Global perspectives on diabetes Volume 59 – June 2014 SPECIAL ISS U E
BRIDGES: from the ivory tower to real life 16 29
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International Diabetes Federation All correspondence and advertising enquiries link to third-party websites, which are not under Promoting diabetes care, prevention and should be addressed to the Managing Editor: IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by a cure worldwide International Diabetes Federation, Chaussée de IDF of any material, information, products and La Hulpe 166, 1170 Brussels, Belgium services advertised on third-party websites, and IDF Diabetes Voice is published quarterly and is Phone: +32-2-538 55 11 – Fax: +32-2-538 51 14 disclaims any liability with regard to your access of such linked websites and use of any products or freely available online at www.diabetesvoice.org. services advertised there. While some information This publication is also available in French and © International Diabetes Federation, 2014 – All in Diabetes Voice is about medical issues, it is not rights reserved. No part of this publication may Spanish. medical advice and should not be construed as such. be reproduced or transmitted in any form or by any means without the written prior permis- ISSN: 1437-4064 Editor-in-Chief: Rhys Williams sion of the International Diabetes Federation Guest Editor: Linda Siminerio (IDF). Requests to reproduce or translate IDF Cover photo : © William Vazquez Managing Editor: Olivier Jacqmain, publications should be addressed to the IDF [email protected] Communications Unit, Chaussée de La Hulpe The production of this Special Issue has been 166, B-1170 Brussels, by fax +32-2-5385114, or made possible thanks to the support of BRIDGES. Editor: Elizabeth Snouffer by e-mail at [email protected]. BRIDGES is an IDF programme supported by Editorial Assistant: Agnese Abolina an educational grant from Lilly Diabetes.
Advisory group: Pablo Aschner (Colombia), The information in this magazine is for information Ruth Colagiuri (Australia), Maha Taysir Barakat purposes only. IDF makes no representations or (United Arab Emirates), Viswanathan Mohan warranties about the accuracy and reliability of any (India), João Valente Nabais (Portugal), Kaushik content in the magazine. Any opinions expressed are those of their authors, and do not necessarily Ramaiya (Tanzania), Carolyn Robertson (USA). represent the views of IDF. IDF shall not be liable Layout and printing: Ex Nihilo, Belgium, for any loss or damage in connection with your use www.exnihilo.be of this magazine. Through this magazine, you may Contents
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Diabetes Views 4 Integrated efforts key for optimal diabetes care in China 36 Ming-xia Yuan and Shen-yuan Yuan News in Brief 9 self-management and education IDF BRIDGES Professional workshops help fill gaps in IDF and BRIDGES span the globe to tackle diabetes 16 diabetes self-management 40 Ronan L’Hévéder Heloisa de Carvalho Torres, Ilka Afonso Reis and BRIDGES at a glance 20 Mariana Almeida Maia Education to change the course of diabetes PREVENTION in the Caribbean 44 Schools open doors to lifestyle lessons in Tunisia 22 Errol Morrison, Shelly McFarlane, Cliff Riley and Novie Younger-Coleman Jihene Maatoug, Nawel Zammit, Firas Chouikha, Sana Bhiri, Aymen Salem, Nathalie Farpour-Lambert Health coaching increases self-esteem and and Hassen Ghanem healthy smiles 47 Reducing diabetes risk after gestational diabetes 25 Ayse Basak Cinar and Lone Schou Ruth McManus, Lois Donovan, David Miller, Education helps decision-making for affordable, Isabelle Giroux, Michelle Mottola, Trisha Joy, Charlotte McDonald and Patricia Rosas-Arellano healthy food and control 52 Bettina Tahsin Lifestyle intervention eases battle with diabetes 29 Asma Ahmed and Qing Qiao Everything you ever needed to know about gestational diabetes 56 Valerie Holmes and Claire Draffin health delivery Can a peer support intervention improve type 2 Motivating better diabetes self-care with diabetes outcomes? 60 SMS text messaging 32 Tim Johansson, Sophie Keller, Henrike Winkler, Josefien van Olmen, Grace Marie Ku, Raimund Weitgasser and Andreas Sönnichsen Maurits van Pelt, Christian Darras and Guy Kegels List of projects supported by IDF BRIDGES 64
June 2014 • Volume 59 • Special Issue DiabetesVoice 3 Diabetes views United in our vision to save sight
Diabetic retinopathy (DR) will become the leading type 2 diabetes and the doctors who treat them. cause of blindness worldwide in the next 20 years. The survey estimates that 42 percent of people By 2035, it is estimated that 177 million people or with type 2 diabetes do not reach blood glucose ⅓ of all people living with diabetes will be at risk goals, putting them at high risk for complications, for DR. including blindness. Dr David Strain, Chairman of Time2DoMore’s Steering Committee tells us, “When These troubling statistics are thrown around people are first diagnosed they regard diabetes as quite a lot. How many times have we heard about a ‘mild condition’. Our data suggests the majority the serious and often tragic connection between of people with diabetes regard complications as diabetes and blindness? The messages are shocking, something that may happen in the future, and but the reality is often forgotten. Just like other therefore not something to be concerned about in hard-to-detect diabetes complications, DR can be the early years.” difficult to recognise until it is too late. One of the key principles the International Diabetes How uncanny that a case of blurred vision is often Federation (IDF) will be working towards is better the first-step before a person is even diagnosed with engagement between healthcare practitioners and diabetes. When an individual finally sees a doctor, people with diabetes, but that’s not all. Greater the blurred vision translates to a double diagnosis of collaboration is required locally, nationally and diabetes and eye disease. These circumstances reveal globally among policy makers, service providers, just how long a person can live with undiagnosed the private sector and communities, to reduce the diabetes (often more than a decade) and not know impact of DR. it. It also validates a global need for greater diabetes and DR awareness. For this very reason, The Fred Hollows Foundation and IDF formed a ten year partnership at the end The global burden of diabetes and DR also brings of 2013. IDF’s alliance with the Foundation is the to mind another important issue. Findings from the most significant initiative ever executed by IDF soon-to-be published Time2DoMore global survey leadership in order to help “save sight” for millions highlight the “clinical inertia” among people with of people with diabetes.
4 DiabetesVoice June 2014 • Volume 59 • Special Issue Diabetes views
The Fred Hollows Foundation works throughout will be meaningful to people who live with diabetes Asia, Africa and the Pacific as well as with and vision challenges. Indigenous communities in Australia. A hallmark of the Foundation’s approach is working closely I hope you will join us in advocating the right of all with partners like IDF on blindness and people living with diabetes to see the future. prevention programmes, particularly in poor and isolated regions. Our partnership will provide an opportunity to raise awareness of eye disease as a health priority.
Brian Doolan, CEO of The Fred Hollows Foundation, believes the combined efforts of IDF and the Foundation will increase the capacity to influence change. The focus of the global partnership will be advocacy, workforce development, research, programmes and technology development, and community education and awareness. Over the next ten years, IDF and Hollows will: ■ Embed DR as a health priority, and advocate for increased resources, research and global guidelines for DR prevention and care. ■ Collaborate on and roll out diabetes and eye healthcare programmes in a range of developing countries. ■ Promote investment in innovative, cost effective technology for screening and treatment services for DR to build the capacity and extend the service reach of programmes and services. ■ Contribute to building a skilled workforce to provide good quality care in all aspects of screening, treatment and management of the condition.
In closing, I would like to point out that this second 2014 issue of Diabetes Voice is devoted to IDF’s BRIDGES programme. As a small step forward, and to empower all people living with diabetes and eye disease, this issue has been specially formatted for the visually impaired. IDF will continue this Michael Hirst practice for all publications in the future. The President, International difference may seem minor, but the new format Diabetes Federation
June 2014 • Volume 59 • Special Issue DiabetesVoice 5 Diabetes views Building BRIDGES for diabetes prevention and treatment
I have had the opportunity to observe advances blood glucose and hemoglobin HbA1c testing in diabetes over the course of 50 years. Looking provided the needed information to people with backward and forward, the process tells a story diabetes and healthcare providers. The diabetes of promise. community yet again breathed a sigh of relief. If there was a way to monitor glucose, of course In the 1960s, I recall watching my father who complications could be prevented. struggled with the crude treatments and tools available to people with diabetes at the time. He When monitoring became available, scientists and was prescribed a strict diet, urine testing, and a governments from around the world in the 1980s dose of insulin delivered through a glass syringe and 90s were finally able to invest time and funds with a very long needle. There were no tests for to find answers to pending questions. Does blood monitoring. All of his care decisions were based glucose control really prevent the complications of on guesses. Despite his best efforts, his diabetes diabetes? If people are at risk, can we prevent diabetes led to a series of complications and a tragic end. from happening? From major studies, we learned that good glucose control could prevent complications Years went by in the diabetes community with little in people with type 1 diabetes. Blood pressure and advancement. New medications, insulin products glucose control are very important for people with and better delivery tools were introduced in the type 2 diabetes. For people at risk, several large 1970s and there was a sigh of relief in the diabetes studies showed that lifestyle interventions help lower community. Yet people living with diabetes still had the chance of developing diabetes. The diabetes no way of knowing when their glucose was high community breathed yet another sigh of relief, until or low. As a result, people still suffered the serious they realised that these important scientific findings complications of the disease. were sitting on shelves in universities.
Methods for monitoring blood glucose finally To everyone’s relief...investigators, health decision became available during the 1980s. Tools to perform makers and funding agencies realised that there was
6 DiabetesVoice June 2014 • Volume 59 • Special Issue Diabetes views
more work to do on the diabetes journey. Bridges from each other, adapt to our own communities and were built to translate important findings from rely on tested approaches. I hope that you agree, the research world to communities where people after reading this issue that highlights BRIDGES either with diabetes or at risk for the condition live. translational research, that there is promise for the future in reaching out to the world of people affected In this issue of Diabetes Voice, you will get a by diabetes. peek into the world of translational research. Through an educational grant from Lilly Diabetes, In closing, I would like to thank Lilly Diabetes for BRIDGES (Bringing Research in Diabetes to Global their continued support. I would also like to thank Environments and Systems), is an International the members of BRIDGES Executive Committee, Diabetes Federation (IDF) programme dedicated BRIDGES Review Committee and IDF Executive to translational research projects. BRIDGES takes Office for their dedication and hard work to make lessons learned in research into communities. In this programme a success. this issue you can learn more about real-world projects that investigators from around the world are currently working on in the fight to prevent and treat diabetes.
In Tunisia, a lifestyle intervention is being tested in schoolchildren. Project leaders in Pakistan are partnering with prevention experts from Finland. They are adapting the effective Finnish Diabetes Prevention into a culturally specific lifestyle intervention for the prevention of type 2 diabetes in Pakistan.
In looking at ways to provide better care and education to people in their respective countries, care models, education and peer programmes are being developed and tested in Austria, Brazil, Caribbean Islands, China and Denmark.
Other projects are relying on technology. For example, a mobile phone self-management system is being used to help people with diabetes in the Democratic Republic of Congo, Cambodia and the Philippines. A DVD on gestational diabetes Linda Siminerio is Professor of Medicine is being piloted with expectant mothers in the at the University of Pittsburgh Diabetes United Kingdom. Institute in Pittsburgh, USA. She is Chair of the Bridges Executive Committee Much effort has gone into testing strategies to prevent (2009-2014) and Guest Editor of this and treat diabetes. We need to work together, learn BRIDGES Special Issue of Diabetes Voice.
June 2014 • Volume 59 • Special Issue DiabetesVoice 7 This young girl from Dushanbe, Tajikistan, receives support from Life for a Child no child should die of diabetes The International Diabetes Federation’s Life for a Child Programme is currently supporting over 12,000 children with diabetes in 45 countries. MANY MORE CHILDREN WITH DIABETES ARE IN NEED. YOU CAN HELP SAVE LIVES!
www.lifeforachild.org News in brief New WDD initiative asks people to “Go Blue for Breakfast”
The World Diabetes Day (WDD) “Healthy eating active in supporting the diabetes 2014 campaign marks the first of cause will be featured, too. a three-year (2014-16) focus on begins with healthy living and diabetes. The breakfast” The WDD campaign will contin- impact of healthy eating on the ue to actively promote action to prevention of type 2 diabetes and protect the health and well-being effective self-management will World Diabetes Day 2014 features of future generations and achieve be featured in WDD activities a new initiative: “Go Blue meaningful outcomes for people and materials. Key messages of for Breakfast”. The initiative with diabetes and those at risk. the campaign will raise aware- encourages the diabetes and ness about how healthy choices wider global community to join Visit www.worlddiabetesday.org for nutrition can be easy choices. together by organising a healthy to learn more about the cam- Guidance for the various steps breakfast event in their city, town paign. individuals can take to make in- or neighbourhood on November formed decisions about what they 14, 2014. All breakfasts will be eat will also be provided. Special collected and showcased on a attention will be placed on the custom IDF online platform that importance of starting the day will also feature healthy breakfast with a healthy breakfast, focusing recipes from around the world. on the theme: Special breakfasts created by chefs
June 2014 • Volume 59 • Special Issue DiabetesVoice 9 News in brief
Challenging our cities to be “diabetes aware”
The International Diabetes Federation (IDF) Using mobile health tools and apps, key stakehold- and the European Connected Health Alliance ers in city life will be able to target diabetes aware (ECHAlliance) have partnered to create a new options to those at risk of diabetes and those with scheme that will help maximise diabetes preven- the disease. tion and awareness through the creation of a global network of “diabetes aware” cities. Plans to launch “By 2035 one in ten of the world’s population will the programme are scheduled for World Diabetes have diabetes unless there is radical change,” says Dr Day, 14 November 2014. Petra Wilson, IDF’s Chief Executive Officer. “People in urban areas will be particularly vulnerable. It is A “diabetes aware” city will demonstrate that all important that we find new ways of working across sections of the community are committed to a all sectors to provide people with targeted infor- healthy urban environment. Local public services, mation on healthier lifestyle options,” she added. businesses and institutions will demonstrate that Brian O’Connor, Chair of the ECHAlliance wel- they understand challenges faced by people with comed the new partnership, “Providing people with diabetes and those at risk. This may include city mobile information on healthier places to eat, shop requirements to provide appropriate nutritional and exercise in cities is the first step toward making information in restaurants and clean, crime-free the healthy choice the easy choice. Information is green spaces for physical activity in parks. the key to enabling healthy choices.”
10 DiabetesVoice June 2014 • Volume 59 • Special Issue SAVE-THE-DATE!
30 November – 4 December Connect. Learn. Discover.
SCIENTIFIC PROGRAMME Chaired by Bernard Zinman Basic & Clinical Science lead by Steven Kahn Diabetes in Indigenous Peoples lead by Malcolm King Education & Integrated Care lead by Unn-Britt Johansson Global Challenges in Health lead by James Gavin III Living with Diabetes lead by Gordon Bunyan Public Health & Epidemiology lead by Edward Boyko
worlddiabetescongress.org #WDC2015
WDC 2015 advert Diabetes Voice 210x280 mm B.indd 1 16/04/2014 16:15:45 News in brief
World Diabetes Congress headed for Vancouver in 2015
In 2015, the International Diabetes Federation (IDF) brings the World Diabetes Congress (WDC) to Vancouver, Canada. Experts in diabetes care from around the world will exchange research and best practices on diabetes prevention, education, treatment and management. IDF estimates that 10% of Canadians have diabetes. Strategically, Vancouver - bridges North America and Asia Pacific regions providing an ap propriate setting for discussions on how to tackle the global diabetes epidemic. The WDC 2015 will coincide with the expiration of the current Millennium Development Goals and adoption of the new Post-2015 Development Framework. Within this context, IDF will continue to push for expanded access to diabetes prevention, treat- ment and cure. The return of the WDC to Canada in 2015 will help to ensure the conference has a lasting impact throughout IDF North 30 November – 4 December America and Caribbean (NAC) Region, as well as the world.
www.idf.org/worlddiabetescongress
12 DiabetesVoice June 2014 • Volume 59 • Special Issue News in brief
on the Bookshelf
DIABETIC RETINOPATHY: FROM DIAGNO- the complexities of managing diabetes. Written by SIS TO TREATMENT a team of Johns Hopkins diabetes specialists, this By David S. Boyer MD (Author), Homayoun Tabandeh second edition will help people who have diabetes MD (Author) work effectively with their care team to achieve st 115 pages, English, Addicus Books, 1 edition (April 1, targets and maintain good health. 2014)
The most common eye disease among those with type 1 or type 2 diabetes is diabetic retinopathy and this book explains the disease, how it develops, and CHILDHOOD OBESITY: ETHICAL AND POLICY options for treatment. This guide will help both ISSUES patients and their families by covering such topics as By Kristin Voigt (Author), Stuart G. Nicholls (Author), symptoms, stages of the disease, how it is diagnosed, Garrath Williams (Author) 272 pages, English, Oxford University Press, USA, 1st treatment options, ways to slow its progression, and edition (April 25, 2014) lifestyle changes that lead to better glucose control. This co-authored book is the first to focus on the ethical and policy questions raised by childhood obesity and its prevention. Throughout the book, THE JOHNS HOPKINS GUIDE TO DIABETES authors Kristin Voigt, Stuart G. Nicholls, and By Christopher D. Saudek (Author), Richard R. Rubin Garrath Williams emphasise that childhood obe- (Author), Thomas W. Donner (Author) sity is a multi-faceted phenomenon, and just one 504 pages, English, Johns Hopkins University Press, of many issues that parents, schools and societies 2nd edition (April 8 2014) face. They argue that it is important to acknowledge The Johns Hopkins Guide to Diabetes is a com- the resulting complexities and not to think in terms prehensive easy-to-read guide to better understand “single-issue” policies.
June 2014 • Volume 59 • Special Issue DiabetesVoice 13 News in brief
Volume 1 Issue 1 September 2013 ISSN 0379-0738 Currently in
DIABETES Diabetes Research RESEARCH AND CLINICAL PRACTICE Official Journal of the International Diabetes Federation and Clinical Practice
From pancreatic islet formation to beta-cell regeneration
The double burden of diabetes and tuberculosis – Public health implications
Serum uric acid levels and incidence of impaired fasting glucose and type 2 diabetes mellitus: A meta-analysis of cohort studies
Evidence-based management of hyperglycemic emergencies in diabetes mellitus DRCP is the official journal of IDF. The following articles have appeared recently or are about to appear in that journal. Access information can be found in the QR code.
INTERNATIONAL DIABETES INTERNATIONAL DIABETES FEDERATION ATLAS PAPERS FEDERATION GUIDELINES Guariguata L and 50 other authors. Diabetes Res Clin International Diabetes Federation Guideline Pract 2014; 103: 137-255. Development Group. Diabetes Res Clin Pract 2014; A series of 12 papers providing recent global esti- 103: 256-68. mates for a range of topics relevant to diabetes and Guideline for management of postmeal glucose in hyperglycaemia in pregnancy, together with data diabetes – an update which builds on the original and discussion specific to IDF regions. IDF guideline published in 2007.
Glycaemic and haemoglobin A1c DEPRESSION AND TYPE 2 DIABETES thresholds for detecting diabet- IN LOW- AND MIDDLE-INCOME ic retinopathy: the fifth Korea COUNTRIES: A SYSTEMATIC REVIEW National Health and Nutrition Mendenhall E, Norris SA, Shidhaye R, et al. Diabetes Examination Survey (2011) Res Clin Pract 2014; 103: 276-85. Park YM, Ko SH, Lee JM, et al. Diabetes Res Clin Research studies identified relevant to this topic Pract 2014; doi: 10.1016/j.diabres.2014.04.003. included those from India (n = 8), Mexico (n = 8), “Few representative population-based data are avail- Brazil (n = 5) and China (n = 5). One of the authors’
able regarding glycaemic and HbA1c thresholds for conclusions is that “despite substantial diabetes bur- detecting diabetic retinopathy (DR) in Asia. We den in LMICs [low- and middle-income countries], investigated the association between DR and fast- few [studies] have reviewed comorbid depression
ing plasma glucose (FPG) and HbA1c levels among and diabetes.” The review, nevertheless, suggests that Korean adults.” depression among people with diabetes in LIMCs may be higher than in high-income countries.
14 DiabetesVoice June 2014 • Volume 59 • Special Issue 1 News in brief Parliamentarians respond to call for action
Hon Judi Moylan
A quiet revolution unfolded in Dr Rachael Nyamai MP (Kenya) The Global Parliamentary Champions the bustling city of Melbourne, elected Vice Presidents. for Diabetes Forum called for po- Australia, last December, where the litical action, which was embraced World Diabetes Congress hosted The Global Parliamentary enthusiastically by the MP’s. Since the inaugural Global Parliamentary Champions for Diabetes Forum and then debates and events have taken Champions for Diabetes Forum. the Parliamentarians for Diabetes place in the Parliaments of the United Global Network were the inspiration Kingdom, Malta, Scotland, Australia, Parliamentarians from over 55 of IDF President, Sir Michael Hirst Kenya and Bolivia. Reports of the countries signed the Melbourne and former Australian Senator Guy growing incidence of diabetes in Declaration on Diabetes and established Barnett, who remain Chair and Vice countries large and small highlighted a new advocacy programme, the Chair of the Group. the need for action. International Diabetes Federation (IDF) Parliamentarians for Diabetes Diabetes is a challenge for all na- When Members of Parliament un- Global Network. Adrian Sanders MP tions as its malevolent march wreaks derstand the impact of diabetes on (UK) was elected President and Honor havoc on the health and fortunes of people in their constituencies, they Dr Simon Busuttil MP, (Malta) and citizens and governments alike. become powerful advocates and allies. Their support ensures that diabetes has a central place in health policy, planning and regulation.
The newly established Parliamentar- ians for Diabetes Global Network looks toward expanding its member- ship to become a powerful presence at the next World Diabetes Congress in Vancouver in 2015.
Details of the Melbourne Declaration From left to right: Mr Guy Barnett, Co-Chair, Parliamentary Champions for Diabetes Forum; Hon Judi Moylan, Global Coordinator, IDF Parliamentarians for on Diabetes and Parliamentary ac- Diabetes Global Network; Her Excellency Madam Bongi Ngema-Zuma, First Lady tion since Melbourne can be found of South Africa; Mr Adrian Sanders, President, IDF Parliamentarians for Diabetes Global Network; Sir Michael Hirst, President, International Diabetes Federation on: www.idf.org/pdgn along with contact details of the Secretariat.
June 2014 • Volume 59 • Special Issue DiabetesVoice 15 IDF BRIDGES IDF and BRIDGES span the globe to tackle diabetes
Ronan L’Hévéder
16 DiabetesVoice June 2014 • Volume 59 • Special Issue IDF BRIDGES IDF and BRIDGES span the globe to tackle diabetes
Translational research helps to Diabetes to Global Environments apply successful outcomes from and Systems) is an International basic science into practical real- Diabetes Federation (IDF) pro- life applications in communities. gramme dedicated to translational Today, this type of research is research projects developed to gaining widespread attention in prevent diabetes, diabetes compli- the prevention and treatment of cations and improve quality of life diabetes. of people with diabetes. Across all BRIDGES projects, IDF identifies Several large-scale trials imple- lessons learned in clinical research mented in different healthcare and places them into communities settings and communities have where the need is great. In turn, demonstrated that lifestyle in- BRIDGES community projects terventions can prevent devel- benefit people affected by diabe- opment of diabetes in people tes, and help protect those at risk at high risk. Large multicentre from developing the disease. studies have also demonstrated that with prevention strategies The Programme’s five overarch- and treatment plans, diabetes ing goals define its activities chronic complications can be worldwide: managed thereby decreasing ■ Enhancing interaction with diabetes care costs and provid- health ministries to optimise ing an improved quality of life healthcare systems outcomes. for people with diabetes. ■ Improving quality of life. ■ Improving access to affordable, BRIDGES organisation in brief good-quality education. Launched in 2007, through an ■ Reinforcing human rights of educational grant from Lilly people with diabetes. Diabetes (USD 10,000,000), ■ Strengthening preventive efforts
hoto : T im N olan P hoto BRIDGES (Bringing Research in worldwide.
June 2014 • Volume 59 • Special Issue DiabetesVoice 17 IDF BRIDGES
The programme is managed by project is available on our website from supported projects. The IDF under the supervision of www.idf.org/bridges and in our sessions were lively and interac- BRIDGES Executive Committee World Guide to IDF BRIDGES tive, and provided expert input (BEC), chaired by Professor 2013 which can be downloaded on key elements in writing good- Linda Siminerio, and BRIDGES on the website. quality presentations and papers Review Committee (BRC) for international congresses and chaired by Professor Robert IDF BRIDGES workshops: peer-reviewed journals. All of Gabbay. Each committee is com- promoting excellence in transla- the participants were invited by posed of international experts tional research worldwide and received financial support representing each region of the In 2008, under the auspices of for travel and accommodation world and bringing expertise in the BRIDGES programme, IDF from IDF. The How to get pub- health economics, epidemiology, provided a series of one-day lished – workshops for researchers education, statistics, clinical re- workshops to encourage and event has already been replicated search, and ethics. Lilly Diabetes support young investigators in Colombia and IDF is looking has one observer within BEC in low- and middle-income at the possibility of providing the without voting rights, represen- countries in the development and sessions online. tation on the Review Committee implementation of translational or access to members. research projects. Professor K.M. Venkat Narayan (Emory Reaching the community University, USA) provided worldwide expert input on the structure In the last six years, IDF has and content of the sessions. Since managed four calls for proposals that time, nine workshops have receiving 449 applications from been held in various parts of 104 countries. The assessment of the world, attracting more than each project proposal was based 140 participants. Attendance on the quality of the proposed is free of charge, and many of intervention and the potential participating researchers receive for a favourable impact in the financial support from IDF for healthcare setting. Today, 41 their travel and accommodation. projects supported by IDF The materials of the workshops BRIDGES are under way in 36 will soon be available online. countries in close contact with the local health authorities. Each In addition to the translational re- project is followed closely through search workshops, IDF BRIDGES regular reporting and via an launched a series of educational ongoing mentoring programme. events, How to get published – This Special Issue of Diabetes workshops for researchers in 2013. Voice dedicated to BRIDGES The aim of these workshops, held will introduce a few of these in Miami and Dubai, was to help projects. A detailed presentation, improve the dissemination of Photo : Tim Nolan including outcomes, of each the findings and best practices
18 DiabetesVoice June 2014 • Volume 59 • Special Issue IDF BRIDGES
D-START: adapting to changing adapted to be used effectively in ■ Zimbabwe Diabetes Association, environments local circumstances in Pakistan Harare (Zimbabwe) During the initial implementa- and Vietnam. In this publication ■ Ambulatory Healthcare Center tion of the BRIDGES projects, you will find, as an example, a “CAA Cotocollao”, National a number of challenges were report on the Pakistan project, Social Security in Quito, identified. In low- and middle- “Lifestyle intervention eases (Ecuador) income countries where diabetes battle with diabetes.” prevalence is continuously rising, Before launching the intervention there was a lack of experienced BRIDGES Research Net: putting in each region, the selected researchers ready to develop, im- forward successful interventions applicants received a full week plement and evaluate diabetes BRIDGES Research Net is a of onsite training under the prevention programmes in their BRIDGES intervention concep- leadership of Professor Samir respective communities. It also tually based on D-START. Here’s Helmy Assaad-Khalil, Principal became clear that the sustainabil- how it works: when a project has Investigator of the project in ity of BRIDGES projects would proven to be successful in one Egypt.The interventions are depend on the commitment of country, it is selected, reproduced currently in place and IDF is local healthcare authorities. and implemented in another re- mentoring progress of each gion under the guidance of the through regular conference calls. The search for effective solu- leader of the original one with tions led to the development of an active partnership of the lo- D-START, with support from a cal healthcare authorities. The team of international experts, process is initiated with a call such as Peter Bennett (USA), Juan for proposals: applicants need to José Gagliardino (Argentina), explain how they will adapt the Ayesha Motala (South Africa) and chosen intervention culturally and Jaakko Tuomilehto (Finland). A socially to its novel context, and call for proposals was issued and more importantly demonstrate project partnerships were estab- strong support for the project lished involving researchers and from local authorities. healthcare authorities in devel- oping regions, their colleagues The first round of BRIDGES in developed countries and IDF. Research Net replicated a successful project focusing on Selecting the prevention of improving foot care for diabetes: diabetes as the exclusive area for “The Impact of the Initiation of Ronan L’Hévéder research has been central to this an Educational and Preventive Ronan L’Hévéder is in charge of the new approach. The D-START Foot Care Centre for People with management of BRIDGES for the International Diabetes Federation. projects are based on the protocol Diabetes in Alexandria, Egypt.” developed by Qing Qiao at the Acknowledgement This project is supported by BRIDGES. University of Helsinki, Finland. Three organisations were selected: BRIDGES is an International Diabetes In both interventions, the seminal ■ Qingdao Endocrine and Diabetes Federation programme supported by an educational grant from Lilly Diabetes. Finnish prevention trial was Hospital, Qingdao (China)
June 2014 • Volume 59 • Special Issue DiabetesVoice 19 IDF BRIDGES BRIDGES at a glance
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41: number of projects supported by BRIDGES
38: number of countries in which a project is taking place
11: number of workshops organised to support young investigators and member associations to increase skills in grant, 93: number of posters abstract and publication presented to date writing. Workshops took place in Chinese, English, 104: number of countries French, Spanish and from which we received Russian applications
20 DiabetesVoice June 2014 • Volume 59 • Special Issue IDF BRIDGES BRIDGES at a glance
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145: total number of 2007 – 2014: participants in the timeline of BRIDGES workshops USD 10,000,000: 449: number of applications amount received from received since the start Lilly Diabetes in support of of BRIDGES BRIDGES
June 2014 • Volume 59 • Special Issue DiabetesVoice 21 Prevention Schools open doors to lifestyle lessons in Tunisia
Jihene Maatoug, Nawel Zammit, Firas Chouikha, Sana Bhiri, Aymen Salem, Nathalie Farpour-Lambert and Hassen Ghanem
An epidemiological transition is management of excess weight intervention for overweight and occurring in Tunisia. Prevalence are critical at an early age before obese school children aged 14-16 of diabetes has increased from chronic problems develop. years to prevent type 2 diabetes. 2.3% in 1977 to 6.4% in 1990 Lifestyle interventions included and reached 10 to 15% in 2000. Many studies in developed encouragement for regular phys- Increased diabetes prevalence is countries have proven the ef- ical activity, a healthy diet and rising hand-in-hand with obesity, fectiveness of lifestyle interven- included psychological support which represents an important tions to manage obesity and the over the course of one year. This risk factor of type 2 diabetes. overweight, including the Swiss intervention represented the “Contrepoids” programme.2 first school-based programme The prevalence of childhood for overweight or obese children obesity has increased worldwide Impact of lifestyle interventions in Tunisia. It was also a “first” for during recent decades. Current in school setting the study team. prevalence of overweight and For this BRIDGES supported The challenge in obese children was respectively project, “Lifestyle interven- 23.7% and 5.1% among girls tion among overweight and this step was to and 21.1% and 7% among boys obese school children in Sousse, sensitise school in the region of Sousse, Tunisia. Tunisia”, key persons from the children about their Additionally, a cohort study Swiss “Contrepoids” programme overweight status. demonstrated the stability of trained the study team. Our task obesity among these children was to implement and evaluate The programme began by in the region.1 Prevention and a culturally appropriate lifestyle screening children who were
22 DiabetesVoice June 2014 • Volume 59 • Special Issue Prevention
overweight. Our recruitment plan was simple; we asked the children and their parents to participate in the study in or- der to achieve weight-loss. The challenge in this step was to sensitise schoolchildren about their overweight status. In fact, excess weight is still cultural- ly perceived as a sign of good health in Tunisia. This project Children visit a Nurse to test their blood glucose levels, was used as an opportunity to Messaadine college, Msaken, Tunisia explain possible consequences and risk factors associated with being overweight to children and included groups of ten or more motivated to change lifestyle be- their parents. schoolchildren led by a psycholo- haviours during this occasion, gist, dietician and medical doctor. the information may help them The intervention programme Unfortunately, the participation acknowledge the problem to po- occurred for one year from rate of children and their par- tentially address it in the future. December 2012 to the end of ents was low in these sessions Other parents were very moti- November 2013. There were two although we invited them many vated to participate and brought intervention strategies: a collec- times in a variety of ways, such as their other overweight children to tive intervention for all recruited invitation letters and phone calls. join the intervention in hopes of children (overweight and obese) helping them, too. The study team and an individual intervention Some parents and their children seized these opportunities to help only for obese children who re- were not motivated to participate the entire family by instructing quired intensive managing. in the intervention programme parents, particularly mothers, to because they did not understand use healthy methods of cooking. Collective sessions were managed or perceive the risks associated for all participants (overweight with being overweight or obese. The medical doctors assigned and obese children). Sessions However, even if they were not to the project were trained to manage overweight and obese children. This grant also permit- ted support to improve school sport equipment, which was Some parents and their children found to be too rudimentary were not motivated to participate to encourage physical activity or teaching involvement. The because they did not understand school-based programme also encouraged the schoolchildren or perceive the risks. to interact. Girls ambitious to lose weight in the programme
June 2014 • Volume 59 • Special Issue DiabetesVoice 23 Prevention
developed a sense of friendly doctors have consultations. Jihene Maatoug, Nawel Zammit, competition with their peers. In addition, training physical Firas Chouikha, Sana Bhiri, activity teachers to adapt ex- Aymen Salem, Nathalie Farpour- Lambert and Hassen Ghanem Study insight ercises to assist obese children Jihene Maatoug is Assistant Professor This intervention captured would be very helpful. of Public Health at the Department of Epidemiology, University Hospital multiple opportunities for 3. School directors need to man- Farhat Hached, Sousse, Tunisia. the prevention of obesity and age and improve school in- Nawel Zammit is in residency training at the Department of Epidemiology, University diabetes. The most important frastructure to provide daily Hospital Farhat Hached, Sousse, Tunisia. element was the multidisciplinary physical activity for all inter- Firas Chouikha is Practical Nurse at the Department of Epidemiology, University management of overweight and ested schoolchildren. Hospital Farhat Hached, Sousse, Tunisia. obese children, which does not Sana Bhiri is in residency training at the Department of Epidemiology, University exist in Tunisia. Additionally, the The continuity of the intervention Hospital Farhat Hached, Sousse, Tunisia. study programme enhanced the programme could help all Aymen Salem is Medical Doctor at the Department of Epidemiology, University accessibility of care for children partners listed above reduce and Hospital Farhat Hached, Sousse, Tunisia. lacking time or money for prevent obesity and diabetes, Nathalie Farpour-Lambert is Head of the Obesity Care Program, Service medical consultations. Although which is a significant public of Pediatric Specialties, Department of Child and Adolescent University obesity prevalence is on the health problem in Tunisia. It is Hospitals of Geneva and University increase for youths in Tunisia, recommended that our school- of Geneva, Geneva, Switzerland. Hassen Ghanem is Professor of Public medical assistance does not exist based intervention programme Health and Head of the Department to help manage overweight and be used as a national foundation of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia. obese children. This gives a programme for Tunisia. A report weighty rationale for a school- of this study will be presented to BRIDGES project based intervention. health and education ministries, Lifestyle intervention among overweight and obese schoolchildren: a pre- post-quasi which will be shared with all experimental study with control group in Sousse, Tunisia At the end of the intervention schools in Tunisia. programme, several products and Acknowledgement services remain in the schools This project is supported by BRIDGES. BRIDGES is an International Diabetes today. The following are recom- Federation programme supported by an mendations for strategically curb- educational grant from Lilly Diabetes. ing the rise in childhood obesity and type 2 diabetes in Tunisia: 1. Brochures and fliers promot- ing dietary changes and an in- crease in availability of medical References doctors and nurses in schools. 1. Harrabi I, Maatoug J, Ben Hammouda H, et al. Tracking of overweight among urban school 2. Capacity building for train- children: a 4 years cohort study in Sousse Tunisia. ing school medical doctors J. Public Health Epidemiol 2009; 1: 31-6.
and nurses to better manage 2. Baker JL, Farpour-Lambert NJ, Nowicka P, et overweight and obese chil- al. Evaluation of the overweight/obese child – practical tips for the primary health care provider: dren. Training activities could recommendations from the Childhood Obesity also be provided in primary Task Force of the European Association for the Study of Obesity. Obes Facts 2010; 3: 131-7. healthcare centres where
24 DiabetesVoice June 2014 • Volume 59 • Special Issue Prevention Reducing diabetes risk after gestational diabetes
Ruth McManus, Lois Donovan, David Miller, Isabelle Giroux, Michelle Mottola, Trisha Joy, Charlotte McDonald and Patricia Rosas-Arellano
Primary prevention of type 2 diabetes has been from the immediate family unit. There are also in- shown to be effective in many parts of the world. It creasing concerns surrounding the magnified risks has been years since important studies affirmed that for obesity and metabolic disturbances for children preventive measures such as moderate weight loss, born to mothers with gestational diabetes mellitus moderate physical activity and low-fat, high fibre (GDM).4 For this reason, there is some urgency food choices can help offset impaired glucose toler- to find effective, early metabolic interventions for ance from progressing to a case of type 2 diabetes.1,2 both mothers and their offspring.
Despite years of building the evidence, why is Women with GDM are at greater type 2 diabetes still an ongoing epidemic? The health risk for developing diabetes community often knows what works to prevent type than the general population. 2 diabetes in highly controlled research studies, but doesn’t necessarily know how to usefully translate dia- Women with recently diagnosed GDM are an ap- betes prevention into real world situations. Effective propriate population to target with type 2 diabetes and proven programmes are desperately needed prevention messages. Women with GDM are usu- that can translate diabetes prevention research ally informed about their risk for developing true findings into programmes for people at risk for diabetes, at greater risk for developing diabetes than diabetes. Type 2 diabetes is also a “familial disease”. the general population and should be in active com- This statement emphasises not only the inherited munication with healthcare providers. genetic risks3 but also highlights a connection to the home environment. The importance of com- Families Defeating Diabetes munity context associated with type 2 diabetes risk The Families Defeating Diabetes (FDD) BRIDGES not only includes physical surroundings or social project was designed to deliver a diabetes preven- frameworks, but also includes significant influences tion programme through the existing network of
June 2014 • Volume 59 • Special Issue DiabetesVoice 25 Prevention
Canadian diabetes education centres, while evaluat- ing time and personnel costs. FDD is a 12-month, randomised, controlled intervention for type 2 dia- DO… betes prevention directed at women with recent GDM. Special consideration is also directed to the Most of your food shopping in the outer context of family lifestyle. This additional focus aisles of grocery stores or food markets demonstrates the ways in which family members and avoid the inner aisles. The outer aisles can influence lifestyle behaviours in people with of the store are where real, whole foods diabetes. The rationale in delivering interventions are placed. These are foods highest in fibre and nutrition. They are the most naturally targeted to immediate family members of a person colourful, too. living with diabetes is based on the idea that people with diabetes who receive assistance from family are Try to eat with your family at least once a often highly functioning. day. Children who eat with their families are less likely to be overweight. Participating sites include London, Ontario; Calgary, Eat a healthy breakfast every day. People who Alberta; and Victoria, British Columbia. FDD started eat breakfast are less likely to be overweight. in 2011 and active intervention will finish at the end Exercise for 30 minutes a day because it of 2014. A 24-month phone or electronic contact to will help protect you from developing type 2 enquire about diet, exercise and body measurements diabetes. Children require 60 minutes per day. is being used in this study. Make family activity fun for both you and your children. Play! Dance! Run! Dare to The FDD study will assess physical outcomes such be a bit silly!
as maternal weight loss, HbA1c, and participant and family member body measurements. Important sec- ondary outcomes will evaluate family member en- gagement, the frequency usage of electronic media and correlations between physical outcomes and study engagement parameters. ■ Twice monthly e-mail alerts with diabetes preven- tion hints. Studying women with GDM and their families ■ Access to a password-protected FDD website with Overweight English-speaking women with GDM a variety of lifestyle behaviour and diabetes preven- were offered admission to the study. Women ran- tion information. domised as controls received contemporary diabetes prevention literature from the Canadian Diabetes Immediate family members Association. Women randomised to active interven- were also actively encouraged tion have received the following: to participate. ■ Attendance at a one-hour seminar at three months post-partum. The seminar, website, and electronic updates de- ■ An invitation to a weekly mall-walking group, where livered repetitive and simple messages designed to children were welcome (babysitting provided). be presented in an enthusiastic and entertaining ■ Offer for a gift card incentive after 15 group walks manner. Message examples included: encouraging were achieved. a 7% weight loss after one year, advocating a family
26 DiabetesVoice June 2014 • Volume 59 • Special Issue Prevention
Preliminary insights One hundred and sixty women consented to be in the study (81 women for intervention and 79 DON’T… for control). Women who were eligible but did not participate were more likely to smoke, have a family Be attracted by the colourful boxes or history of diabetes, have a prescription drug plan advertisements for highly processed foods. and be less likely to use insulin. Non-participation Highly processed foods are low in nutrition reasons included being too busy and being uncon- but high in fat, sugar and additives – all of cerned about a personal risk for type 2 diabetes. This which are not good for you. non-participation rate was somewhat unexpected Believe that your children aren’t watching because women with GDM usually indicate that what you eat. They are and will want to eat they wish to avoid type 2 diabetes. However, this the same thing. process finding is important as it illustrates that Buy fast-food. Even if you can afford the even in a population knowledgeable about the risk of cost, fast food meals (including breakfast diabetes, many may choose not to participate. In the sandwiches) are high fat, high sodium, and future, wider population interventions intended to low fibre meals, which mean you don’t feel offer diabetes prevention will need to develop solu- satiated or full after you eat them. tions to address significant levels of unconcern and Sit for more than 2-3 hours at a time. Move process disengagement from their target audience. around, and take a walk. Innovative approaches to capture attention will need to be considered.
Family members signed on as part of FDD, but at lower rates; 25 of the intervention family members agreed to participate along with 19 of the control friendly low-fat, high fibre diet and encouraging family members. To some extent, this finding was ½ hour of daily exercise for all family members. expected. Family members, who are one step re- moved from the experience of treating or experi- Control and intervention groups completed ques- encing GDM, may be less likely to be motivated to tionnaires enquiring about diabetes prevention participate in an investigation for personal health knowledge and lifestyle habits at pre-delivery and habits. It is important to note that while some fam- ily members, especially partners, are receptive to three, six, twelve months postpartum. HbA1c was measured at three and twelve months postpar- adapting a healthier lifestyle in an effort to support tum. All women were encouraged to breastfeed. partners with GDM, others are not. A more focused Consenting family members of both control and survey of family members’ opinions about their role intervention groups were also actively encouraged in healthy lifestyle interventions might offer useful to participate. Family members who consented were insights for future programme designs. surveyed for knowledge about diabetes prevention including dietary and exercise habits. Body meas- Multiple prompts and reminders were provided urements were recorded at three and twelve months. during the year for participants to log onto the Family members of the intervention group also had FDD website. Website accession rates have been access to electronic media and updates. recorded at 41% of interventional women and 38%
June 2014 • Volume 59 • Special Issue DiabetesVoice 27 Prevention
of interventional family members. Most frequent Ruth McManus, Lois Donovan, David Miller, Isabelle website hits were noted on the following areas: com- Giroux, Michelle Mottola, Trisha Joy, Charlotte munity, programme seminar, links, powerful foods, McDonald and Patricia Rosas-Arellano Ruth McManus is Professor of Medicine at the Division of feeding baby and planning pregnancy. Most FDD Endocrinology and Metabolism, Department of Medicine, The participants accessed the website five times over the University of Western Ontario, London, Ontario, Canada. Lois Donovan is Clinical Associate Professor at the Division course of a year. Targeted engagement with a diabetes of Endocrinology and Metabolism, Department of Obstetrics prevention website resulted in approximately 40% and Gynecology, University of Calgary, Canada. David Miller is Affiliate Assistant Professor at the Department of uptake. It was assumed that building an electronic Medicine, University of Victoria, British Columbia, Canada. presence into the FDD programme would allow Isabelle Giroux is Associate Professor for a Nutrition Program at for expanded opportunities for knowledge and be- Faculty of Health Sciences, University of Ottawa, Ontario, Canada. Michelle Mottola is Professor at the School of Kinesiology, Department havioural support through links to other helpful of Anatomy and Cell Biology, Schulich School of Medicine and sites. Although the study team anticipated that an Dentistry, The University of Western Ontario, London, Ontario, Canada. Trisha Joy is Assistant Professor of Medicine at the Division of engaging website would be a good way to reach Endocrinology and Metabolism, Department of Medicine, The University of Western Ontario, London, Ontario, Canada. participants with health information, visits to the Charlotte McDonald is Associate Professor of Medicine at the website were disappointingly low. At completion, Division of Endocrinology and Metabolism, Department of Medicine, The University of Western Ontario, London, Ontario, Canada. programme data will provide the website compo- Patricia Rosas-Arellano is Research Coordinator of the nents which were most frequently accessed as well Families Defeating Diabetes project, Canada. as correlations between electronic engagement and BRIDGES project quantitative outcomes such as exercise frequency, Families Defeating Diabetes (FDD): a Canadian intervention for breastfeeding duration, and weight loss. family-centred diabetes prevention after gestational diabetes
Acknowledgement Next steps The FDD researchers are truly grateful for the enthusiasm and good humour of our site coordinators: Kristen When FDD is complete and all results are analysed, Barton (Calgary) and Karen Coles (Victoria). we propose to evaluate which intervention activities This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported are associated with positive physical and process by an educational grant from Lilly Diabetes. outcomes. Building these aspects into a type 2 diabetes prevention programme for GDM at diabetes education centres would be ideal. It is further anticipated that physical and process outcomes from the FDD programme may provide a foundation for wider population diabetes prevention initiatives, including: developing educational programmes References for women at risk for type 2 diabetes, determining 1. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM how varying levels of family involvement impact in people with impaired glucose tolerance. The Da Qing IGT and diabetes study. Diabetes Care 1997; 20: 534-44. healthy lifestyle behaviour, and demonstrating the power of educational tools, including electronic 2. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. media, for enhancing healthy lifestyle knowledge N Engl J Med 2001; 344: 1343-50. and behaviour. 3. Franks PW. Diabetes family history: a metabolic storm you should not sit out. Diabetes 2010; 59: 2732-3.
4. Wroblewska-Seniuk K, Wender-Ozegowska E, Szczapa J. Long-term effects of diabetes during pregnancy on the offspring. Pediatr Diabetes 2009; 10: 432-40.
28 DiabetesVoice June 2014 • Volume 59 • Special Issue Prevention Lifestyle intervention eases battle with diabetes
Asma Ahmed and Qing Qiao
Pakistan is the sixth most popu- diabetes at a lower body mass only on individuals but on their lous country in Southeast Asia index (BMI) than Caucasians. families as well, especially in cir- with a population exceeding 180 This becomes a very signifi- cumstances where the head of million. Today, diabetes preva- cant concern in a country like the household is the only income lence in Pakistan is estimated to Pakistan where 12.8% of male provider. Programmes to prevent be 6.8%.1 In 2010, a World Bank and 27.3% of the female popu- and manage diabetes are required report warned that Pakistan is lation are physically inactive. A in order for Pakistan to tackle the facing a health crisis, with ris- population based survey in both diabetes epidemic. ing rates of diabetes, obesity, rural and urban areas of Pakistan heart disease and other Non- revealed the prevalence of over- 25% of the Pakistani communicable diseases (NCDs). all glucose intolerance at 22% in population is According to the report, NCDs urban areas and 17.2% in rural account for 59% of the total dis- areas. Furthermore, 25% of the classified as ease burden in Pakistan.2 The Pakistani population is classified overweight rising prevalence of diabetes in as overweight and obese accord- and obese. Pakistan is eclipsed only by the ing to Asian specific BMI defini- 88,000 annual deaths attributed tions. Unfortunately the expendi- The study to complications of diabetes. By ture on healthcare in Pakistan is In collaboration with the 2035, it is estimated that 12.8 mil- only 2% of the gross domestic University of Helsinki, the on- lion people will be living with product (GDP) and people with going Karachi-based Pakistan diabetes in Pakistan. diabetes and their families have Diabetes Prevention Programme to bear most all costs associated (PDPP) addresses key issues in Ample evidence indicates that with diabetes related care. This the prevention of type 2 diabetes. Asian populations develop type 2 poses a significant burden not The capital city of Karachi is the
June 2014 • Volume 59 • Special Issue DiabetesVoice 29 Prevention
Front row from left to right: Mr Mohsin Ali, Ms Marvi Hussain, Ms Hamidah Aziz and Ms Mehreen Sultana Back row from left to right: Mr Jamal Iqbal, Ms Hina Shabbir, Mr Arif Hussain and Mr Tariq Hussain
largest city in Pakistan with an settings. Another important aspect were also consistent with the estimated population of more than of this study has been to assess the landmark Da Qing study, which 18 million. Approximately 20,000 impact of urban planning on the achieved 51% lower incidence of Karachi residents are currently be- prevalence of obesity and diabetes. diabetes with lifestyle interven- ing screened for diabetes risk fac- tion. In follow-up, studies have in- tors using a non-invasive diabetes Lifestyle intervention impact dicated long term success includ- risk-score system. Those already Randomised trials in individuals at ing 43% sustained lower incidence found at increased risk have been high risk for diabetes support the of diabetes over a 20-year period.3 given an oral glucose tolerance test hypothesis that explicitly target- (OGTT). After the OGTT, those ing lifestyle-factors can substan- However, the lifestyle inter- identified as having metabolic syn- tially help reduce the incidence vention in the Indian Diabetes drome (or pre-diabetes) are asked of type 2 diabetes. The Diabetes Prevention Program (IDPP) had to take part in the PDPP lifestyle Prevention Program (DPP) and a less significant effect (28.5% re- intervention. The intervention the Finnish Diabetes Prevention duction in diabetes incidence) on consists of culturally adjusted pre- Study (FDPS) showed a 58% diabetes prevention. Apart from ventive strategies focusing on diet reduction in the incidence of clinical outcomes, the IDPP did and physical activity in real-life type 2 diabetes. These findings prove to be cost effective which is
30 DiabetesVoice June 2014 • Volume 59 • Special Issue Prevention
an important element for health- for low levels of exercise. Current Lifestyle intervention for individ- care policy decision-making. political circumstances also have uals with the high-risk scoring sys- an impact on life in Pakistan; tem is in progress. Approximately Country context there is significant psychological 475 participants have been given To date, the effectiveness of stress that may further contribute intervention sessions. The PDPP lifestyle interventions for the to “insulin resistance syndrome” intervention programme objec- prevention of diabetes has not resulting in an increased preva- tive is to improve the awareness been investigated in the native lence of diabetes. of the community, to reduce the Asian Pakistani population. It incidence of obesity, diabetes and could be hypothesised that IDPP Current PDPP progress other related complications. PDPP could be partly applicable to The primary objective of PDPP is will be complete in October 2014. the Asian Pakistani population to implement culturally tailored as they belong to the same lifestyle intervention programmes subcontinent, but even amongst into real-life settings for two the South Asian population years. Educating the community variation in susceptibility to on ways to change unhealthy eat- diabetes has been observed ing and lifestyle practices is ex- within the same geographical pected to produce a reduction in Asma Ahmed and Qing Qiao location. Moreover, there is the incidence of type 2 diabetes. Asma Ahmed is Assistant Professor significant diversity among South The study is being conducted in and Endocrinologist at the Aga Khan Asians in terms of their cultural two major areas of Karachi based University Hospital, Karachi, Pakistan. Qing Qiao is Adjunct Professor, practices and dietary habits. on the differences in dietary cul- Department of Public Health, University of Helsinki, Finland. For example, the prevalence ture and city plan. of diabetes between Gujrati BRIDGES project (Indian) Muslims and Pakistani To date, 13,969 individuals have A translational randomized trial of culturally specific and cost-effective life Muslims among migrants of been screened with the help of a style intervention for the prevention of type 2 diabetes in Pakistan (Pakistan South Asian descent living in non-invasive diabetes risk scor- Diabetes Prevention Program PDPP) the United Kingdom differs by ing system out of which OGTT approximately twofold. has been done for 2,677 partici- Acknowledgement This project is supported by BRIDGES. pants. The results so far show BRIDGES is an International Diabetes The population of Pakistan is an increased prevalence of obe- Federation programme supported by an educational grant from Lilly Diabetes. comprised of five major diverse sity (35.2%), physical inactivity ethnic subgroups originating (56.9%) and glucose intolerance References 1. International Diabetes Federation. IDF from different parts of Central in the Karachi population. The Diabetes Atlas, 6th edn. IDF. Brussels, 2013. and South Asia with distinct lan- overall prevalence of pre-diabetes 2. Engelgau MM, El-Saharty S, Kudesia P. guages, dietary practices, places and diabetes in high-risk indi- Capitalizing on the Demographic Transition: of origin, cultural values, health viduals was 31.3 (95% CI 29.6- Tackling Noncommunicable Diseases in South Asia. World Bank. Washington DC, 2010. beliefs and behaviours. In addi- 33.1) and 15.2 (95% CI 13.9-16.6) tion, the perceived unsuitability respectively. Raised BMI and 3. Lindstrom J, Ilanne-Parikka P, Peltonen M, et al. Sustained reduction in the incidence of women’s participation in physi- central adiposity was found to of type 2 diabetes by lifestyle intervention: cal activity in a number of Muslim significantly correlate with both follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368: 1673-9. communities is also responsible pre-diabetes and diabetes.
June 2014 • Volume 59 • Special Issue DiabetesVoice 31 Health Delivery Motivating better diabetes self-care with SMS text messaging
Josefien van Olmen, Grace Marie Ku, Maurits van Pelt, Christian Darras and Guy Kegels
Good self-management is cru- In recent years, the fast increasing phone technology can be used cial for experiencing a healthy penetration and use of mobile in a simple but intelligent way life with diabetes. Diabetes Self- technology worldwide has been for diabetes programmes in a Management Education (DSME) seen as a potential game changer variety of settings. Evaluating the and Diabetes Self-Management to enhance current approaches to impact of mobile technology on Support (DSMS) activities pro- DSME/DSMS. Mobile technology the challenges associated with vide a process for people living today provides a variety of health diabetes will also be vital once with diabetes to gain the knowl- enhancing tools for people and the study is complete. These edge and skills needed to modify professionals connected to challenges include changes their behaviour. DSME and DSMS diabetes. For example, smart- related to physical health, also help people with diabetes self- phone technology can be directly feelings of control, utilisation manage the disease and related linked to blood glucose measuring of healthcare services and self- conditions. The implementation equipment enhancing patient and management behaviour. of DSME/DSMS takes different professional collaboration. For forms depending on the organi- enhanced motivation and better Study sation of care for people with self-care behaviours, lifestyle- We designed a randomised diabetes including their health- based short-message-service controlled trial for people with care system and their healthcare (SMS) text messaging can be diabetes from existing diabetes provision. The impact of the delivered to people with diabetes. programmes in three coun- cultural and socio-economic tries: Democratic Republic of environment in which they live is The TEXT4DSM study was the Congo (DRC), Cambodia also an important factor. developed to find out how mobile and the Philippines. Each site
32 DiabetesVoice June 2014 • Volume 59 • Special Issue health delivery
The BRIDGES evaluation team visiting a peer educator group in Cambodia. Photo: Tim Nolan
recruited 480 participants. All Data collection for all partici- by a participant’s usage of mobile study participants (exposure and pants occurred before the start technology for diabetes. control groups) continued to re- of the intervention as well as one- ceive diabetes care and DSME in year and two-year completion. Context of study settings their normal setting and all par- Data included biomedical and The estimated prevalence of
ticipants received a new mobile anthropometric variables (HbA1c, diabetes for each study country phone. In addition, the exposure BMI, WC, WHR) as well as in- according to the IDF Diabetes group received short-message- formation related to participant Atlas:1 services related to different di- knowledge, attitudes, percep- ■ DRC: 6.1% mensions of diabetes self-man- tions, practices and feelings of ■ Cambodia: 3.0% agement such as advice related to control. After six months, we ■ Philippines: 6.9% diet and exercise, self-monitoring also performed an intermediate and how to handle emergencies. data collection restricted to the The programme in the DRC is a Exposure participants were also biomedical and anthropometric 40-year-old network of 80 prima- encouraged to use their phone variables. In our study analyses, ry care centres located in the capi- when they had questions or felt we will focus on the evolution tal city of Kinshasa. These centres the need for support on self- of outcome variables in all three deliver diabetes care as part of a management requirements. In settings and assess possible dif- basic package to approximately this instance participants were ferences. For instance, we will 8,000 people with diabetes. The encouraged to contact their evaluate how different mecha- first contact person for the person healthcare provider. nisms may have been triggered with diabetes is a nurse. Every
June 2014 • Volume 59 • Special Issue DiabetesVoice 33 Health Delivery
Saturday, people with diabetes can come to the health centre for education sessions and a urine glucose test. Every two months anyone with diabetes who has ac- cess to a primary care centre sees a doctor and is given a blood glu- cose test, blood pressure monitor and a foot examination. They can also buy prescribed medicines at a subsidised price. People on insulin generally receive their injections at the health centre, rather than self-administer.
In Cambodia, the diabetes Diabetes Educator in a Diabetes Self-Management Education programme, initiated in 2005, session with patients in Barangay, the Philippines operates through community- based peer educator networks. Currently, there are 130 peer educators work an average of people with diabetes is a fam- educators working with 7,000 one and a half days per week and ily physician. However, there are people with diabetes. Peer receive a small financial incentive also education nurses, dieticians, for each education activity they pharmacists, and medical special- help facilitate. They are supported ists available. FiLDCare is also of- by the NGO, MoPoTsyo Patient fered in two rural areas where the Information Centre, located in CHW provides DSMS alongside the capital city of Phnom Penh. the rural health unit physician The information centre also who provides DSME. At present, organises access to local medical 70 CHWs in the programme sup- services, a revolving drug fund port approximately 1,000 people and laboratory examinations. with diabetes.
In the Philippines, people with Progress to date diabetes receive primary care At the time of writing this report, and DSME in a healthcare facil- the project was in the midst of its ity. DSMS is community-based implementation phase. We have and provided by Community been able to include 480 patients Health Workers (CHWs) in in each country and collect their Project Manager explaining the “First Line Diabetes Care baseline data. Contracts with the study in an information Project” (FiLDCare). FiLDCare local telephone providers for the meeting for potential is operational in one urban area provision of 480 cellular phones participants in DRC where the primary contact for (to match the 480 participants in
34 DiabetesVoice June 2014 • Volume 59 • Special Issue health delivery
each setting) have been signed. of the analysis will be published Josefien van Olmen, Grace Marie Currently, the study team is in peer-reviewed journals. Ku, Maurits van Pelt, Christian sending daily text messages to Darras and Guy Kegels Josefien van Olmen is Pre-doctoral each of the 240 participants. Possible expectations beyond Researcher at the Institute of Tropical Overall, SMS messages covering the initial rationale Medicine, Antwerp, Belgium. Grace Marie Ku is Pre-doctoral Researcher all nine dimensions of the DSME The partly unforeseen difficulties at the Institute of Tropical Medicine, guidelines2 have been sent for one in the implementation of a mobile Antwerp, Belgium and in charge of the FiLDCare project in the Philippines. year at a rate of five per week. To phone support intervention Maurits van Pelt is Director of date, the study team has collected have brought to light some of MoPoTsyo in Cambodia. Christian Darras is Advisor to data from all participants one year the limitations and barriers to Memisa, Brussels, Belgium. after their inclusion. Processing mobile health solutions that Guy Kegels is Senior Lecturer at the Institute of the information is ongoing. could be posed on a larger scale. of Tropical Medicine, Antwerp, Belgium. Nevertheless, the feedback and BRIDGES project The main challenges for the discussion of the first analyses Mobile phone Diabetes Self-Management Support: a multi country analysis of its TEXT4DM study relate to au- of the baseline data from implementation in existing Diabetes Self-Management Education programmes thenticating sent and received practitioners and people with in the Democratic Republic of Congo, SMS messages and the follow- diabetes in each setting have led Cambodia and the Philippines
up of participants. All partici- to new insights and enthusiasm Acknowledgement pants received a new cellular about ways to improve diabetes This project is supported by BRIDGES. phone and a new mobile number, care and DSME/DSMS. BRIDGES is an International Diabetes Federation programme supported by an which TEXT4DM used to send educational grant from Lilly Diabetes. the study messages. In all coun- The TEXT4DM study has tries, we met people who had lost, turned out to be an enriching broken or given away their study experience in many ways. phones. We realised that most Collaborating in a joint research people had access to another programme meant learning phone and used the alternative opportunities for everyone “study mobile number” for mes- associated with the TEXT4DM’s sages. We had specific constraints international consortium. in Cambodia, where we wanted The capacity for designing, to be able to communicate in the implementing and analysing local language (Khmer), which research has grown in all the would have required special font study settings. The sharing of phones. We decided to shift to diabetes practices between the voice-SMS or sending SMS as sites has helped to enhance voice-mails to participants there. diabetes care knowledge as
well as other contexts. Most References In the follow-up of study importantly, this project has 1. International Diabetes Federation. IDF participants, we have lost provided insights on how to Diabetes Atlas, 6th edn. IDF. Brussels, 2013.
roughly 5% either due to death effectively use technological 2. National Diabetes Education Program. or participant movement to a resources for access to DSME Guiding principles for diabetes care: for health care professionals. NDEP. USA, 2009. different area. The first results and DSMS.
June 2014 • Volume 59 • Special Issue DiabetesVoice 35 Health Delivery Integrated efforts key for optimal diabetes care in China
Ming-xia Yuan and Shen-yuan Yuan
The prevalence of diabetes is estimated to be 11.6% relatively untapped resource pool. Once organised, in the Chinese adult population, which represents GPs could deliver better care for a broader base of up to 113.9 million Chinese adults with diabetes people living with diabetes in China. There is a or a third of the world’s diabetes population. The growing realisation that integrated efforts between prevalence of diabetes is higher in older age groups, specialists and GPs may be the ideal way to ensure in urban residents and in persons living in eco- optimal outcomes of management for diabetes. nomically developed regions. Among people with diabetes, only 25.8% received treatment for diabe- The study tes and only 39.7% of those treated had adequate This ongoing BRIDGES supported project is glycaemic control.1,2 These numbers suggest that implementing and evaluating a community-hospital China has overtaken India as the epicentre of the integrated management system for type 2 diabetes global diabetes epidemic.3 in Beijing, China. The quality and efforts of the community-hospital integrated model for diabetes Worldwide censuses have shown an increasing role care will be assessed by analysing group changes in of general practitioners (GPs) in diabetes care.4 the primary outcome: principally the proportion While the role of GPs in diabetes care should and of participants reaching optimal control of blood must be increased in China, an urgent issue is glucose, blood pressure and lipids, as well as clinical whether the quality of diabetes care will be com- outcomes, such as the incidence and progress of promised as care shifts from the specialist to the diabetes-related microvascular complications. primary level. Due to the relatively short history of GP practice in China, and overall GP inexperience Current data with diabetes management, people with diabetes It is well established that intensive glycaemic choose specialist care over primary care. However, control, blood pressure (BP), lipid management GPs from the local healthcare community remain a and aspirin usage in people with diabetes reduce
36 DiabetesVoice June 2014 • Volume 59 • Special Issue health delivery Integrated efforts key for optimal diabetes care in China
the risk of microvascular and macrovascular blood pressure, and serum lipid control in complications.5 However, translation of these Shanghai,7,8 the largest city (by population) in interventions to real-life settings remains a the world. It is evident that more intensive care is major challenge in China. In the 2006 nationwide required for people living with diabetes in China. Diabcare-China surveys,6 only 26.8% of patients More specifically, the following issues require
with type 2 diabetes reached HbA1c ≤6.5% attention: (International Diabetes Federation criteria) and ■ GPs need further expert guidance, including train-
41.1% of people with diabetes reached an HbA1c ing on updated diabetes guidelines in practice. <7% (American Diabetes Association criteria). ■ Preventive measures are required for controlling The proportion of patients with “poor control” multiple risk factors associated with diabetes.
(HbA1c >8%) was 28.3%. In addition, only 22.4% ■ Proactive systems for surveillance and support are of patients achieved a BP goal of below 130/80 needed to enhance current diabetes management. mmHg and the proportion of patients achieving high density lipoprotein (HDL) levels >1.1 mmol/L General practitioner training and triglyceride (TG) levels <1.5 mmol/L was Training for community GPs is provided by tertiary 60.9% and 40.7% respectively. hospital specialists and developed by the pro- ject’s principal investigators along with an Expert The quality of diabetes management in Beijing Committee. The Expert Committee consists of ten is similar to data collected nationwide. National experts from relevant professional fields including reports from community centres show diabetes Endocrinology, Cardiology, and Ophthalmology as care status is even worse with approximately 10% well as 20 endocrinologists from tertiary hospitals. of people with type 2 diabetes having achieved Training modules include group training class,
an HbA1c ≤6.5%. More importantly, only 2.7% of interactive workshops and specialist outpatient people with diabetes obtained optimal glycaemic, services in the community. Specialists assist GPs in
June 2014 • Volume 59 • Special Issue DiabetesVoice 37 Health Delivery
clinical practice twice per week for the entire trial. participants with type 2 diabetes. Five urban dis- A total of 150 GPs are participating in the training tricts were chosen over suburban regions because programme. Specialists supervise a specific com- the urban economic conditions offer a sufficiently munity and a fixed number of GPs, who in turn stronger medical infrastructure to carry out the are responsible for a fixed number of participants. study. Participants were randomised into either the All levels of the trial organisation are linked via a intensive-care group or the control group. web-based electronic monitoring platform, allow-
ing participant records (such as HbA1c data) to be Trial management shared quickly and easily. The web-based platform To achieve good target control, management ad- also facilitates the rapid flow of information and justment strategies on guidelines,9 continued to professional feedback from specialists to GPs and be applied by a collaborative team consisting of patient participants. participating tertiary hospital specialists and the programme’s community GPs. Further, to ensure Patient recruitment the integrity and quality of data collection, a super- Greater Beijing is divided into two regions, one vision team consisting of four trained specialists has urban and the other rural. Each of these regions been checking study progress and data records in consists of eight districts. Out of five districts in the every community centre twice yearly. Data checks urban region, 15 communities with their health- result in a quality score and ranking issued in re- care centres were selected by a multi-stage random port form to corresponding researcher meetings. sampling approach, resulting in a total of 4,080 The researcher meetings consist of 150 researchers including the specialists and GPs. These are held
38 DiabetesVoice June 2014 • Volume 59 • Special Issue health delivery
every four months. The researcher meetings pro- Ming-xia Yuan and Shen-yuan Yuan vide: updated follow-up data, summary of endpoint Ming-xia Yuan is Chief-Physician and Vice-Director events, lectures by the principal investigators, and at the Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China. GP generated oral presentations. Shen-yuan Yuan is Professor at the Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
Preliminary results BRIDGES project By analysis, 9.4% in the intensive-care group and Promotion of community-hospital integrated model for diabetes management in Beijing 8.4% in the control group met all the HbA1c, BP, and LDL-C target values at the baseline (p=0.35). Acknowledgement People with diabetes who were treated by commu- This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported nity GPs in training showed a significant improve- by an educational grant from Lilly Diabetes. ment after 18 months intervention (14.6% vs. 12%, p=0.03) compared to the control group, as well as a significant increase compared with the baseline.
To date, the community-based care system has proved to be an effective approach, although re- sults will not be complete until the study ends in December 2014.
Public health significance
Optimal target control of glycaemia, BP and lipids References should significantly reduce the risk of chronic com- 1. Ning G, Zhao W, Wang W, et al. Prevalence and control of diabetes in Chinese plications, improve quality of life for people living adults. 2010 China Noncommunicable Disease Surveillance Group. JAMA 2013; 310: 948-59 with diabetes and lessen the financial burden for 2. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women diabetes care. However, the challenge to maintain in China. N Engl J Med 2010; 362: 1090-101. continuous optimal diabetes management during 3. Hu FB. Globalization of Diabetes. The role of diet, lifestyle, and genes. the long-term is considerable. Diabetes Care 2011; 34: 1249-57.
4. Goyder EC, Drucquer M, McNally PG, et al. Shifting of care for diabetes from Sustainability plan secondary to primary care, 1990-5: review of general practices. BMJ 1998; 316: Results and experiences gained in this study will 1505-6. be used on a wider scale in Beijing and in more 5. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes regions in China. Further exploration and follow- (UKPDS 35): prospective observational study. BMJ 2000; 321: 405-12. up studies across larger communities will continue 6. Pan C, Yang W, Jia W, et al. Management of Chinese patients with type 2 diabetes, for the next five years, ten years or longer. 1998-2006: the Diabcare-China surveys. Curr Med Res Opin 2009; 25: 39-45.
7. Lu B, Yang Y, Song X, et al. Analysis of diabetes management in population-based patients diagnosed with type 2 diabetes in the Shanghai downtown. J Clin Intern Med 2008; 25: 466-8.
8. Yuan MX, Yuan SY, Fu HJ, et al. Current HbA1c status of type 2 diabetes in Beijing communities and the related factors. Chin J Diabetes 2010; 18: 752-5.
9. Chinese Diabetes Society (CDS). China guideline for type 2 diabetes - 2010. Chin J Diabetes Mellitus 2010; 2: 1-56.
June 2014 • Volume 59 • Special Issue DiabetesVoice 39 self-management and education Professional workshops help fill gaps in diabetes self-management
Heloisa de Carvalho Torres, Ilka Afonso Reis and Mariana Almeida Maia
More than seven million people This requires effective, ongoing link between professionals and have diabetes in Brazil, the fifth education and support, and healthcare service users. largest country in the world. should match the individual’s Prevalence of diabetes in 2013 ability and capacity to learn. The study exceeded 9% and it is estimated Including individual lifestyle and This BRIDGES project team that diabetes is responsible for culture in diabetes education is organised diabetes education more than 80,000 deaths each also important for success. into multiple strategies: operative year.1 The increase in life expec- groups, home visits and telephone tancy of the global population, For various reasons, including monitoring, all of which were combined with a poor diet and a mobility challenges, there is designed to enhance self-care sedentary lifestyle are contribut- frequently poor adherence to practices related to diet and ing to higher rates of type 2 dia- lifestyle modification activities. physical activity. The project was betes and Brazil is no exception. The Brazilian Health Ministry2 carried out in four “basic health has proposed a goal to train units” in Belo Horizonte, Brazil Maintenance of near normal blood healthcare professionals and with 240 participants living with glucose levels is crucial to the thereby transform and increase type 2 diabetes. prevention of the microvascular knowledge in current diabetes and macrovascular complications care practice. The Health Professional workshops of diabetes. Actively involving Ministry is seeking development Educational workshops were people with diabetes in their of competencies in the field of strategically chosen for the devel- own care is the cornerstone of healthcare communication – opment and training of partici- good diabetes management. essential for establishing a valued pating healthcare professionals.
40 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
The workshops were designed to conduct. They were also encour- people living with diabetes was update best practices about diabe- aged to reflect about self-care ed- also encouraged. tes care and adaptation of healthy ucation. Each workshop lasted lifestyle habits. A problem-posing approximately two hours. In group education for behav- methodology was used in tan- ioural interventions, the partici- dem with healthcare participant There was a marked interest in pants discussed primary needs: experience and knowledge as a the importance of teamwork to dietary management, exercise, starting point. promote successful education taking medication as prescribed, activities for people living with monitoring of blood glucose During the workshops, discus- diabetes. The professional work- levels and knowing what action sions addressed educational shops emphasised the develop- to take when problems arise. practices and knowledge about ment of a systematic approach to Participants agreed that helping diabetes, nutrition, and physical diabetes education as well as the people prioritise diabetes and as- activity. The healthcare partici- importance of respecting indi- sume co-responsibility for behav- pants highlighted their experi- vidual needs, values and beliefs. iour change associated with diet ences in caring for people with Additionally, the need to use and physical activity were crucial diabetes, focusing on defining appropriate language to address components for success. Various and differentiating professional different management themes for diabetes themes (Figure 1) were presented to groups of thirteen by a nurse and a dietician through interactive and recreational ac- tivities. Healthcare professionals (physician, nurse, physiothera- pist, occupational therapist and dietician) were instructed on posture, language and positive communication.
Home visits and telephone monitoring Once the programme had defined the essential competencies for the participants in group training, facilitating “home visits” between people with diabetes and our pro- fessional trainees began. It was assumed that real-life educational interventions utilised as part of the programme would provide a greater opportunity for first- Participants being taught how to stretch hand professional experience. and exercise at home Home visits were scheduled to
June 2014 • Volume 59 • Special Issue DiabetesVoice 41 self-management and education
help the professional trainees bet- ter understand how to advance Figure 1. Diabetes education group. improved behaviour change and self-management skills for the FACILITATING THEME IMPORTANCE local population with diabetes. TECHNIQUES Success in changing specific as- Healthy nutrition ■ F ood plan ■ Exchanging recipes pects of healthcare professional ■ Tasting behaviour was intended to pro- ■ F ood record mote more efficient and effective Practicing self-care ■ Encouragement of ■ Reading texts and consultations. For guided diabe- and developing self-care practices reflecting on them autonomy tes self-management to progress, ■ A cceptance of the ■ Writing poems disease a positive healthcare provider and ■ Recreational Health promotion patient relationship has shown to ■ dynamics Changing lifestyles ■ Physical activity Group dynamics be a key factor. Here was an op- ■ ■ Proper diet Presentation of portunity to observe the effect of ■ ■ Autonomy objects professional diabetes educational ■ Writing poems training on the health status of Belo Horizonte-MG, 2012 people living with diabetes.
The home visits enhanced the development of a bond between people with diabetes and the healthcare professional train- ees in part based on the group with the International Diabetes Health professionals were also training experience. Visiting the Federation, and supported by trained to use telephone moni- individual participants living Lilly Diabetes. The Conversation toring as a method to encourage with diabetes in their home en- MapTM visual is a 3-foot by adherence to daily treatment regi- vironments gave the trainees an 5-foot colourful picture or mens as well as help investigate opportunity to provide diabetes metaphor for teams to navigate personal difficulties with self-care guidance with a deeper under- during diabetes sessions. The practices. Teaching people with standing of individual circum- Conversation MapTM education diabetes how to prevent acute and stances. Home visits also provid- tools are aligned with the patient- chronic complications of diabe- ed diabetes education to people centred model, which focuses on tes, and helping them decide the with limited access to primary empowerment, independence best way to improve metabolic healthcare services. and individually defined needs. control was emphasised. Many It enables participants to participants used the telephone Professionals were trained to use integrate concepts of diabetes calls as an opportunity to express the Conversation MapTM for home and relate health information personal challenges with their visits, which is a highly visual and from personal experience, need to do more physical activity interactive diabetes educational resulting in a greater awareness and adhere to dietary restrictions. tool created by Healthy and acceptance of changing Some of the people with diabetes Interactions in collaboration needs for life with diabetes. expressed feelings of anguish, too.
42 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
Practitioners utilised this time to The idea of combining several centred on a dialogical and re- better connect to the emotions educational interventions, such flective educational practice for people with diabetes often have as monitoring physical activities diabetes healthcare professionals. and develop trust, essential for gave people with diabetes a It is expected that the results of good practice. choice for engagement. The this study can be utilised by ad- opportunity for alternative ditional healthcare units in Brazil. Summary contact outside working hours Every attempt should be made to In summary, preparing health- and avoiding unnecessary visits identify ways to improve control care professionals to be motivat- to the healthcare service proved of diabetes through the enhance- ed, skilled and better equipped to to be beneficial. ment of self-care activities. help people overcome the bar-
riers associated with improving The programme was effective at Heloisa de Carvalho Torres, diabetes self-care appears to be changing a range of behaviours Ilka Afonso Reis and a promising strategy. Custom associated with diabetes and bet- Mariana Almeida Maia Heloisa de Carvalho Torres is Professor at the tailoring is critical and specific ter glucose control, including: Nursing Department in Universidade Federal details for success include pro- ■ Improvement of dietary habits de Minas Gerais in Belo Horizonte, Brazil. Ilka Afonso Reis is Professor at the Statistics viding the necessary conditions and physical activities. Department in Universidade Federal de for learning, facilitating group ■ Enhanced diabetes knowledge Minas Gerais in Belo Horizonte, Brazil. Mariana Almeida Maia is Nurse at meetings with short intervals, and awareness. the Universidade Federal de Minas and constant encouragement. ■ More positive attitude attached Gerais in Belo Horizonte, Brazil.
to living with diabetes. BRIDGES project The expansion of behavioural Evaluation of the diabetes education programme for people with type 2 diabetes interventions in the educational The effectiveness of the diabe- in primary care, Belo Horizonte, Brazil programme fulfilled the objective tes education programme study of actively engaging healthcare was executed largely by theoreti- Acknowledgement This project is funded by BRIDGES. professionals with diabetes. cal and methodological choice, BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.
References 1. International Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013.
2. Ministério da Saúde. Plano de Ações Estratégicas para o Enfrentamento das doenças crônicas não Transmissíveis (DCNT) no Brasil, 2011- Participants learning about healthy diet 2022. Ministério da Saúde. Brasil, 2011.
June 2014 • Volume 59 • Special Issue DiabetesVoice 43 self-management and education Education to change the course of diabetes in the Caribbean
Errol Morrison, Shelly McFarlane, Cliff Riley and Novie Younger-Coleman
The International Diabetes of diabetes and its associated adults with type 2 diabetes in six Federation (IDF) estimates that complications present significant Caribbean countries. The pro- over 382 million people currently socio-economic, medical and sci- gramme’s primary objective is live with diabetes globally. This entific challenges. Additionally, to empower community health accounts for 11% of the adult the aetiology and pathophysiol- workers (CHWs) with essential population and is projected to in- ogy of the disease are markedly tools in a region where such dia- crease to near 592 million by 2035. different among people living betes patient educational services The data reveals that over 80% of with diabetes across the region are not typically provided. The persons living with diabetes are and therefore dictate different effectiveness of the programme from developing countries. The prevention strategies, diagnostic is expected to enhance indi- IDF estimates that one in every screening and treatment meth- vidual self-management skills, ten adults in the North America ods. Currently diabetes is the thereby improving blood glu- and Caribbean Region has diabe- third leading cause of death in the cose control for people living tes.1 In 2013, over 178,520 adult Caribbean.3 This is further com- with diabetes in the participat- Jamaicans (20-79 years) were re- pounded by high net migration ing countries. The programme is ported to have diabetes with prev- rates of healthcare professionals utilising the newly developed and alence rates estimated at 10.6%. in the region, particularly nurses. culturally specific Community This represents a 2.8% increase Empowerment through Diabetes between 2008 and 2013.2 Implementing culturally sensi- Self-Management Education tive diabetes education Training guideline.4 Further, the It is well known that diabetes and This BRIDGES supported pro- long-term goal of the study in its complications are a leading ject seeks to implement a cul- conjunction with the minis- cause of adult morbidity world- turally sensitive, peer/lay dia- tries of health for participating wide. The increasing prevalence betes education programme for countries and the Pan American
44 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
Health Organization (PAHO) is 1. Train and educate six country in the final stages of assessing to increase diabetes awareness, coordinators and 12 CHWs. the curricula. The programme knowledge and improve self- Using the peer/lay education intervention has been delivered to care behaviours of people with curriculum, the CHWs carry 115 study participants living with diabetes in the region. The study out the community based dia- diabetes. Demographic data and programme will be completed in betes education to participants baseline characteristics, including
February 2015. living with diabetes. HbA1c, blood pressure, and waist 2. Measure progress by monitoring circumference were obtained from Currently diabetes HbA1c, waist circumference a total of 237 participants (115 is the 3rd leading (adiposity), and blood pressure. intervention and 122 control). cause of death in Participants living with diabetes Quality of life and self-care completed standardised questionnaires were administered the Caribbean. self-care and quality of life and evaluated to all participants Conducted in six Caribbean coun- questionnaires, which were also at baseline. Additionally, all 12 tries (Jamaica, Grenada, St Lucia, part of the evaluation process. CHWs have been responsible for Barbados, Belize and Antigua), 3. Empower regional communi- conducting data entry for patient the study will test the applicabil- ties and CHWs with training to demographic and biomedical ity, versatility and effectiveness increase awareness and knowl- measures with the tablets provided of the educational programme. edge of diabetes and self-care by the study programme. This The effectiveness of the lay pro- behaviours. information is uploaded each gramme will be determined by week to a password-protected evaluating the impact on patient Study methodology folder and transported from participant outcomes. Overall, To date, the project has completed the field in a secure manner to the project aims to improve and the training of the CHWs and is the coordinating site, where a increase the level of knowledge and awareness of diabetes and self-management at the commu- nity level. Other specific activities and objectives include:
Low-cost educational activity: footwear demonstrations in Antigua
June 2014 • Volume 59 • Special Issue DiabetesVoice 45 self-management and education
statistician downloads the field Barbados) showed no statistically Errol Morrison, Shelly data for analysis. significant difference in change McFarlane, Cliff Riley and from baseline. Complete data will Novie Younger-Coleman Errol Morrison is President of the The programme curriculum is not be available until the project’s University of Technology, Kingston based on four modules: Diabetes end in February 2015. Jamaica and President of the Diabetes Association of Jamaica. Basics and Medication; Nutrition Shelly McFarlane is Research Fellow in and Psychosocial Issues; It is important to note that across the Epidemiology Research Unit, Tropical Medicine Research Institute at University of Physical Activity; and Diabetes all six participating countries sub- the West Indies, Mona, in Kingston, Jamaica. Complications. Currently, a jects with diabetes who received Cliff Riley is Associate Professor and Associate Dean of Graduate Studies at the College of major proportion of the pro- diabetes education stated that Health Sciences, University of Technology, Kingston Jamaica and Board Member at gramme’s CHWs from each of the they are grateful for the support the Diabetes Association of Jamaica. participating countries has suc- because they have been “strug- Novie Younger-Coleman is Biostatistician in the Epidemiology Research Unit, Tropical cessfully implemented 75% of the gling” to manage diabetes for Medicine Research Institute, University of curriculum for people with diabe- many years. One comment from the West Indies, Mona, Kingston, Jamaica.
tes. The self-care questionnaires a male participant in St Lucia re- BRIDGES project administered to the participants flects the toll type 2 diabetes has Implementation of a culture sensitive peer /lay diabetes education program for with diabetes are maintained on the uninformed individual, adults with type 2 diabetes in six English with excel workbooks, unique to “Since I was enrolled last October, speaking Caribbean countries by 2015 each participant. Each CHW has I lost two toes; I wish I knew then Acknowledgement conducted at least two sessions what I have learned from the first This project is supported by BRIDGES. with their respective intervention session. I would have been in bet- BRIDGES is an International Diabetes Federation programme supported by an groups covering Modules 1 and 2 ter control of my diabetes.” educational grant from Lilly Diabetes. (Diabetes Basics and Medication, and Nutrition and Psychosocial Project challenges issues, respectively). The CHWs Delays in programme data input utilise low cost training materials have resulted in a lag-time between such as flip charts and cue cards data collection and data entry. This when conducting sessions. The was primarily due to slow adapta- cue cards were adapted from the tion for the CHWs use of tablets Conversation MapTM Education provided to facilitate real-time data References tools. Simple low-cost activities, entry at the point of collection. 1. International Diabetes Federation. IDF such as footwear demonstrations Additionally, the CHWs showed Diabetes Atlas, 6th edn. IDF. Brussels, 2013. and presentations related to mod- a preference for collecting data on 2. Wilks R, Younger N, Tulloch-Reid M, et al. ifying food portions, have been paper rather than inputting the Jamaica Health and Lifestyle Survey 2007-8. Tropical Medicine Research Institute, employed by the facilitators for data on the tablets. This is a clear University of the West Indies. Mona, 2008. demonstrative purposes. indication that the transition to electronic devices from the paper 3. Lowe H. Caribbean Herbs for Diabetes Management: Fact or Fiction? Pelican Publishers. Kingston, 2012. Preliminary results and pen approach among CHWs Preliminary results based on pri- can pose challenges or lead to de- 4. Pan American Health Organization (PAHO), Diabetes Association of Jamaica (DAJ), mary and secondary outcomes lays in data entry and analysis. The Ministry of Health – Jamaica. Community Empowerment through Diabetes Self- for 38 participants in three coun- transition is being addressed via Management Education Training. 2012. tries (Antigua, Grenada, and monthly team meetings via Skype.
46 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education Health coaching increases self-esteem and healthy smiles
Ayse Basak Cinar and Lone Schou
Promoting oral health is essential in order to pre- management among people with type 2 diabetes in vent and reduce the negative consequences of Turkey and Denmark. In principal, HC focuses on type 2 diabetes and to maintain good health.1 transformation and maintenance of positive health Periodontal inflammation in early old age tends behaviours by person-centred empowerment. It is to be associated with mortality in older age2 and directly associated with positive lifestyle outcomes people with diabetes are more likely to have peri- including smoking cessation and improved man- odontal disease than people without diabetes.3 agement of obesity and diabetes. Besides sharing common biological mechanisms, type 2 diabetes and oral diseases,4,5 also called life- HC creates awareness about individual values and style diseases, share the same lifestyle related risk empowers people to transition towards a healthy factors such as poor dietary habits or smoking. lifestyle. The HC process enables people with diabetes to adapt and change health behaviours Project overview for long-term compliance. In this study, coach- This BRIDGES project aims to assess the impact of ing focused on empowerment for daily diabetes Health Coaching (HC) on diabetes and oral health health-related practices, and compliance, and oral
June 2014 • Volume 59 • Special Issue DiabetesVoice 47 self-management and education
48 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
health related self-care regimes. Health-related capacity skills, self-monitoring skills and taking responsibility for health and quality of life were The health coach focused also targeted. Participants set up their own goals on empowering people and action plans with supervision of their health coach. Coaching sessions were individualised and with diabetes for daily tailored to expectations, challenges, and progress health-related practices. of the person living with diabetes.
After the last HC session, participants were told to fill in open-ended semi-structured questionnaires. Examples of their results, featured at the end of this consent and filled out questionnaires including article, represent gratitude for the HC opportunity background, psychosocial and behavioural and an increased sense of empowerment. One 60- information. The last current medical reports
69 year-old participant living with diabetes for 14 (HbA1c, fasting blood glucose, HDL, LDL, years discussed how he had improved his lifestyle triglyceride) were drawn from the hospital. habits, but wished for regular oral health service. Following the oral examination, participants were Another participant in her 50’s who has lived with allocated to HC or formal Health Education groups. diabetes for 12 years expressed how the coaching The intervention included two phases (initiation had given her a fresh start. and maintenance and follow-up). During the initiation and maintenance, all participants in both Overall, the aim of the study is to highlight how groups were invited for free periodontal cleaning HC can be effective for the adoption of healthy and were called between one and three times for an lifestyles and better diabetes management. appointment. The cleaning included the removal of soft and calcified deposits by an ultrasonic device. Material and methods Educational and motivational brochures supported This international prospective intervention study each participant in the HC group. among people with type 2 diabetes (Turkey, n=186; Denmark, n=130) randomly selected participants An internationally accredited health coach with a from the outpatient clinics of two hospitals in Master-level degree in Behavioural Sciences and a Istanbul, Turkey and the electronic patient reg- PhD in Community Dentistry was assigned to the HC istry of Department of Odontology, University of group.7 Each participant had a face-to-face session Copenhagen in Denmark. The phase in Turkey with the coach within two weeks of the first visit. The is complete (2010-12) and the phase in Denmark health coach focused on empowering people with is to be finalised in November 2014 (2012-14).6,7 diabetes for daily health-related practices, compliance Eligibility criteria were: 1) confirmed type 2 diabe- to diabetes and oral health related self-care regimes. tes; 2) 30-65 olds with at least four functional teeth; Additional coaching objectives included building up 3) no psychological treatment and no hospitalisa- health-related capacity skills, self-monitoring skills tion due to diabetes. and taking responsibility for health.
Procedure and randomisation Participants set up their own goals and action plans, At the baseline visit, participants provided informed focusing on improvement of lifestyle and clinical
June 2014 • Volume 59 • Special Issue DiabetesVoice 49 self-management and education
measures, under the supervision of the coach. Each The Health Education group received standard life- coaching session was utilised as the foundation for style advice referring to oral healthcare practices, diet the next coaching session, and influenced progress and physical exercise. One dentist provided Health towards the achievement of target goals. Duration Education interventions and group participants for face-to-face coaching sessions was between 20- were supported by the same educational brochures 60 minutes. Sessions covered needs, expectations, as the HC group. challenges, and progress of the person living with diabetes. Telephone monitoring also supported Qualitative outcome variables and results progress of the participants. After cessation of the intervention, participants in the HC group were asked to answer semi-structured A Wheel of Health (Figure 1) was administered questions to evaluate the HC intervention and during the initial HC session to explore values, its impact on their life. A selection of those are establish priorities, and set goals. Participants featured below: reported how satisfied they were (0%-100%) re- cently and how satisfied they would like to be in By the year 2012, Turkey the future. Participants were then asked to define 60-69 aged male with a diabetes history of 14 years each domain on the Wheel of Health and choose a “I have adopted healthy eating habits and regular specific goal and action plan. Although the coach tooth brushing. I didn’t know how oral health was regularly asked participants to explore goals in rela- important for my diabetes. Additionally I lost some tion to oral health and diabetes care, participants of my teeth and I suffered from bleeding of my were free to select any additional goals such as gums. I wish there was an oral healthcare service stress management. at diabetes polyclinics.”
50-59 aged female with a diabetes history of 2 years “I learned everything about oral health and diabetes Figure 1. An example for Wheel of Health, each domain defined by management by coaching sessions. My psychology person living with diabetes is much better. My life has completely changed in a positive direction. Before the coaching sessions, my life was a misery and hopeless.” 100% 100% 50-59 aged male with a diabetes history of 14 years Physical “My self-esteem has increased by the coaching Diet/Weight Exercise sessions. I felt and recognised that I was worthy as a person during these sessions. All the negative 0% thoughts about living with diabetes were erased by these sessions.” Examples: Oral Health Stress management Socialising By the year 2014, Denmark 100% 50-59 aged female with a diabetes history of 12 years “My lifestyle and social life have changed; I started a new life. I found new ideas and re- built my life.”
50 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
70-75 aged male with a diabetes history of 10 years Ayse Basak Cinar and Lone Schou “I am now more physically active (going swimming, Ayse Basak Cinar is Assistant Professor at Section 1, Institute of walking) and drinking more water and less alcohol. Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. I changed and adopted these new habits because I Lone Schou is Head of Section 6 (Section for Global Oral Health), have recognised that I want to do better during the Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark. coaching sessions. I changed the wrong behaviour and replaced it with the healthy one.” BRIDGES project Smile healthy with your diabetes: a translational randomized trial of culturally specific health coaching intervention for patients with Health Coaching may be diabetes (phase II Denmark) used as an effective common Acknowledgement We express our deepest thanks to our collaborators in Turkey health promotion approach (Prof Nazif Bagriacik, Asst Prof Mehmet Sargin, Head Nurse Sengul Isik, Prof Inci Oktay) and Denmark (Christian Dinesen, Prof for better management of Maximilian de Courten). Many thanks are due to our study patients for their participation and cooperation. diabetes and oral health. The Turkish phase is supported by FDI and the University of Copenhagen, and Danish Phase by TRYG Fonden. This project is supported by BRIDGES. BRIDGES is an International Summary Diabetes Federation programme supported by an educational grant Dentists, physicians and diabetes educators undergo from Lilly Diabetes. extensive education and training to learn “what is best” for people with diabetes. However, tradi- tional delivery of education and training can miss “how” to achieve that best. “How” is implied in a person’s motivation and specific motivators need to be identified with support and encouragement of healthcare providers. Health Coaching may be used as an effective common health promotion approach for better management of diabetes and References oral health. 1. WHO European Region. Health21: The Health for All Policy Framework for the WHO European Region. WHO. Denmark, 1999.
2. Avlund K, Schultz-Larsen K, Krustrup U, et al. Effect of inflammation in the periodontium in early old age on mortality at 21-year follow-up. J Am GeriatrSoc 2009; 57: 1206-12.
3. Sandberg GE, Sundberg HE, Fjellstrom CA. Type 2 diabetes and oral health: a comparison between diabetic and non-diabetic subjects. Diabetes Res Clin Pract 2000; 50: 27-34.
4. Genco RJ, Grossi SG, Ho A. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. J Periodontol 2005; 76: 2075-84.
5. Nishimura F, Kono T, Fujimoto C. Negative effects of chronic inflammatory periodontal disease on diabetes mellitus. J IntAcadPeriodontol 2000; 2: 49-55.
6. Cinar AB, Schou L. Health Promotion for patients with diabetes: Health Coaching or Health Education? Int Dent J 2014; 64: 20-8. doi: 10.1111/idj.12058. [Epub ahead of print]
7. Cinar AB, Oktay I, Schou L. “Smile healthy to your diabetes”: health coaching-based intervention for oral health and diabetes management. Clin Oral Investig 2013. [Epub ahead of print]
June 2014 • Volume 59 • Special Issue DiabetesVoice 51 self-management and education Education helps decision- making for affordable, healthy food and control
Bettina Tahsin
Barriers to successful diabetes Control of type 2 diabetes is cally targeted to the needs of a self-management in low-income heavily influenced by dietary low-income, ethnically diverse populations include reduced ac- choices. A frequent complaint population in the US suffering cess to healthy food along with of low-income individuals with from obesity and uncontrolled limited awareness of healthy eat- diabetes is that by the end of the type 2 diabetes. ing. In the United States, it is a month all they can afford are public health paradox that those cheap high-carbohydrate snack The core principles of diabetes at the highest risk for obesity foods. Without money left for nutrition management are uni- and type 2 diabetes are the most healthy, low-carbohydrate, low- versal: carbohydrate and portion food insecure, meaning unable to calorie vegetables, this dilemma control, meal timing and coor- consistently afford or have access is a recipe for obesity and poor dination with medications, and to enough healthy food to meet diabetes control. Can targeted, weight management. What that their nutritional needs.1 additional diabetes education actually looks like on the plate help deter this trend? and how that is managed day-to- One challenge faced by healthcare day is unique to each individual. Control of type 2 providers serving low-income Food and cultural preferences, populations is reducing the health diabetes is heavily and ability to buy appropriate risks posed by the consequences influenced by foods that will keep people with of these barriers. Can education dietary choices. diabetes healthy must be con- and counselling empower low- sidered. Our study focused on income patients with type 2 Study these universal principles while diabetes to make healthier food The study focuses on imple- also making it very specific to choices within their means and menting a diabetes nutrition the needs and challenges of our improve their health? education curriculum specifi- population.
52 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education Education helps decision- making for affordable, healthy food and control
The study setting is the diabetes clinic and lifestyle centre in the Fantus Clinic, the primary out- patient clinic of the Cook County Health and Hospitals System (CCHHS), located in Chicago, Illinois, USA. CCHHS is a net- work of hospitals and community clinics servicing a primarily low- income, ethnically diverse popu- lation at high risk for developing chronic diseases. Those over- weight or obese make up 80% of participants with type 2 diabetes with specialised diabetes train- the patient population. Ethnically, lose weight and better manage ing, experience, and certification. close to half of the CCHHS patient their diabetes. Participants in the population is African American, study were patients seen in the The site for the intervention class- one third Hispanic and the re- Fantus clinic’s Network Diabetes es is the Therapeutic Lifestyle maining reflective of Chicago’s Program (NDP), a diabetes clinic Center (TLC), which is adjacent urban diversity. devoted to helping those with to the diabetes clinic. Conducting uncontrolled diabetes achieve the intervention in the lifestyle The purpose of this study is to greater diabetes control. NDP is centre is one of the advantages of evaluate whether additional class- staffed by endocrinologists, nurse the study programme compared es in nutrition and basic cook- practitioners, nurses, registered to other hospital and commu- ing could help obese, low-income dieticians, and pharmacists, all nity settings in low- and middle-
June 2014 • Volume 59 • Special Issue DiabetesVoice 53 self-management and education
income countries. Our lifestyle The eight classes, taught by a reg- 4. Eating on a budget translates centre includes a virtual kitchen istered dietician/certified diabe- dietary principles into cost- and a mock grocery store plus tes educator, follow the basics of effective strategies for eating additional classroom and exercise diabetes nutrition management healthy on limited means. areas. While the study focused and focus on foods commonly 5. Feeling full on less covers the exclusively on nutrition, exer- eaten by the participant popula- benefits of eating whole foods cise was encouraged as part of a tion. In this study to date, 67% are for more fibre and greater sa- healthy lifestyle. African American, 14% Hispanic, tiation. 11% Asian, and 8% White. The 6. Heart-healthy fats addresses In total, 98 patients who have type classes include: dietary that support good heart
2 diabetes and an HbA1c ≥ 7% and 1. Label reading for diabetes health, a primary concern in obese (BMI ≥ 30) are being re- teaches which foods raise diabetes. cruited from the diabetes centre. blood glucose, appropriate 7. Eating to control blood pres- Participants are randomised into portion sizes, and how to as- sure combines both sodium either the control group, who re- sess food content by using the restriction and increasing ceive their usual care at the dia- nutrition facts label. vegetables for more potassium betes centre, or the intervention 2. Meal planning for diabe- to improve hypertension. group, who receive their usual care tes discusses how the Plate 8. Eating out applies the strate- plus the additional classes. Method, which includes half gies already discussed to main- a plate of non-starchy vegeta- tain healthy dietary control Each group of eight participants bles, quarter plate of starchy while dining out. going through the intervention foods, quarter plate of protein, attends a series of eight one-hour plus a fruit and milk, can be A grocery store tour at a budget- classes over the course of six used to both accommodate conscious supermarket concludes months, followed by a two-hour dietary preferences while also the programme and serves to put grocery store tour. Classes are supporting good blood glucose into practice healthy food selec- bi-weekly the first two months control. tion on a budget. and then monthly for the next 3. Eating to lose weight empha- four months. At the end of the sises appropriate portion con- Preliminary results six months, participants are as- trol and dietary strategies that To date, three groups of the sessed for weight, blood glucose will provide a healthy plate of planned six groups to participate control, and other markers of food and also promote weight in the intervention have already overall health. loss. completed the study and several interesting results have emerged. Compared to their control group While the study focused counterparts, the intervention group participants have im- exclusively on nutrition, proved blood glucose control,
exercise was encouraged as as measured by their HbA1c re- sults. For instance, participants part of a healthy lifestyle. in one of the intervention groups
decreased their average HbA1c by
54 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
how to plan healthy meals that fit their budget and cultural eating patterns resulting in better blood sugar levels.
Summary Given that a significant number of intervention group participants
have improved HbA1c results and achieved greater weight loss than control participants validates the power of diabetes education and counselling. Helping low-income individuals with type 2 diabe- tes make healthier food choices within their means can provide positive outcomes and a chance for better futures.
Bettina Tahsin Bettina Tahsin is Research Dietician and Diabetes Educator at Cook County Health and Hospitals System, Chicago, Illinois, USA. People with diabetes learning about healthy and unhealthy food choices, Chicago, USA BRIDGES project Medical lifestyle centre community healthy eating initiative to improve diabetes outcomes
Acknowledgement 0.7% compared to a decrease of loss, reflecting the challenges of The project’s principal investigator is Leon Fogelfeld, MD, the Chair of the 0.2% in participants in its paired insulin and weight control. But Division of Endocrinology, Cook County control group. Those interven- even these patients had improved Health & Hospitals System, Chicago, Illinois, USA. The author is the study tion patients with their diabetes blood glucose when compared to coordinator and educator for this project, solely managed by oral medi- the control patients, reflecting a which is supported by BRIDGES. This project is supported by BRIDGES. cations also achieved greater better understanding of match- BRIDGES is an International Diabetes Federation programme supported by an weight loss with an average 9.6 ing carbohydrate content with educational grant from Lilly Diabetes. kg weight loss versus only 1.2 kg insulin dosing. weight loss in its paired control References 1. Seligman HK, Jacobs EA, Lopez A, et al. group. However, intervention pa- Overall, participants who con- Food insecurity and glycemic control tients managed on insulin had a sistently attended classes dem- among low-income patients with type 2 diabetes. Diabetes Care 2012; 35: 233-8. more difficult time with weight onstrated better understanding of
June 2014 • Volume 59 • Special Issue DiabetesVoice 55 self-management and education Everything you ever needed to know about gestational diabetes
Valerie Holmes and Claire Draffin
Gestational diabetes mellitus side an increased prevalence (GDM) is glucose intolerance of type 2 diabetes in the back- that begins or is first identified ground population. Additionally, during pregnancy. GDM is as- the adoption of IADPSG criteria sociated with increased peri- has even further increased GDM natal morbidity.1 In the long prevalence almost three-fold in term women with GDM have a some populations.4 seven-fold risk of developing type 2 diabetes in later life com- A need for novel educational pared to pregnancies with nor- resources mal blood glucose levels.2 Recent Women currently diagnosed with research has centred on investi- GDM are referred to antenatal- gating the effect of treating GDM metabolic clinics for specialist on pregnancy outcome, and de- medical and obstetric care from fining the diagnostic criteria for multi-disciplinary teams. Much GDM. This research has led to the of the information a woman with recent recommendations from GDM receives is direct from the International Association of healthcare professionals during Diabetes and Pregnancy Study her initial consultation. Apart Groups (IADPSG) for diagnosis from some locally produced of GDM.3 Prevalence of GDM has leaflets, very few user-friendly increased in recent years, along- supplementary materials are
56 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
available to women newly diag- nosed with GDM. Patient educa- tion is a crucial step and a better understanding of GDM will in- fluence and enhance treatment compliance. Women diagnosed with GDM face a steep learning curve in terms of how to process their new diagnosis. Challenges include how to: ■ Learn about the associated risks of GDM to pregnancy and for the future. ■ Adapt to a GDM specialised diet and lifestyle. ■ Self-monitor blood glucose and meet individualised targets. ■ Administer insulin, if necessary.
Furthermore, changes to the di- agnostic criteria for GDM im- pact the workload of diabetes teams caring for women in set- tings where services are already in partnership with women GDM was incorporated to ensure stretched. Novel approaches diagnosed with GDM and the DVD meets the needs of its are urgently needed to support healthcare professionals. We target audience. Focus groups of healthcare professionals in the hypothesise that this DVD will women with GDM explored their delivery of education to women alleviate anxiety and improve anxieties, needs and knowledge diagnosed with GDM during measure of glucose homeostasis in order to direct the tone, key pregnancy. An educational tool for women with GDM during messages and format of the DVD. such as a DVD will help ensure pregnancy and provide diet and Findings from focus groups con- that women with GDM adapt to lifestyle advice for the prevention firmed that the development of their new diagnosis as quickly as of type 2 diabetes in later life. user-friendly educational re- possible, reduce stress and anxi- sources was warranted and suit- ety and re-establish some sem- Study design able for women with GDM from blance of normality. This type of This is a two-phase project. Phase different ethnic backgrounds. In information should be driven by one was the development of the particular, women were keen for the needs of the target audience. educational DVD under the di- a resource such as a DVD to be rection of healthcare profession- available during the early stages Our hypothesis als adhering to National Institute of diagnosis when they have so The hypothesis of this project is for Clinical Excellence guide- many unanswered questions. to develop an educational DVD lines.5 Input from women with They valued the documentary
June 2014 • Volume 59 • Special Issue DiabetesVoice 57 self-management and education
production style, which included Women with GDM participated the impact of this DVD on mater- real women living with GDM in the development phase of the nal anxiety and stress, glycaemic telling their stories. Focus group DVD, and viewed the prototype control, diabetes knowledge, and participants felt this helped them in focus groups. Their feedback maternal and neonatal outcomes realise that they were not alone. was incorporated into the final in a multicentre randomised con- Women were keen to hear the editing of the DVD. The result- trolled trial. The trial commenced views of healthcare professionals ing 46-minute DVD features five in January 2013 in three antena- and wanted more information women with GDM sharing their tal metabolic clinics in Northern about what having gestational views and experiences alongside Ireland and Manchester. Women diabetes means for the baby. an evidence-based commentary. who had just been diagnosed with They also wanted to know what GDM for the first time were invit- impact it might have on their The DVD consists of three main ed to participate. They were ran- delivery as they felt this was not sections: domised to one of two treatment always explained in pregnancy ■ What is gestational diabetes? groups: usual care plus DVD or clinics. It was important to wom- ■ Living with gestational diabetes usual care only. The study has en that the resource focused on ■ Life after gestational diabetes now fully recruited, with 150 the benefits of starting insulin, women enrolled. Follow-up is allaying fears in relation to ad- The DVD also provides addi- ongoing and results will be avail- ministering and tolerating the tional features offering women able by the end of 2014. drug. Women were also eager step-by-step guidance on how to to learn about the future risk of monitor blood glucose; how to While we do not have results type 2 diabetes. inject insulin; how to eat healthy from the trial to report as yet, foods and how to determine feedback received from women Feedback received whether weight-loss is required who watched the DVD has over- from women who after pregnancy. The DVD has all been positive: been produced in English, Urdu, ■ “Thought DVD was fantastic, watched the DVD Somali and Arabic. Phase two of very glad I took part.” has been positive. the project involves evaluating ■ “DVD put me at ease because I was very apprehensive at first visit.”
One woman commented that she would have preferred to have an online resource. Members of clin- ic staff responded positively to the trial, and are waiting for it to end so they can use the resource with all their patients. There is a general sense among partici- pants and staff that the GDM educational DVD has filled a knowledge gap, and that it helps
58 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
women with GDM better under- countries. This tool is suitable Valerie Holmes and Claire Draffin stand their condition and man- for use by patients for individual Valerie Holmes is Senior Lecturer at the Centre agement of GDM. Clinic staff also support, or may be considered for Public Health, Queen’s University Belfast, UK. Claire Draffin is Research Fellow at the Centre for commented that the DVD is a as an educational aid for group Public Health, Queen’s University Belfast, UK. valuable resource to assist with education. Adaption to other patient education, and one that media formats such as podcasts BRIDGES project The development of an educational DVD for could be used for group educa- and webcasts could maximise its women with gestational diabetes: “Gestational diabetes: things you need to know (but maybe tion sessions. impact on women with GDM. don’t)” Knowledge transfer following a Public health significance project such as this is key if we Acknowledgement The authors are the principal investigator This project has substantial are to maximise the impact of (Valerie Holmes) and the researcher (Claire public health significance, par- the research. In a sister project we Draffin) of this project. Co-investigators on this project are: Prof Fiona Alderdice, ticularly in the context of rising have recently converted our pre- School of Nursing and Midwifery, Queens University Belfast, Belfast, UK; Prof David prevalence of GDM and type 2 conception counselling DVD to a McCance, Belfast Health and Social Care diabetes globally. Women with website platform (http://go.qub. Trust, Royal Victoria Hospital, Belfast, UK; Prof Chris Patterson, Centre for Public GDM have an increased risk of ac.uk/womenwithdiabetes). Here Health, Queen’s University Belfast, UK. Dr Michael Maresh, St Mary’s Hospital, Central developing type 2 diabetes in later the goal is to increase awareness Manchester University Hospitals NHS life.2 Diagnosis of GDM in preg- of the importance of planning Foundation, Manchester, UK; and Prof Roy Harper, South Eastern Health and Social Care nancy presents both women and for pregnancy for all women Trust, Ulster Hospital, Dundonald, UK. healthcare professionals with a with diabetes, and provide guid- This project is supported by BRIDGES. BRIDGES is an International Diabetes golden opportunity to intervene ance about preconception care Federation programme supported by an educational grant from Lilly Diabetes. in the progression to diabetes. for those women planning a However, despite clear guidelines pregnancy (funded by Diabetes References on postpartum screening and fol- UK and Public Health Agency, 1. Crowther CA, Hiller JE, Moss JR, et al. Effect 6 of treatment of gestational diabetes mellitus on low-up, uptake of postpartum Northern Ireland). We envisage pregnancy outcomes. N Engl J Med 2005; glucose testing is low, due in part a similar approach on completion 352: 2477-86. 2. Bellamy L, Casas JP, Hingorani AD. to low attendance at follow-up of this project. Type 2 diabetes mellitus after gestational appointments. Providing women diabetes: a systematic review and meta- analysis. Lancet 2009; 373: 1773-9. with comprehensive information 3. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. on long-term lifestyle modifica- International Association of Diabetes and tion during the antenatal period Pregnancy Study Groups Recommendations on the diagnosis and classification of hyperglycemia may maximise the potential in pregnancy. Diabetes Care 2010; 33: 676-82. presented by GDM. It may also 4. Waugh N, Royle P, Clar C, et al. Screening for hyperglycaemia in pregnancy: a encourage follow-up in the post- rapid update for the National Screening natal period. Committee. Health Technol Assess 2010; 14. 5. National Collaborating Centre for Women’s and Children’s Health (Great Britain), National Sustainability Institute for Clinical Excellence. Diabetes in Pregnancy: Management of Diabetes and After the project completion, its Complications from Preconception to the we envisage that the DVD could Postnatal Period. RCOG Press. London, 2008. 6. Sjögren B, Robeus N, Hansson U. Gestational be “adopted”, reproduced and diabetes: a case-control study of women’s further translated for use in experience of pregnancy, health and the child. J Psychosom Res 1994; 38: 815-22. healthcare settings in different
June 2014 • Volume 59 • Special Issue DiabetesVoice 59 self-management and education Can a peer support intervention improve type 2 diabetes outcomes?
Tim Johansson, Sophie Keller, Henrike Winkler, Raimund Weitgasser and Andreas Sönnichsen
Type 2 diabetes is on the rise the practice of each doctor’s office. peer support programme to im- worldwide and the burden asso- To what extent diabetes services prove diabetes self-management ciated with diabetes complications are offered may vary in accord- and achieve lifestyle changes, poses a serious threat to global ance with the regional particulars such as increased physical activ- health and national health sys- as national regulations, medical ity. World Health Organization tems. Austria, a country of 8.47 fees, and availability of services. (WHO) acknowledges “peer sup- million in Central Europe, is es- Disease management and modern port” as an economical, flexible in- timated to have a diabetes preva- drug treatments have improved tervention for improving diabetes lence of 9.27%.1 Austria had an diabetes care but current thera- care and outcomes.3 Peer sup- estimated 4,705 deaths due to dia- pies are far from effectively pre- port models include face-to-face betes in 2013; a rate of 12 citizens venting micro- or macrovascular self-management programmes, a day.1 Spending on diabetes as a complications. There is a strong peer mentorships and commu- percentage of Austria’s total health need to intensify lifestyle inter- nity health workers. Peers can expenditure was 10% in 2011.2 vention and motivate patients to provide coaching and leadership better manage diabetes. and often serve as role models The care of people with type 2 for sustained behavioural change. diabetes in Austria either takes Peer support to improve place within the framework of diabetes care The programme existing disease management pro- The objective of this randomised The peer support programme grammes (DMPs) or according to controlled study is to evaluate a was offered to all patients en-
60 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
rolled in the DMP of statutory from physicians, diabetes nurse cholesterol, HDL-cholesterol, and health insurance in the province educators, dieticians, clinical triglycerides). Other secondary of Salzburg, Austria. Participants psychologists and physical measures included lowering were recruited from the offices of education trainers as required. of global cardiovascular risk local general practitioners. To as- (UKPDS-Risk-Engine Version sure concealment of allocation, all The primary outcome meas- 2.0), weight reduction (body mass
patients were cluster-randomised ure was the difference in HbA1c index [kg/m²]) and self-reported after completion of recruitment change between intervention and smoking cessation. and allocation to groups. The control groups after two years. control group received usual care Secondary outcome measures The peer support programme according to the disease manage- comprised quality of life (EQ-5D- goal was to provide a founda- ment programme. 3L index and EQ-5D visual ana- tion for diabetes groups that logue scale) and improved control would continue after the study Groups of eight to of cardiovascular risk factors (sys- without further intervention by ten participants also tolic and diastolic blood pressure, healthcare providers other than met to talk about creatinine, total cholesterol, LDL- professional support as specified. personal, social and emotional issues in the context of diabetes.
In each intervention peer group, two participants living with diabetes were trained as peer leaders. The groups met every week for at least an hour of Diabetes peer group on a hiking tour in the Austrian Alps outdoor physical exercise and were intermittently supported by a physical education trainer. Once a month, exercise was followed by an educational group meeting, where groups received further professional support every other month. Groups of eight to ten participants also met to talk about personal, social and emotional issues in the context of diabetes and were organised by a trained peer supporter living with type 2 diabetes. Each intervention Peer support activity in the Austrian Alps group received additional support
June 2014 • Volume 59 • Special Issue DiabetesVoice 61 self-managEment and education
Results significant. We also found no marginally improved HbA1c Of the eligible 77 general practi- significant improvements in the values compared to the tioner (GP) surgeries, 49 (63.6%) intervention group compared to control-group. In addition, the recruited 393 participants fulfill- controls regarding the majority programme did not significantly ing all inclusion criteria. These of the secondary outcomes. improve clinical outcomes, risk participants were assigned to profile or quality of life after 41 peer groups (21 intervention Discussion two years of observation. These groups [n=202] and 20 control Group peer support intervention findings are most likely due to groups [n=191]). A total of 56 utilised as an additional the well-controlled baseline
participants withdrew consent component of a traditional values (e.g. HbA1c 7.0% in both before the intervention started. disease management programme groups), leaving little room for improving lifestyle for glycaemic improvement. At follow-up, an intention-to- behaviours associated with type The control group revealed the treat analysis revealed stable 2 diabetes self-management is same increase seen in the United
HbA1c values in the intervention feasible. Theoretically peer Kingdom Prospective Diabetes group while a small rise could support is a very promising Study (UKPDS)4 and in this
be seen in controls. The differ- approach, but the intervention regard, stable HbA1c results for ence between groups was not in this study achieved only the intervention group can be
62 DiabetesVoice June 2014 • Volume 59 • Special Issue self-managEment and education
interpreted as success. A larger were on average older than 60 Tim Johansson, Sophie Keller, sample size would be necessary years, so external validity is Henrike Winkler, Raimund to demonstrate this effect to be limited and our results are not Weitgasser and Andreas Sönnichsen Tim Johansson is Research Fellow at the significant. generally transferable to all Institute of General Practice, Family Medicine diabetes patients. and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria. Another programme insight Sophie Keller is Research Fellow at the was the observed practice by Conclusion and further action Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus participating GPs to mainly A peer support programme may Medical University, Salzburg, Austria. recruit well-controlled patients, enable GPs to offer additional Henrike Winkler is Lecturer at Paris Lodron University, Salzburg, Austria. even though they had been support to patients willing to get Raimund Weitgasser is Associate Professor requested to invite all people active and change their lifestyle. and Head of Department of Internal Medicine, Clinic Diakonissen, Salzburg, Austria. with type 2 diabetes, regardless Our intervention was successful Andreas Sönnichsen is Professor of Family of glycaemic control. Thus, a in maintaining adequate HbA Medicine and Director at the Institute of 1c General Practice and Family Medicine, selection bias of more motivated results versus the control group. University of Witten/Herdecke, Germany. and better self-managed patients While peer support interventions BRIDGES project may have occurred. Additionally, may be seen to respond to the Effectiveness of a peer support programme in the intensity of our intervention needs of people living with disease management regarding improvement of metabolic control, diabetes management might have been too weak diabetes, so far there is little self-efficacy, quality of life and risk profile to demonstrate an effect on evidence in the literature proving Acknowledgement HbA although increasing its effectiveness.5 Peer support 1c This project is supported by BRIDGES. professional support would have interventions may be appreciated BRIDGES is an International Diabetes Federation programme supported by an conflicted with the programme’s by those seeking help and can be educational grant from Lilly Diabetes. concept of group based peer used to supplement treatment for support. Our intervention was patients motivated to improve
intentionally based on a low- behaviours related to diabetes. References intensity level of professional However, current evidence does 1. International Diabetes Federation. IDF support. Due to withdrawal not support a major impact of Diabetes Atlas, 6th edn. IDF. Brussels, 2013. of consent, some groups were peer support on the outcome 2. IDF Europe, FEND, PCDE, EURADIA. Diabetes 6 The Policy Puzzle: Is Europe Making Progress? smaller than planned with a of type 2 diabetes. Additional Third edition. http://ec.europa.eu/health/major_ potentially negative impact on studies are needed to determine chronic_diseases/docs/policy_puzzle_2011.pdf group dynamics. Our continuous the effect of peer support in 3. World Health Organization. Peer Support programmes in Diabetes. www.who.int/diabetes/ contact with peer supporters different populations, various publications/Diabetes_final_13_6.pdf and participants throughout peer intervention approaches 4. Prospective Diabetes Study (UKPDS) the study allowed modifications and long-term outcomes and Group. Effect of intensive blood-glucose control with metformin on complications based on participant feedback. sustainability. in overweight patients with type 2 diabetes Increasing individual support (UKPDS 34). Lancet 1998; 352: 854-65.
according to the groups’ needs 5. Dale JR, Williams SM, Bowyer V. What was also heeded. The programme is the effect of peer support on diabetes outcomes in adults? A systematic review. intervention was offered at Diabet Med 2012; 29: 1361-77.
no cost to avoid exclusion 6. Smith SM, Paul G, Kelly A, et al. Peer support for of potential participants for patients with type 2 diabetes: cluster randomised controlled trial. BMJ 2011; 342: d715. economic reasons. Participants
June 2014 • Volume 59 • Special Issue DiabetesVoice 63 List of projects supported by IDF BRIDGES
Australia Democratic Republic of Congo, Cambodia ■ Stop diabetes: health related behavior and and the Philippines risk perception in women with lifestyle related metabolic diseases at high risk of Cameroon/Guinea
diabetes ■ Improving access to HbA1c measurement in sub-Saharan Africa Austria ■ Effectiveness of a peer support programme Canada in disease management regarding ■ Family Defeating Diabetes: a Canadian improvement of metabolic control, diabetes intervention for family-centred diabetes management self-efficacy, quality of life and prevention following gestational diabetes risk profile in London, Calgary and Victoria
Brazil Caribbean ■ Evaluation of the diabetes education ■ Implementation of a culturally sensitive programme for people with type 2 diabetes peer/lay diabetes education programme in primary care, Belo Horizonte, Brazil for adults with type 2 diabetes in six English- speaking Caribbean countries Cambodia, the Democratic Republic of Congo and the Philippines China ■ Mobile phone Diabetes Self-Management ■ Pathway to health: a lifestyle intervention to Support: a multi country analysis of its prevent diabetes implementation in existing Diabetes Self- ■ Promotion of a community-hospital integrated Management Education programmes in the model for diabetes management in Beijing
64 DiabetesVoice June 2014 • Volume 59 • Special Issue ■ A randomized translational study to examine India the effects of shared care versus usual care ■ A translational randomized trial of a culturally in management of gestational diabetes in a specific lifestyle intervention for diabetes three-tier prenatal care network in Tianjin, prevention in India China ■ Prevention of type 2 diabetes in women ■ The impact of initiation of an Educational with gestational diabetes in urban India – a and Preventive Foot Care Centre for subjects feasibility study with diabetes in Qingdao, China network in Tianjin, China Jordan ■ The Jordan Diabetes Micro-Clinic Project: Colombia community ownership and awareness to ■ DEMOJUAN – Demonstration area for improve health and wellbeing primary prevention of type 2 diabetes, JUAN Mina and Soledad, Barranquilla, Colombia Mali ■ A randomized trial of an intensive education Denmark intervention using a network of peer ■ Smile Healthy with Your Diabetes: a educators to improve glycaemic control of translational randomized trial of a culturally people with type 2 diabetes in Bamako, Mali specific health-coaching intervention for people with diabetes Netherlands ■ Cardiovascular risk in people with type 2 Ecuador diabetes: an innovative dynamic prediction ■ The impact of a demonstrative Educational model and Preventive Foot Care Centre for subjects with diabetes in the first-line ambulatory Pakistan healthcare center “CAA Cotocollao” ■ A translational randomized trial of culturally pertaining to the National Social Security specific and cost-effective life style inter- in Quito, Ecuador vention for the prevention of type 2 diabetes in Pakistan (Pakistan Diabetes Prevention Egypt Program PDPP) ■ The impact of an Educational and Preventive ■ Bridging the knowledge-to-practice gap Foot Care Centre for people with diabetes in to control diabetes in a rural population in Alexandria, Egypt Pakistan
Fiji Philippines ■ Using community theatre to promote ■ Family stress reduction and coping response diabetes education and prevention in Fiji training among Filipino people with type 2 diabetes in Quezon City, Philippines Haiti ■ Effectiveness of a community-based diabetes ■ Improving diabetes care in Cap Haitien, Haiti self-management education programme: a pilot study in San Juan, Batangas, Philippines
June 2014 • Volume 59 • Special Issue DiabetesVoice 65 South Africa ■ Tailored intervention for inpatients: tran- ■ Effectiveness of a group diabetes education sitional diabetes care coordinator versus programme using motivational interviewing conventional care in underserved communities in South Africa ■ Project SEED: support, education and evaluation in diabetes Sri Lanka ■ Medical lifestyle centre community healthy ■ “Diabrisk-SL”; Evaluation of risk factors eating initiative to improve diabetes outcomes in the development of type 2 diabetes and ■ Motivational interviewing to maximize cardiovascular disease in a young urban utilization of self-management education population in Sri Lanka for adults with type 2 diabetes ■ Non-visual foot inspection for people with Thailand visual impairment ■ A community-based diabetes prevention programme in Thai population Venezuela ■ Peer-led and telehealth interventions for Tunisia diabetes prevention in Maracaibo, Venezuela ■ Lifestyle intervention among overweight and obese schoolchildren: a pre- post-quasi Vietnam experimental study with control group in ■ Lifestyle intervention trial programme to Sousse, Tunisia prevent type 2 diabetes in the Northern province of Ninh Binh, Vietnam - a D-START United Kingdom project ■ G estational diabetes: things you need to know (but maybe don’t) – design, development, Vietnam pilot and evaluation of a DVD for women with ■ Programme for the detection and prevention gestational diabetes of diabetes in people at high risk in a medium- size city in Vietnam USA ■ Feasibility of developing a training program Zimbabwe for peer leaders in diabetes in Ypsilanti, ■ The establishment of an Educational and Michigan, USA Preventive Foot Care Service for subjects with diabetes in Zimbabwe
More information on each project is available on www.idf.org/bridges
66 DiabetesVoice June 2014 • Volume 59 • Special Issue Lilly Diabetes is proud to partner with the International Diabetes Federation to bring you the BRIDGES programme, in an effort to provide innovative healthcare practices that will improve the everyday lives of people living with diabetes.
LILLY is a registered trademark of Eli Lilly and Company. Through BRIDGES, the International Diabetes Federation is supporting 41 projects dedicated to translational research in 38 countries.
3 9
More information on www.idf.org/bridges
BRIDGES is an IDF programme supported by an educational grant from Lilly Diabetes