National Diabetes Plans• To improve the situation for people with diabetes
44. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, Egypt 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
45. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptImagine…….
46. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptWe are the Social Network www.activeindiabetesprevention.com www.virtualpreventioncenter.com www.globaldiabetessurvey.com Let‘s act
47. Upper Egypt Diabetes Association Conference 8. February 2012, Aswan, EgyptNetwork –who are active indiabetes prevention www.activeindiabetesprevention.com