Dietary interventional motivational program (dimp) (1) for type 2 diabetes
1. DietaryInterventional Motivational Program(DIMP) for diabeticadults newlydiagnosed with
Type 2 Diabetes Mellitus (T2DM) amongthe NewZealand overweight and obese workforce.
PRESENTED BY- MR. PANDURANG GOPALRAO CHAVAN
PROGRAM- POST GRADUATE DIPLOMA IN HEALTH SCIENCES
COURSE-NUTRITION FOR SPECIAL POPULATIONS 2020"
2. Global prevalence: -
Diabetes is one of the major international public health issues, worldwide the
rates of type 2 diabetes escalating due to unhealthy diet, overweight, obesity,
and physical inactivity (WHO, n.d.)
Diabetes is one of the major risk factors for cardiovascular diseases, chronic
kidney diseases, stroke, and infection (WHO, n.d.).
Worldwide 422 million people suffering from diabetes, it is predicted to reach
up to 629 million by the year 2045 (Forouhi et al., 2018; WHO, n.d.).
Nearly 193 million people remain undiagnosed due to mild or asymptomatic
nature of diabetes (WHO, n.d.).
Nearly 1.6 million deaths are directly associated with diabetes each year. (WHO
n.d.a; Al-Lawati, 2017).
422
629
2020 2045
Global Prevalence
(in Million)
3. New Zealand Prevalence: -
In New Zealand, more than 250,000 people have diagnosed with diabetes(mostly type 2
diabetes) almost six percent of the total population(Ministry of Health, 2019; BPAVNZ, 2018)
The ratio of diabetes prevalence is three times higher in Māori people, Pacific Islanders, and
socioeconomically deprived people (Ministry of Health, 2019).
The incidence of diabetes is higher in elderly people aged over 65 years, almost 15 to 20
percent. (BPAVNZ, 2018).
Recent data of VDR from Ministry of Health’s in the last 12 years the prevalence of diabetes in
people aged 30–39 years has almost doubled (BPAVNZ, 2018).
In New Zealand Diabetes is one of the leading and fastest escalating health issues causing
highest death along with cardiac disease.(Ministry of Health, 2019).
4. What is diabetes
Diabetes is one of the chronic metabolic diseases known by a high level of blood
glucose which leads to serious injury to the many organs of the body. (WHO, n.d.a).
There are two types of diabetes type one and two,
Type one diabetes is insulin-dependent, that occurs because of chronic disease of the
pancreas in which the pancreas secretes a small amount of or no insulin (WHO, n.d.a).
type two Diabetes is most common and around ninety-five percent of the population
are suffering from it, it mainly occurs because of the body’s resistant to insulin or body
unable to make adequate insulin. (WHO, n.d.a).
5. Complications
The most important complication is hyperglycaemia it leads to atherosclerosis which
makes the blood vessels hard and narrow. (Sone et al., 2011).
Other risks linked to diabetes include herat failure, stroke, chronic kidney diseases,
diabetic retinopathy, Neuropathy, and amputation (Sone et al., 2011).
Such illnesses diminish the patients’ quality of life, and possibly rapport with others
around them. (Sone et al., 2011).
6. Why Diet Is an Important Intervention
Dietary intervention helps to control glucose fluctuation and minimise possible future
health complications , with or without physical activity and medication (Kam et al., 2016).
There is much strong evidence from globally suggested that lifestyle modification along
with a healthy diet and physical activity can prevent or delay the onset and
complication of type 2 diabetes. (The International Diabetes Federation, 2019; Green et
al.,2016).
Exercise and nutrition-based intervention for the diabetic are cost-effective (Di Onofrio
et al., 2018), which contributes to a decrease in the overall financial pressure on public
care, as well as increase patient well-being. (Kam et al., 2016)
7. Public health and Public Health Intervention
Public health is described as "the science and art of fostering and safeguarding health
and well-being, preventing ill-health and prolonging life by coordinated social efforts"
(Ministry of Health, 2016).
The public health sector plays a pivotal role in tracking the risk of diabetes, organising
collaborations to develop high-risk diabetes prevention services, and ensuring the
quality of those initiatives (Bergman et al, 2012).
Considering the economic side, healthcare expenses for diabetic people are average
twice higher than people with no diabetes. (Al-Lawati, 2017). According to The
American Diabetes Association, the average expense of health care for a person with
diabetes is over $1,100 per month and $13,741 a year (Corinna, 2018).
8. Why Workplace is Important for Intervention
The workplace has long been used as an effective environment for encouraging health and
well-being. Information regarding health and well-being can touch in a significant
percentage to the adult (working age) population (Griffiths et al., 2007).
This is associated with the fact that many people who make up the workforce come from
groups that are traditionally difficult to reach and lower socio-economic groups, for them it
is always difficult to get information about health, wellbeing, and lifestyle (Griffiths et al.,
2007)
A second major benefit of choosing workplace is that it has a positive influence on the
economic well-being of an organisation due to productive workforce, turning into the
creation of wealth in the community as a whole (Griffiths et al., 2007; Ministry of Health,
2020)
9. Nutrition Motivational Intervention, Di Onofrio et al. (2018) Community based long-term intervention,
implemented in Naples south Italy on type 2 diabetes people. In conclusion after the nine months of
intervention improvement seen in BMI and waist circumference, blood pressure and eating behaviour
pattern.
“Living Well, Taking Control” (LWTC) programme, Smith, et al. (2019) program was implemented in United
Kingdom (UK) Intervention was implemented in local community places on type 2 diabetic people. After six
months in the outcome, participants lost weight and improved their self-reported dietary behaviour and
health condition.
Low Carbohydrate High Fat Diet (LCHF) intervention the study was done by Ahmed et al., (2020) in the
United States on low carbohydrate high fat diet, community-based intervention for three months in which
participations were recommended to eat low carbohydrate high fat diet (LCHF) in the assessment of post
three moths intervention, there was a significant improvement seen in A1C level, BMI, and reduction in
antihyperglycemic medication.
10. The research article from CSIRO stated that a low carbohydrate diet and exercise program is highly effective in
reducing complication type 2 Diabetes by controlling glycaemic level and also helps in 40 percent reduction in a
medication intake (CSIRO, 2016).
The meta-analysis done by Shrestha et al. (2018) to recapitulate the evidence on lowering blood sugar levels by
dietary interventions in working place indicated that dietary intervention in working set up lower the level of
blood glucose.
The study done by Sluijs et al. (2010) on more than 37000 participants among which 915 incidences of diabetes
were registered over a decade, concluded that a positive association lies between higher GI food and diabetes
and fibre intake reversely associated with diabetes. Intriguingly, only starch in the carbohydrate sub-types was
noted to be related to diabetes risk. They confirmed that dietary element plays an important role in managing
diabetes.
The study was done by Asaad et al. (2016) in Alberta with the intervention of Physical Activity and Nutrition on
203 participants for 6 months, in conclusion, they found significant beneficial changes seen in A1c level, lipid
profile, BMI and dietary habits.
11. There is robust evidence of the successful implementation of this kind of
intervention in other countries.
Limited evidence in the literature regarding similar interventions implemented
in New Zealand.
The dietary intervention given in the studies can be modified according to food
access, affordability and culture (Di Onofrio et al., 2018)
The data from VDR for 2018. in 2018, 253,000 people had diabetes which is rose
from 245,000 in the year 2017 and 241,000 in 2016. It indicates poor control of
diabetes in New Zealand.
241,000
245,000
253,000
2016 2017 2018
Diabetes Growing Rate
12. This is a long-term community-based plan primarily focused to promote well-being and
improve quality of life of Type 2 Diabetes (T2D) people which is diminished due to
complications.
It is a renewed and comprehensive therapeutic approach that can be provided through
nutritional intervention with accurate and conscious food choices associated with active
lifestyle promotion which can be used as an effective tool to manage the disease.
13. Inclusion criteria & Exclusion criteria
Inclusion criteria.
Type 2 diabetic patient/workers
BMI >25.0
Age between 24 to 64
Diagnosed at least 1 year prior
Exclusion Criteria
Other medical complication
14. Intervention set up & Duration of intervention
Intervention set up
Workplaces
Hospitals
Large corporation
Duration of intervention
Nine months follow up after every 3 months.
15. Intervention Procedure
It will be divided into three phases
5As approach (Ask, Assess, Advise, Assist, and Arrange), will assist to accept a plan that
considers personal, cultural, and lifestyle factors in advising with food selections. (Deed et
al, 2016)
First phase: -
It will include all the stakeholders Participants, Nutritionist, Program facilitator, Employer,
Trade union, Laboratory, Company fund insurance, and Ministry of Health
Participants will be recruited as per inclusion criteria of intervention, detail information will
be given regarding intervention
Consent will be taken, from Ministry of health,/ local government, employer and
participants.
16. Second phase: -
Stakeholders involved, Participants, Nutritionists, Program facilitator, Laboratories,
Company fund insurance, and Ministry of Health.
Pre-intervention assessment of outcome measure will be done
Physical assessment - BMI, Waist circumference, Eyes: visual acuity Feet; sensation, skin
condition, pressure areas and blood pressure (RACGP
, 2014).
Laboratory testing: to measure baseline metabolic parameters, fasting plasma glucose
(FPG), lipids, and A1C (Smith, et al.,2019).
Dietary Self-Care Behaviour (DSCB) Questionnaire
Well-d app- based on “Diet Evaluation System (DES)”
17. SNAP (Smoking, nutrition, alcohol, physical activity) guideline will be given (RACGP
,
2014).
Recommended diet –low carbohydrate high-fat diet (LCHF).Carbohydrate intake to
≤20 g/day or 5%–10%, protein 20%–25% and fat intake 65%–70% of total calorie intake
(Ahmed et al., 2020).
Instruction-- participants will be recommended to eat only when they feel hungry,
advised not to eat late at night, asked to drink a minimum of six to eight glasses of water
in a day, at list six to eight hours of sleep and 30 minutes of physical activity in a day.
(Ahmed et al., 2020).
18. Third phase: -
Stakeholders’ Participants, Nutritionist, Program facilitator, Employer, Trade union,
Laboratory, Company fund insurance, and Ministry of Health
Follow up meeting will be held after every three months
Same instruction and advice will be given
Outcome measures will be checked and reviewed after every three months of
Intervention
Personal feedback will be taken every three months
19. Fourth phase: -
Stakeholders’ Participants, Nutritionist, Program facilitator, Employer, Trade union, and
Ministry of Health
Analysis of all the outcome measure which will be taken every post three months of
intervention.
The cost will be checked for entire months of intervention
Personal feedback will be taken from all the participants
Reported will be submitted to Employer, Trade union and Ministry of Health
20. Employee/ Participants
Nutritionist
Program facilitators
Employer/ administrative management
Trade unions
Company insurance funds
Ministry of Health
21. The Role of Ministry of Health
Permission for the implementation of the intervention, financial support, and ensuring
the safety of intervention places,
Creating a supportive environment by providing healthcare workers, providing free
laboratory testing, motivating an employee to participate by creating awareness about
diabetes through a national and local media campaign.
Developing public health policies (Laxminarayan, 2011) that includes food and
agricultural policies that will increase healthy food availability, banning, or heavy taxing
on unhealthy foods.
22. Participants dropouts during the nine months of intervention (Crichton et al., 2015)
Participants may be seasonal workers or migrant,
Language barrier
Participants may have a financial issue due to Nutritious food tends to cost more as the
intervention is long-term
Non-availability of food in the working place as well as locality
Personal, family, cultural issues (Fitzgerald et al., 2015), other medical complication, the
position at the work and working time shifts
Financial issue to carried out intervention due to fewer allocation funds from the Ministry of
Health.
23. Community initiatives for delivering affordable fresh fruit and vegetables .(Ex. Nourished for
Nil)
Government schemes, incentives, and the organizational structure that supports staff and their
culture, to solve funding issue (Quirk et al.,2018)
The government initiatives by starting stalls and shops of vegetables and fruits selling at
affordable prices for lower-income people. (Sacks et al., 2015
Food labelling for those who have language barriers (Kerins et al.,2018)
To prevent dropout, holding daily communication with participants during the intervention
period (Crichton et al., 2015).
By developing guidelines to facilitate the implementation of health intervention at workplace.
(Martinsson et al., 2016).
24. hort term: -
Assessment of all the outcome measures every three months
Dietary Self-Care Behaviour (DSCB) Questionnaire
Monitoring participant through dietary self-monitoring mobile app
named Well-D; (Ahn et al.,2019)
Feedback questioner after every three months (Crichton et al., 2012)
25. Long term: -
Assessment of all the outcome measures after 9 months (long term
effect)
Analysing all the outcome measures
Costing
Final participant feedback
26. As per previous, this kind of interventional study has shown significant improvement in the
quality of life of Type 2 Diabetic people, so it can be implemented in NZ set up.
As per economic analysis diet and exercise-based intervention for the diabetic is always
cost-effective especially in highly complicated cases (Di Onofrio et al., 2018).
Participants and will not require big amounts of personnel or financial resources.
It is a community-based intervention at the workplace it will help to cover a larger
population of groups.
It will also help to improve economic and social well-being of workers, increase the
productivity of the employer/ company, and reduce extra-pressure on healthcare services
and overall economic burden of the country.
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