Diabetes Voice

Volume 59 – June 2014

SPECIAL ISS U E

Global perspectives on diabetes

BRIDGES: from the ivory tower to real life

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47 International Diabetes Federation

All correspondence and advertising enquiries

Promoting diabetes care, prevention and

should be addressed to the Managing Editor:

a cure worldwide

International Diabetes Federation, Chaussée de La Hulpe 166, 1170 Brussels, Belgium

Diabetes Voice is published quarterly and is freely available online at www.diabetesvoice.org.

Phone: +32-2-538 55 11 – Fax: +32-2-538 51 14

This publication is also available in French and Spanish.

© International Diabetes Federation, 2014 – All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means without the written prior permission of the International Diabetes Federation (IDF). Requests to reproduce or translate IDF publications should be addressed to the IDF Communications Unit, Chaussée de La Hulpe 166, B-1170 Brussels, by fax +32-2-5385114, or by e-mail at communications@idf.org.

Editor-in-Chief: Rhys Williams Guest Editor: Linda Siminerio Managing Editor: Olivier Jacqmain, diabetesvoice@idf.org Editor: Elizabeth Snouffer Editorial Assistant: Agnese Abolina Advisory group: Pablo Aschner (Colombia), Ruth Colagiuri (Australia), Maha Taysir Barakat (United Arab Emirates), Viswanathan Mohan (India), João Valente Nabais (Portugal), Kaushik Ramaiya (Tanzania), Carolyn Robertson (USA).

Layout and printing: Ex Nihilo, Belgium, www.exnihilo.be

The information in this magazine is for information purposes only. IDF makes no representations or warranties about the accuracy and reliability of any content in the magazine. Any opinions expressed are those of their authors, and do not necessarily represent the views of IDF. IDF shall not be liable for any loss or damage in connection with your use of this magazine. Through this magazine, you may

link to third-party websites, which are not under IDF’s control. The inclusion of such links does not imply a recommendation or an endorsement by IDF of any material, information, products and services advertised on third-party websites, and IDF disclaims any liability with regard to your access of such linked websites and use of any products or services advertised there. While some information in Diabetes Voice is about medical issues, it is not medical advice and should not be construed as such.

ISSN: 1437-4064 Cover photo : © William Vazquez The production of this Special Issue has been made possible thanks to the support of BRIDGES. BRIDGES is an IDF programme supported by an educational grant from Lilly Diabetes.

Contents

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40 Diabetes Views News in Brief

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IDF and BRIDGES span the globe to tackle diabetes 16 Ronan L’Hévéder

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PREVENTION Schools open doors to lifestyle lessons in Tunisia 22 Jihene Maatoug, Nawel Zammit, Firas Chouikha, Sana Bhiri, Aymen Salem, Nathalie Farpour-Lambert and Hassen Ghanem

Reducing diabetes risk after gestational diabetes

Ruth McManus, Lois Donovan, David Miller, Isabelle Giroux, Michelle Mottola, Trisha Joy, Charlotte McDonald and Patricia Rosas-Arellano

Lifestyle intervention eases battle with diabetes Asma Ahmed and Qing Qiao

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Josefien van Olmen, Grace Marie Ku, Maurits van Pelt, Christian Darras and Guy Kegels

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Professional workshops help fill gaps in diabetes self-management

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Education to change the course of diabetes in the Caribbean

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Health coaching increases self-esteem and healthy smiles

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Education helps decision-making for affordable, healthy food and control

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Everything you ever needed to know about gestational diabetes

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Can a peer support intervention improve type 2 diabetes outcomes?

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List of projects supported b y IDF BRID G ES

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Heloisa de Carvalho Torres, Ilka Afonso Reis and Mariana Almeida Maia

Errol Morrison, Shelly McFarlane, Cliff Riley and Novie Younger-Coleman

Ayse Basak Cinar and Lone Schou

Bettina Tahsin

Valerie Holmes and Claire Draffin

h e a lt h d e l i v e r y Motivating better diabetes self-care with SMS text messaging

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Ming-xia Yuan and Shen-yuan Yuan

self-management and education

IDF BRID G ES

BRIDGES at a glance

Integrated efforts key for optimal diabetes care in China

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Tim Johansson, Sophie Keller, Henrike Winkler, Raimund Weitgasser and Andreas Sönnichsen

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Diabetes views

United in our vision to save sight Diabetic retinopathy (DR) will become the leading cause of blindness worldwide in the next 20 years.

By 2035, it is estimated that 177 million people or ⅓ of all people living with diabetes will be at risk for DR. These troubling statistics are thrown around quite a lot. How many times have we heard about the serious and often tragic connection between diabetes and blindness? The messages are shocking, but the reality is often forgotten. Just like other hard-to-detect diabetes complications, DR can be difficult to recognise until it is too late.

type 2 diabetes and the doctors who treat them.

The survey estimates that 42 percent of people with type 2 diabetes do not reach blood glucose goals, putting them at high risk for complications, including blindness. Dr David Strain, Chairman of Time2DoMore’s Steering Committee tells us, “When people are first diagnosed they regard diabetes as a ‘mild condition’. Our data suggests the majority of people with diabetes regard complications as something that may happen in the future, and therefore not something to be concerned about in the early years.”

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.

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Diabetes views

The Fred Hollows Foundation works throughout Asia, Africa and the Pacific as well as with Indigenous communities in Australia. A hallmark of the Foundation’s approach is working closely with partners like IDF on blindness and prevention programmes, particularly in poor and isolated regions. Our partnership will provide an opportunity to raise awareness of eye disease as a health priority.

will be meaningful to people who live with diabetes and vision challenges.

I hope you will join us in advocating the right of all people living with diabetes to see the future.

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.

■P romote 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.

■C ontribute 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 practice for all publications in the future. The difference may seem minor, but the new format

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Michael Hirst President, International Diabetes Federation

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Diabetes views

Building BRIDGES for diabetes prevention and treatment I have had the opportunity to observe advances in diabetes over the course of 50 years. Looking backward and forward, the process tells a story of promise.

In the 1960s, I recall watching my father who struggled with the crude treatments and tools available to people with diabetes at the time. He was prescribed a strict diet, urine testing, and a dose of insulin delivered through a glass syringe with a very long needle. There were no tests for monitoring. All of his care decisions were based on guesses. Despite his best efforts, his diabetes led to a series of complications and a tragic end.

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blood glucose and hemoglobin HbA1c testing provided the needed information to people with diabetes and healthcare providers. The diabetes community yet again breathed a sigh of relief.

If there was a way to monitor glucose, of course complications could be prevented.

Years went by in the diabetes community with little advancement. New medications, insulin products and better delivery tools were introduced in the 1970s and there was a sigh of relief in the diabetes community. Yet people living with diabetes still had no way of knowing when their glucose was high or low. As a result, people still suffered the serious complications of the disease.

When monitoring became available, scientists and governments from around the world in the 1980s and 90s were finally able to invest time and funds to find answers to pending questions. Does blood glucose control really prevent the complications of diabetes? If people are at risk, can we prevent diabetes from happening? From major studies, we learned that good glucose control could prevent complications in people with type 1 diabetes. Blood pressure and glucose control are very important for people with type 2 diabetes. For people at risk, several large studies showed that lifestyle interventions help lower the chance of developing diabetes. The diabetes community breathed yet another sigh of relief, until they realised that these important scientific findings were sitting on shelves in universities.

Methods for monitoring blood glucose finally became available during the 1980s. Tools to perform

To everyone’s relief...investigators, health decision makers and funding agencies realised that there was

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Diabetes views

more work to do on the diabetes journey. Bridges were built to translate important findings from the research world to communities where people either with diabetes or at risk for the condition live.

In this issue of Diabetes Voice, you will get a peek into the world of translational research.

Through an educational grant from Lilly Diabetes, BRIDGES (Bringing Research in Diabetes to Global Environments and Systems), is an International Diabetes Federation (IDF) programme dedicated to translational research projects. BRIDGES takes lessons learned in research into communities. In 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.

from each other, adapt to our own communities and rely on tested approaches. I hope that you agree, after reading this issue that highlights BRIDGES translational research, that there is promise for the future in reaching out to the world of people affected by diabetes.

In closing, I would like to thank Lilly Diabetes for their continued support. I would also like to thank the members of BRIDGES Executive Committee, BRIDGES Review Committee and IDF Executive Office for their dedication and hard work to make this programme a success.

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 is being piloted with expectant mothers in the United Kingdom.

Much effort has gone into testing strategies to prevent and treat diabetes. We need to work together, learn

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Linda Siminerio is Professor of Medicine at the University of Pittsburgh Diabetes Institute in Pittsburgh, USA. She is Chair of the Bridges Executive Committee (2009-2014) and Guest Editor of this BRIDGES Special Issue of Diabetes Voice.

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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) 2014 campaign marks the first of a three-year (2014-16) focus on healthy living and diabetes. The impact of healthy eating on the prevention of type 2 diabetes and effective self-management will be featured in WDD activities and materials. Key messages of the campaign will raise awareness about how healthy choices for nutrition can be easy choices.

Guidance for the various steps individuals can take to make informed decisions about what they eat will also be provided. Special attention will be placed on the importance of starting the day with a healthy breakfast, focusing on the theme:

June 2014 • Volume 59 • Special Issue

“ Healthy eating begins with breakfast”

active in supporting the diabetes cause will be featured, too.

The WDD campaign will continue to actively promote action to protect the health and well-being World Diabetes Day 2014 features of future generations and achieve a new initiative: “Go Blue meaningful outcomes for people for Breakfast”. The initiative with diabetes and those at risk. encourages the diabetes and wider global community to join Visit www.worlddiabetesday.org together by organising a healthy to learn more about the cambreakfast event in their city, town paign. or neighbourhood on November 14, 2014. All breakfasts will be collected and showcased on a custom IDF online platform that will also feature healthy breakfast recipes from around the world.

Special breakfasts created by chefs

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News in brief

Challenging our cities to be

“diabetes aware” The International Diabetes Federation (IDF) and the European Connected Health Alliance (ECHAlliance) have partnered to create a new scheme that will help maximise diabetes prevention and awareness through the creation of a global network of “diabetes aware” cities. Plans to launch the programme are scheduled for World Diabetes Day, 14 November 2014.

A “diabetes aware” city will demonstrate that all sections of the community are committed to a healthy urban environment. Local public services, businesses and institutions will demonstrate that they understand challenges faced by people with diabetes and those at risk. This may include city requirements to provide appropriate nutritional information in restaurants and clean, crime-free green spaces for physical activity in parks.

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Using mobile health tools and apps, key stakeholders in city life will be able to target diabetes aware options to those at risk of diabetes and those with the disease.

“By 2035 one in ten of the world’s population will have diabetes unless there is radical change,” says Dr Petra Wilson, IDF’s Chief Executive Officer. “People in urban areas will be particularly vulnerable. It is important that we find new ways of working across all sectors to provide people with targeted information on healthier lifestyle options,” she added.

Brian O’Connor, Chair of the ECHAlliance welcomed the new partnership, “Providing people with mobile information on healthier places to eat, shop and exercise in cities is the first step toward making the healthy choice the easy choice. Information is the key to enabling healthy choices.”

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SA VE

-T

H

E-

DA TE

!

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

News in brief

World Diabetes Congress headed for Vancouver in 2015 World In 2015, the International Diabetes Federation (IDF) brings the diabetes Diabetes Congress (WDC) to Vancouver, Canada. Experts in practices care from around the world will exchange research and best nt. IDF on diabetes prevention, education, treatment and manageme uver estimates that 10% of Canadians have diabetes. Strategically, Vanco an apbridges North America and Asia Pacific regions providing diabetes propriate setting for discussions on how to tackle the global of the epidemic. The WDC 2015 will coincide with the expiration the new current Millennium Development Goals and adoption of IDF will Post-2015 Development Framework. Within this context, , treatcontinue to push for expanded access to diabetes prevention will help ment and cure. The return of the WDC to Canada in 2015 North to ensure the conference has a lasting impact throughout IDF .

America and Caribbean (NAC) Region, as well as the world

30 November – 4 December

www.idf.org/worlddiabetescongress 12

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News in brief

on the Bookshelf DIABETIC RETINOPATHY: FROM DIAGNOSIS TO TREATMENT

By David S. Boyer MD (Author), Homayoun Tabandeh MD (Author) 115 pages, English, Addicus Books, 1st edition (April 1, 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 options for treatment. This guide will help both patients and their families by covering such topics as symptoms, stages of the disease, how it is diagnosed, treatment options, ways to slow its progression, and lifestyle changes that lead to better glucose control.

THE JOHNS HOPKINS GUIDE TO DIABETES

By Christopher D. Saudek (Author), Richard R. Rubin (Author), Thomas W. Donner (Author) 504 pages, English, Johns Hopkins University Press, 2nd edition (April 8 2014)

The Johns Hopkins Guide to Diabetes is a comprehensive easy-to-read guide to better understand

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the complexities of managing diabetes. Written by a team of Johns Hopkins diabetes specialists, this second edition will help people who have diabetes work effectively with their care team to achieve targets and maintain good health.

CHILDHOOD OBESITY: ETHICAL AND POLICY ISSUES

By Kristin Voigt (Author), Stuart G. Nicholls (Author), Garrath Williams (Author) 272 pages, English, Oxford University Press, USA, 1st edition (April 25, 2014)

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, authors Kristin Voigt, Stuart G. Nicholls, and Garrath Williams emphasise that childhood obesity is a multi-faceted phenomenon, and just one of many issues that parents, schools and societies face. They argue that it is important to acknowledge the resulting complexities and not to think in terms “single-issue” policies.

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News in brief

Volume 1 Issue 1 September 2013 ISSN 0379-0738

DIABETES

RESEARCH AND CLINICAL PRACTICE Official Journal of the International Diabetes Federation

Currently in Diabetes Research 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 FEDERATION ATLAS PAPERS

INTERNATIONAL DIABETES FEDERATION GUIDELINES

Guariguata L and 50 other authors. Diabetes Res Clin Pract 2014; 103: 137-255.

International Diabetes Federation Guideline Development Group. Diabetes Res Clin Pract 2014; 103: 256-68.

A series of 12 papers providing recent global estimates for a range of topics relevant to diabetes and hyperglycaemia in pregnancy, together with data and discussion specific to IDF regions.

Glycaemic and haemoglobin A1c thresholds for detecting diabetic retinopathy: the fifth Korea National Health and Nutrition Examination Survey (2011) Park YM, Ko SH, Lee JM, et al. Diabetes Res Clin Pract 2014; doi: 10.1016/j.diabres.2014.04.003.

“Few representative population-based data are available regarding glycaemic and HbA1c thresholds for detecting diabetic retinopathy (DR) in Asia. We investigated the association between DR and fasting plasma glucose (FPG) and HbA1c levels among Korean adults.”

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Guideline for management of postmeal glucose in diabetes – an update which builds on the original IDF guideline published in 2007.

DEPRESSION AND TYPE 2 DIABETES IN LOW- AND MIDDLE-INCOME COUNTRIES: A SYSTEMATIC REVIEW Mendenhall E, Norris SA, Shidhaye R, et al. Diabetes Res Clin Pract 2014; 103: 276-85.

Research studies identified relevant to this topic included those from India (n = 8), Mexico (n = 8), Brazil (n = 5) and China (n = 5). One of the authors’ conclusions is that “despite substantial diabetes burden in LMICs [low- and middle-income countries], few [studies] have reviewed comorbid depression and diabetes.” The review, nevertheless, suggests that depression among people with diabetes in LIMCs may be higher than in high-income countries.

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News in brief

Parliamentarians respond

to call for action Hon Judi Moylan A quiet revolution unfolded in the bustling city of Melbourne, Australia, last December, where the World Diabetes Congress hosted the inaugural Global Parliamentary Champions for Diabetes Forum.

Parliamentarians from over 55 countries signed the Melbourne Declaration on Diabetes and established a new advocacy programme, the International Diabetes Federation (IDF) Parliamentarians for Diabetes Global Network. Adrian Sanders MP (UK) was elected President and Honor Dr Simon Busuttil MP, (Malta) and

Dr Rachael Nyamai MP (Kenya) elected Vice Presidents.

The Global Parliamentar y Champions for Diabetes Forum and the Parliamentarians for Diabetes Global Network were the inspiration of IDF President, Sir Michael Hirst and former Australian Senator Guy Barnett, who remain Chair and Vice Chair of the Group.

Diabetes is a challenge for all nations as its malevolent march wreaks havoc on the health and fortunes of citizens and governments alike.

The Global Parliamentary Champions for Diabetes Forum called for political action, which was embraced enthusiastically by the MP’s. Since then debates and events have taken place in the Parliaments of the United Kingdom, Malta, Scotland, Australia, Kenya and Bolivia. Reports of the growing incidence of diabetes in countries large and small highlighted the need for action.

When Members of Parliament understand the impact of diabetes on people in their constituencies, they become powerful advocates and allies. Their support ensures that diabetes has a central place in health policy, planning and regulation.

The newly established Parliamentarians for Diabetes Global Network looks toward expanding its membership to become a powerful presence at the next World Diabetes Congress in Vancouver in 2015.

From left to right: Mr Guy Barnett, Co-Chair, Parliamentary Champions for Diabetes Forum; Hon Judi Moylan, Global Coordinator, IDF Parliamentarians for Diabetes Global Network; Her Excellency Madam Bongi Ngema-Zuma, First Lady of South Africa; Mr Adrian Sanders, President, IDF Parliamentarians for Diabetes Global Network; Sir Michael Hirst, President, International Diabetes Federation

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Details of the Melbourne Declaration on Diabetes and Parliamentary action since Melbourne can be found on: www.idf.org/pdgn along with contact details of the Secretariat.

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IDF BRIDGES

IDF and BRIDGES globe to tackle Ronan L’Hévéder

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June 2014 • Volume 59 • Special Issue

IDF BRIDGES

span the diabetes Translational research helps to apply successful outcomes from basic science into practical reallife applications in communities.

Today, this type of research is gaining widespread attention in the prevention and treatment of diabetes.

Photo : Tim Nolan

Several large-scale trials implemented in different healthcare settings and communities have demonstrated that lifestyle interventions can prevent development of diabetes in people at high risk. Large multicentre studies have also demonstrated that with prevention strategies and treatment plans, diabetes chronic complications can be managed thereby decreasing diabetes care costs and providing an improved quality of life for people with diabetes.

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BRIDGES organisation in brief Launched in 2007, through an educational grant from Lilly Diabetes (USD 10,000,000), BRIDGES (Bringing Research in

Diabetes to Global Environments and Systems) is an International Diabetes Federation (IDF) programme dedicated to translational research projects developed to prevent diabetes, diabetes complications and improve quality of life of people with diabetes. Across all BRIDGES projects, IDF identifies lessons learned in clinical research and places them into communities where the need is great. In turn, BRIDGES community projects benefit people affected by diabetes, and help protect those at risk from developing the disease.

The Programme’s five overarching goals define its activities worldwide: ■ Enhancing interaction with health ministries to optimise healthcare systems outcomes.

■ I mproving quality of life.

■ Improving access to affordable, good-quality education.

■ Reinforcing human rights of people with diabetes.

■ Strengthening preventive efforts worldwide.

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IDF BRIDGES

The programme is managed by IDF under the supervision of BRIDGES Executive Committee (BEC), chaired by Professor Linda Siminerio, and BRIDGES Review Committee (BRC) chaired by Professor Robert Gabbay. Each committee is composed of international experts representing each region of the world and bringing expertise in health economics, epidemiology, education, statistics, clinical research, and ethics. Lilly Diabetes has one observer within BEC without voting rights, representation on the Review Committee or access to members.

Reaching the community worldwide In the last six years, IDF has managed four calls for proposals receiving 449 applications from 104 countries. The assessment of each project proposal was based on the quality of the proposed intervention and the potential for a favourable impact in the healthcare setting. Today, 41 projects supported by IDF BRIDGES are under way in 36 countries in close contact with the local health authorities. Each project is followed closely through regular reporting and via an ongoing mentoring programme.

This Special Issue of Diabetes Voice dedicated to BRIDGES will introduce a few of these projects. A detailed presentation, including outcomes, of each

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project is available on our website www.idf.org/bridges and in our World Guide to IDF BRIDGES 2013 which can be downloaded on the website.

IDF BRIDGES workshops: promoting excellence in translational research worldwide In 2008, under the auspices of the BRIDGES programme, IDF provided a series of one-day workshops to encourage and support young investigators in low- and middle-income countries in the development and implementation of translational research projects. Professor K.M. Venkat Narayan (Emory University, USA) provided expert input on the structure and content of the sessions. Since that time, nine workshops have been held in various parts of the world, attracting more than 140 participants. Attendance is free of charge, and many of participating researchers receive financial support from IDF for their travel and accommodation.

The materials of the workshops will soon be available online.

In addition to the translational research workshops, IDF BRIDGES launched a series of educational events, How to get published – workshops for researchers in 2013.

The aim of these workshops, held in Miami and Dubai, was to help improve the dissemination of the findings and best practices

from supported projects. The sessions were lively and interactive, and provided expert input on key elements in writing goodquality presentations and papers for international congresses and peer-reviewed journals. All of the participants were invited by and received financial support for travel and accommodation from IDF. The How to get published – workshops for researchers event has already been replicated in Colombia and IDF is looking at the possibility of providing the sessions online.

Photo : Tim Nolan

June 2014 • Volume 59 • Special Issue

IDF BRIDGES

D-START: adapting to changing environments During the initial implementation of the BRIDGES projects, a number of challenges were identified. In low- and middleincome countries where diabetes prevalence is continuously rising, there was a lack of experienced researchers ready to develop, implement and evaluate diabetes prevention programmes in their respective communities. It also became clear that the sustainability of BRIDGES projects would depend on the commitment of local healthcare authorities.

adapted to be used effectively in local circumstances in Pakistan and Vietnam. In this publication you will find, as an example, a report on the Pakistan project, “Lifestyle intervention eases battle with diabetes.”

BRIDGES Research Net: putting forward successful interventions BRIDGES Research Net is a BRIDGES intervention conceptually based on D-START. Here’s how it works: when a project has proven to be successful in one country, it is selected, reproduced and implemented in another region under the guidance of the leader of the original one with an active partnership of the local healthcare authorities. The process is initiated with a call for proposals: applicants need to explain how they will adapt the chosen intervention culturally and socially to its novel context, and more importantly demonstrate strong support for the project from local authorities.

The search for effective solutions led to the development of D-START, with support from a team of international experts, such as Peter Bennett (USA), Juan José Gagliardino (Argentina), Ayesha Motala (South Africa) and Jaakko Tuomilehto (Finland). A call for proposals was issued and project partnerships were established involving researchers and healthcare authorities in developing 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 research has been central to this an Educational and Preventive new approach. The D-START Foot Care Centre for People with projects are based on the protocol Diabetes in Alexandria, Egypt.” developed by Qing Qiao at the University of Helsinki, Finland. Three organisations were selected: In both interventions, the seminal ■ Q ingdao Endocrine and Diabetes Finnish prevention trial was Hospital, Qingdao (China)

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■Z imbabwe Diabetes Association,

Harare (Zimbabwe) ■A mbulatory Healthcare Center “CAA Cotocollao”, National Social Security in Quito, (Ecuador)

Before launching the intervention in each region, the selected applicants received a full week of onsite training under the leadership of Professor Samir Helmy Assaad-Khalil, Principal Investigator of the project in Egypt.The interventions are currently in place and IDF is mentoring progress of each through regular conference calls.

Ronan L’Hévéder Ronan L’Hévéder is in charge of the management of BRIDGES for the International Diabetes Federation.

Acknowledgement This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

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IDF BRIDGES

BRIDGES at a

3

9

41: number of projects

supported by BRIDGES

38: n umber of countries in which a project is taking place

11: n umber of workshops

organised to support young investigators and member associations to increase skills in grant, abstract and publication writing. Workshops took place in Chinese, English, French, Spanish and Russian

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93: number of posters presented to date

104: number of countries

from which we received applications June 2014 • Volume 59 • Special Issue

IDF BRIDGES

glance

145: t otal number of

participants in the workshops

449: n umber of applications

received since the start of BRIDGES

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2007 – 2014:

timeline of BRIDGES

USD 10,000,000:

amount received from Lilly Diabetes in support of BRIDGES 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 occurring in Tunisia. Prevalence of diabetes has increased from 2.3% in 1977 to 6.4% in 1990 and reached 10 to 15% in 2000.

Increased diabetes prevalence is rising hand-in-hand with obesity, which represents an important risk factor of type 2 diabetes.

The prevalence of childhood obesity has increased worldwide during recent decades. Current prevalence of overweight and obese children was respectively 23.7% and 5.1% among girls and 21.1% and 7% among boys in the region of Sousse, Tunisia.

Additionally, a cohort study demonstrated the stability of obesity among these children in the region.1 Prevention and 22

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management of excess weight are critical at an early age before chronic problems develop.

Many studies in developed countries have proven the effectiveness of lifestyle interventions to manage obesity and the overweight, including the Swiss “Contrepoids” programme.2

intervention for overweight and obese school children aged 14-16 years to prevent type 2 diabetes.

Lifestyle interventions included encouragement for regular physical activity, a healthy diet and included psychological support over the course of one year. This intervention represented the first school-based programme for overweight or obese children in Tunisia. It was also a “first” for the study team.

Impact of lifestyle interventions in school setting For this BRIDGES supported project, “Lifestyle interven- The challenge in tion among overweight and this step was to obese school children in Sousse, sensitise school Tunisia”, key persons from the children about their Swiss “Contrepoids” programme trained the study team. Our task overweight status. was to implement and evaluate The programme began by a culturally appropriate lifestyle screening children who were

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Prevention

overweight. Our recruitment plan was simple; we asked the children and their parents to participate in the study in order to achieve weight-loss. The challenge in this step was to sensitise schoolchildren about their overweight status. In fact, excess weight is still culturally 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 betheir 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 pooccurred 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 motiNovember 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 permitted support to improve school sport equipment, which was found to be too rudimentary to encourage physical activity or teaching involvement. The school-based programme also encouraged the schoolchildren to interact. Girls ambitious to lose weight in the programme

Some parents and their children were not motivated to participate because they did not understand or perceive the risks.

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Prevention

developed a sense of friendly competition with their peers.

doctors have consultations.

In addition, training physical activity teachers to adapt exStudy insight ercises to assist obese children This intervention captured would be very helpful. multiple opportunities for 3. School directors need to manthe prevention of obesity and age and improve school indiabetes. The most important frastructure to provide daily physical activity for all interelement was the multidisciplinary management of overweight and ested schoolchildren. obese children, which does not exist in Tunisia. Additionally, the The continuity of the intervention study programme enhanced the programme could help all accessibility of care for children partners listed above reduce and lacking time or money for prevent obesity and diabetes, medical consultations. Although which is a significant public obesity prevalence is on the health problem in Tunisia. It is increase for youths in Tunisia, recommended that our schoolmedical assistance does not exist based intervention programme to help manage overweight and be used as a national foundation obese children. This gives a programme for Tunisia. A report weighty rationale for a school- of this study will be presented to health and education ministries, based intervention. which will be shared with all At the end of the intervention schools in Tunisia. programme, several products and services remain in the schools today. The following are recommendations for strategically curbing the rise in childhood obesity and type 2 diabetes in Tunisia: 1. Brochures and fliers promoting dietary changes and an increase in availability of medical doctors and nurses in schools.

2. Capacity building for training school medical doctors and nurses to better manage overweight and obese children. Training activities could also be provided in primary healthcare centres where

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Jihene Maatoug, Nawel Zammit, Firas Chouikha, Sana Bhiri, Aymen Salem, Nathalie FarpourLambert and Hassen Ghanem Jihene Maatoug is Assistant Professor of Public Health at the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

Nawel Zammit is in residency training at the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

Firas Chouikha is Practical Nurse at the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

Sana Bhiri is in residency training at the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

Aymen Salem is Medical Doctor at the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

Nathalie Farpour-Lambert is Head of the Obesity Care Program, Service of Pediatric Specialties, Department of Child and Adolescent University Hospitals of Geneva and University of Geneva, Geneva, Switzerland.

Hassen Ghanem is Professor of Public Health and Head of the Department of Epidemiology, University Hospital Farhat Hached, Sousse, Tunisia.

BRIDGES project Lifestyle intervention among overweight and obese schoolchildren: a pre- post-quasi experimental study with control group in Sousse, Tunisia

Acknowledgement This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 1. Harrabi I, Maatoug J, Ben Hammouda H, et al.

Tracking of overweight among urban school children: a 4 years cohort study in Sousse Tunisia.

J. Public Health Epidemiol 2009; 1: 31-6.

2. Baker JL, Farpour-Lambert NJ, Nowicka P, et al. Evaluation of the overweight/obese child – practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesity. Obes Facts 2010; 3: 131-7.

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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 shown to be effective in many parts of the world. It has been years since important studies affirmed that preventive measures such as moderate weight loss, moderate physical activity and low-fat, high fibre food choices can help offset impaired glucose tolerance from progressing to a case of type 2 diabetes.1,2 Despite years of building the evidence, why is type 2 diabetes still an ongoing epidemic? The health community often knows what works to prevent type 2 diabetes in highly controlled research studies, but doesn’t necessarily know how to usefully translate diabetes prevention into real world situations. Effective and proven programmes are desperately needed that can translate diabetes prevention research findings into programmes for people at risk for diabetes. Type 2 diabetes is also a “familial disease”.

This statement emphasises not only the inherited genetic risks3 but also highlights a connection to the home environment. The importance of community context associated with type 2 diabetes risk not only includes physical surroundings or social frameworks, but also includes significant influences

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from the immediate family unit. There are also increasing concerns surrounding the magnified risks for obesity and metabolic disturbances for children born to mothers with gestational diabetes mellitus (GDM).4 For this reason, there is some urgency to find effective, early metabolic interventions for both mothers and their offspring.

Women with GDM are at greater risk for developing diabetes than the general population.

Women with recently diagnosed GDM are an appropriate population to target with type 2 diabetes prevention messages. Women with GDM are usually informed about their risk for developing true diabetes, at greater risk for developing diabetes than the general population and should be in active communication with healthcare providers.

Families Defeating Diabetes The Families Defeating Diabetes (FDD) BRIDGES project was designed to deliver a diabetes prevention programme through the existing network of DiabetesVoice 25

Prevention

Canadian diabetes education centres, while evaluating time and personnel costs. FDD is a 12-month, randomised, controlled intervention for type 2 diabetes prevention directed at women with recent GDM. Special consideration is also directed to the context of family lifestyle. This additional focus demonstrates the ways in which family members can influence lifestyle behaviours in people with diabetes. The rationale in delivering interventions targeted to immediate family members of a person living with diabetes is based on the idea that people with diabetes who receive assistance from family are often highly functioning.

Participating sites include London, Ontario; Calgary, Alberta; and Victoria, British Columbia. FDD started in 2011 and active intervention will finish at the end of 2014. A 24-month phone or electronic contact to enquire about diet, exercise and body measurements is being used in this study.

DO…  Most of your food shopping in the outer aisles of grocery stores or food markets and avoid the inner aisles. The outer aisles of the store are where real, whole foods are placed. These are foods highest in fibre and nutrition. They are the most naturally colourful, too.  Try to eat with your family at least once a day. Children who eat with their families are less likely to be overweight.  Eat a healthy breakfast every day. People who eat breakfast are less likely to be overweight.  Exercise for 30 minutes a day because it will help protect you from developing type 2 diabetes. Children require 60 minutes per day.  Make family activity fun for both you and your children. Play! Dance! Run! Dare to be a bit silly!

The FDD study will assess physical outcomes such as maternal weight loss, HbA1c, and participant and family member body measurements. Important secondary outcomes will evaluate family member engagement, the frequency usage of electronic media and correlations between physical outcomes and study engagement parameters.

■T wice monthly e-mail alerts with diabetes prevention 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 prevenwere offered admission to the study. Women rantion 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■A n 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 ■O ffer 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

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DON’T…  Be attracted by the colourful boxes or advertisements for highly processed foods.

Highly processed foods are low in nutrition but high in fat, sugar and additives – all of which are not good for you.  Believe that your children aren’t watching what you eat. They are and will want to eat the same thing.  Buy fast-food. Even if you can afford the cost, fast food meals (including breakfast sandwiches) are high fat, high sodium, and low fibre meals, which mean you don’t feel satiated or full after you eat them.  Sit for more than 2-3 hours at a time. Move around, and take a walk.

friendly low-fat, high fibre diet and encouraging ½ hour of daily exercise for all family members.

Control and intervention groups completed questionnaires enquiring about diabetes prevention knowledge and lifestyle habits at pre-delivery and three, six, twelve months postpartum. HbA1c was measured at three and twelve months postpartum. All women were encouraged to breastfeed.

Consenting family members of both control and intervention groups were also actively encouraged to participate. Family members who consented were surveyed for knowledge about diabetes prevention including dietary and exercise habits. Body measurements were recorded at three and twelve months.

Family members of the intervention group also had access to electronic media and updates.

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Preliminary insights One hundred and sixty women consented to be in the study (81 women for intervention and 79 for control). Women who were eligible but did not participate were more likely to smoke, have a family history of diabetes, have a prescription drug plan and be less likely to use insulin. Non-participation reasons included being too busy and being unconcerned about a personal risk for type 2 diabetes. This non-participation rate was somewhat unexpected because women with GDM usually indicate that they wish to avoid type 2 diabetes. However, this process finding is important as it illustrates that even in a population knowledgeable about the risk of diabetes, many may choose not to participate. In the future, wider population interventions intended to offer diabetes prevention will need to develop solutions to address significant levels of unconcern and process disengagement from their target audience.

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 family members. To some extent, this finding was expected. Family members, who are one step removed from the experience of treating or experiencing GDM, may be less likely to be motivated to participate in an investigation for personal health habits. It is important to note that while some family members, especially partners, are receptive to adapting a healthier lifestyle in an effort to support partners with GDM, others are not. A more focused survey of family members’ opinions about their role in healthy lifestyle interventions might offer useful insights for future programme designs.

Multiple prompts and reminders were provided during the year for participants to log onto the FDD website. Website accession rates have been recorded at 41% of interventional women and 38%

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Prevention

of interventional family members. Most frequent website hits were noted on the following areas: community, programme seminar, links, powerful foods, feeding baby and planning pregnancy. Most FDD participants accessed the website five times over the course of a year. Targeted engagement with a diabetes prevention website resulted in approximately 40% uptake. It was assumed that building an electronic presence into the FDD programme would allow for expanded opportunities for knowledge and behavioural support through links to other helpful sites. Although the study team anticipated that an engaging website would be a good way to reach participants with health information, visits to the website were disappointingly low. At completion, programme data will provide the website components which were most frequently accessed as well as correlations between electronic engagement and quantitative outcomes such as exercise frequency, breastfeeding duration, and weight loss.

Next steps When FDD is complete and all results are analysed, we propose to evaluate which intervention activities are associated with positive physical and process 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 for women at risk for type 2 diabetes, determining how varying levels of family involvement impact healthy lifestyle behaviour, and demonstrating the power of educational tools, including electronic media, for enhancing healthy lifestyle knowledge and behaviour.

Ruth McManus, Lois Donovan, David Miller, Isabelle Giroux, Michelle Mottola, Trisha Joy, Charlotte McDonald and Patricia Rosas-Arellano Ruth McManus is Professor of Medicine at the Division of Endocrinology and Metabolism, Department of Medicine, The University of Western Ontario, London, Ontario, Canada.

Lois Donovan is Clinical Associate Professor at the Division of Endocrinology and Metabolism, Department of Obstetrics and Gynecology, University of Calgary, Canada.

David Miller is Affiliate Assistant Professor at the Department of Medicine, University of Victoria, British Columbia, Canada.

Isabelle Giroux is Associate Professor for a Nutrition Program at Faculty of Health Sciences, University of Ottawa, Ontario, Canada.

Michelle Mottola is Professor at the School of Kinesiology, Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada.

Trisha Joy is Assistant Professor of Medicine at the Division of Endocrinology and Metabolism, Department of Medicine, The University of Western Ontario, London, Ontario, Canada.

Charlotte McDonald is Associate Professor of Medicine at the Division of Endocrinology and Metabolism, Department of Medicine, The University of Western Ontario, London, Ontario, Canada.

Patricia Rosas-Arellano is Research Coordinator of the Families Defeating Diabetes project, Canada.

BRIDGES project Families Defeating Diabetes (FDD): a Canadian intervention for family-centred diabetes prevention after gestational diabetes

Acknowledgement The FDD researchers are truly grateful for the enthusiasm and good humour of our site coordinators: Kristen Barton (Calgary) and Karen Coles (Victoria).

This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 1. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and diabetes study.

Diabetes Care 1997; 20: 534-44.

2. T uomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.

N Engl J Med 2001; 344: 1343-50.

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.

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June 2014 • Volume 59 • Special Issue

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Lifestyle intervention eases battle with diabetes Asma Ahmed and Qing Qiao

diabetes at a lower body mass index (BMI) than Caucasians.

This becomes a very significant concern in a country like Pakistan where 12.8% of male and 27.3% of the female population are physically inactive. A population based survey in both rural and urban areas of Pakistan revealed the prevalence of overall glucose intolerance at 22% in urban areas and 17.2% in rural areas. Furthermore, 25% of the Pakistani population is classified as overweight and obese according to Asian specific BMI definitions. Unfortunately the expenditure on healthcare in Pakistan is only 2% of the gross domestic product (GDP) and people with diabetes and their families have to bear most all costs associated Ample evidence indicates that with diabetes related care. This Asian populations develop type 2 poses a significant burden not

Pakistan is the sixth most populous country in Southeast Asia with a population exceeding 180 million. Today, diabetes prevalence in Pakistan is estimated to be 6.8%.1 In 2010, a World Bank report warned that Pakistan is facing a health crisis, with rising rates of diabetes, obesity, heart disease and other Noncommunicable diseases (NCDs).

According to the report, NCDs account for 59% of the total disease burden in Pakistan.2 The rising prevalence of diabetes in Pakistan is eclipsed only by the 88,000 annual deaths attributed to complications of diabetes. By 2035, it is estimated that 12.8 million people will be living with diabetes in Pakistan.

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only on individuals but on their families as well, especially in circumstances where the head of the household is the only income provider. Programmes to prevent and manage diabetes are required in order for Pakistan to tackle the diabetes epidemic.

25% of the Pakistani population is classified as overweight and obese.

The study In collaboration with the University of Helsinki, the ongoing Karachi-based Pakistan Diabetes Prevention Programme (PDPP) addresses key issues in the prevention of type 2 diabetes.

The capital city of Karachi is the DiabetesVoice 29

Prevention

reen Sultana Marvi Hussain, Ms Hamidah Aziz and Ms Meh Ms Ali, sin Moh Mr : right to left from row t Fron ain Hina Shabbir, Mr Arif Hussain and Mr Tariq Huss Back row from left to right: Mr Jamal Iqbal, Ms

largest city in Pakistan with an estimated population of more than 18 million. Approximately 20,000 Karachi residents are currently being screened for diabetes risk factors using a non-invasive diabetes risk-score system. Those already found at increased risk have been given an oral glucose tolerance test (OGTT). After the OGTT, those identified as having metabolic syndrome (or pre-diabetes) are asked to take part in the PDPP lifestyle intervention. The intervention consists of culturally adjusted preventive strategies focusing on diet and physical activity in real-life 30

DiabetesVoice

settings. Another important aspect of this study has been to assess the impact of urban planning on the prevalence of obesity and diabetes.

were also consistent with the landmark Da Qing study, which achieved 51% lower incidence of diabetes with lifestyle intervention. In follow-up, studies have inLifestyle intervention impact dicated long term success includRandomised trials in individuals at ing 43% sustained lower incidence high risk for diabetes support the of diabetes over a 20-year period.3 hypothesis that explicitly targeting lifestyle-factors can substan- However, the lifestyle intertially help reduce the incidence vention in the Indian Diabetes of type 2 diabetes. The Diabetes Prevention Program (IDPP) had Prevention Program (DPP) and a less significant effect (28.5% rethe Finnish Diabetes Prevention duction in diabetes incidence) on Study (FDPS) showed a 58% diabetes prevention. Apart from reduction in the incidence of clinical outcomes, the IDPP did type 2 diabetes. These findings prove to be cost effective which is

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an important element for health- for low levels of exercise. Current care policy decision-making. political circumstances also have an impact on life in Pakistan; there is significant psychological Country context To date, the effectiveness of stress that may further contribute lifestyle interventions for the to “insulin resistance syndrome” prevention of diabetes has not resulting in an increased prevabeen investigated in the native lence of diabetes.

Asian Pakistani population. It could be hypothesised that IDPP Current PDPP progress could be partly applicable to The primary objective of PDPP is 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 eatdiabetes has been observed ing and lifestyle practices is exwithin the same geographical pected to produce a reduction in location. Moreover, there is the incidence of type 2 diabetes. significant diversity among South The study is being conducted in Asians in terms of their cultural two major areas of Karachi based practices and dietary habits. on the differences in dietary culFor example, the prevalence ture and city plan. of diabetes between Gujrati (Indian) Muslims and Pakistani To date, 13,969 individuals have Muslims among migrants of been screened with the help of a South Asian descent living in non-invasive diabetes risk scorthe United Kingdom differs by ing system out of which OGTT has been done for 2,677 particiapproximately twofold. pants. The results so far show The population of Pakistan is an increased prevalence of obecomprised of five major diverse sity (35.2%), physical inactivity ethnic subgroups originating (56.9%) and glucose intolerance from different parts of Central in the Karachi population. The and South Asia with distinct lan- overall prevalence of pre-diabetes guages, dietary practices, places and diabetes in high-risk indiof origin, cultural values, health viduals was 31.3 (95% CI 29.6beliefs and behaviours. In addi- 33.1) and 15.2 (95% CI 13.9-16.6) tion, the perceived unsuitability respectively. Raised BMI and of women’s participation in physi- central adiposity was found to cal activity in a number of Muslim significantly correlate with both communities is also responsible pre-diabetes and diabetes.

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Lifestyle intervention for individuals with the high-risk scoring system is in progress. Approximately 475 participants have been given intervention sessions. The PDPP intervention programme objective is to improve the awareness of the community, to reduce the incidence of obesity, diabetes and other related complications. PDPP will be complete in October 2014.

Asma Ahmed and Qing Qiao Asma Ahmed is Assistant Professor and Endocrinologist at the Aga Khan University Hospital, Karachi, Pakistan.

Qing Qiao is Adjunct Professor, Department of Public Health, University of Helsinki, Finland.

BRIDGES project A translational randomized trial of culturally specific and cost-effective life style intervention for the prevention of type 2 diabetes in Pakistan (Pakistan Diabetes Prevention Program PDPP)

Acknowledgement This project is supported by BRIDGES. 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. Engelgau MM, El-Saharty S, Kudesia P. Capitalizing on the Demographic Transition: Tackling Noncommunicable Diseases in South Asia. World Bank. Washington DC, 2010.

3. Lindstrom J, Ilanne-Parikka P, Peltonen M, et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368: 1673-9.

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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 crucial for experiencing a healthy life with diabetes. Diabetes SelfManagement Education (DSME) and Diabetes Self-Management Support (DSMS) activities provide a process for people living with diabetes to gain the knowledge and skills needed to modify their behaviour. DSME and DSMS also help people with diabetes selfmanage the disease and related conditions. The implementation of DSME/DSMS takes different forms depending on the organisation of care for people with diabetes including their healthcare system and their healthcare provision. The impact of the cultural and socio-economic environment in which they live is also an important factor.

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In recent years, the fast increasing penetration and use of mobile technology worldwide has been seen as a potential game changer to enhance current approaches to DSME/DSMS. Mobile technology today provides a variety of health enhancing tools for people and professionals connected to diabetes. For example, smartphone technology can be directly linked to blood glucose measuring equipment enhancing patient and professional collaboration. For enhanced motivation and better self-care behaviours, lifestylebased short-message-service (SMS) text messaging can be delivered to people with diabetes.

The TEXT4DSM study was developed to find out how mobile

phone technology can be used in a simple but intelligent way for diabetes programmes in a variety of settings. Evaluating the impact of mobile technology on the challenges associated with diabetes will also be vital once the study is complete. These challenges include changes related to physical health, feelings of control, utilisation of healthcare services and selfmanagement behaviour.

Study We designed a randomised controlled trial for people with diabetes from existing diabetes programmes in three countries: Democratic Republic of the Congo (DRC), Cambodia and the Philippines. Each site

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health delivery

The BRIDGES evaluation team visiting a peer educator group in Cambodia. Photo: Tim Nolan

recruited 480 participants. All study participants (exposure and control groups) continued to receive diabetes care and DSME in their normal setting and all participants received a new mobile phone. In addition, the exposure group received short-messageservices related to different dimensions of diabetes self-management such as advice related to diet and exercise, self-monitoring and how to handle emergencies.

Exposure participants were also encouraged to use their phone when they had questions or felt the need for support on selfmanagement requirements. In this instance participants were encouraged to contact their healthcare provider.

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Data collection for all participants occurred before the start of the intervention as well as oneyear and two-year completion.

Data included biomedical and anthropometric variables (HbA1c, BMI, WC, WHR) as well as information related to participant knowledge, attitudes, perceptions, practices and feelings of control. After six months, we also performed an intermediate data collection restricted to the biomedical and anthropometric variables. In our study analyses, we will focus on the evolution of outcome variables in all three settings and assess possible differences. For instance, we will evaluate how different mechanisms may have been triggered

by a participant’s usage of mobile technology for diabetes.

Context of study settings The estimated prevalence of diabetes for each study country according to the IDF Diabetes Atlas:1 ■D RC: 6.1% ■C ambodia: 3.0% ■P hilippines: 6.9% The programme in the DRC is a 40-year-old network of 80 primary care centres located in the capital city of Kinshasa. These centres deliver diabetes care as part of a basic package to approximately 8,000 people with diabetes. The first contact person for the person with diabetes is a nurse. Every DiabetesVoice 33

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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 access to a primary care centre sees a doctor and is given a blood glucose 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 session with patients in Barangay, the Philippines programme, initiated in 2005, operates through communitybased peer educator networks.

Currently, there are 130 peer educators work an average of people with diabetes is a fameducators 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 specialhelp facilitate. They are supported ists available. FiLDCare is also ofby 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 supservices, a revolving drug fund port approximately 1,000 people and laboratory examinations. with diabetes.

Project Manager explaining the study in an information meeting for potential participants in DRC

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In the Philippines, people with diabetes receive primary care and DSME in a healthcare facility. DSMS is community-based and provided by Community Health Workers (CHWs) in the “First Line Diabetes Care Project” (FiLDCare). FiLDCare is operational in one urban area where the primary contact for

Progress to date At the time of writing this report, the project was in the midst of its implementation phase. We have been able to include 480 patients in each country and collect their baseline data. Contracts with local telephone providers for the provision of 480 cellular phones (to match the 480 participants in

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health delivery

each setting) have been signed.

Currently, the study team is sending daily text messages to each of the 240 participants.

Overall, SMS messages covering all nine dimensions of the DSME guidelines2 have been sent for one year at a rate of five per week. To date, the study team has collected data from all participants one year after their inclusion. Processing of the information is ongoing.

The main challenges for the TEXT4DM study relate to authenticating sent and received SMS messages and the followup of participants. All participants received a new cellular phone and a new mobile number, which TEXT4DM used to send the study messages. In all countries, we met people who had lost, broken or given away their study phones. We realised that most people had access to another phone and used the alternative “study mobile number” for messages. We had specific constraints in Cambodia, where we wanted to be able to communicate in the local language (Khmer), which would have required special font phones. We decided to shift to voice-SMS or sending SMS as voice-mails to participants there.

of the analysis will be published in peer-reviewed journals.

Possible expectations beyond the initial rationale The partly unforeseen difficulties in the implementation of a mobile phone support intervention have brought to light some of the limitations and barriers to mobile health solutions that could be posed on a larger scale.

Nevertheless, the feedback and discussion of the first analyses of the baseline data from practitioners and people with diabetes in each setting have led to new insights and enthusiasm about ways to improve diabetes care and DSME/DSMS.

The TEXT4DM study has turned out to be an enriching experience in many ways.

Collaborating in a joint research programme meant learning opportunities for everyone associated with the TEXT4DM’s international consortium.

The capacity for designing, implementing and analysing research has grown in all the study settings. The sharing of diabetes practices between the sites has helped to enhance diabetes care knowledge as well as other contexts. Most In the follow-up of study importantly, this project has participants, we have lost provided insights on how to roughly 5% either due to death effectively use technological or participant movement to a resources for access to DSME different area. The first results and DSMS.

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Josefien van Olmen, Grace Marie Ku, Maurits van Pelt, Christian Darras and Guy Kegels Josefien van Olmen is Pre-doctoral Researcher at the Institute of Tropical Medicine, Antwerp, Belgium.

Grace Marie Ku is Pre-doctoral Researcher at the Institute of Tropical Medicine, Antwerp, Belgium and in charge of the FiLDCare project in the Philippines.

Maurits van Pelt is Director of MoPoTsyo in Cambodia.

Christian Darras is Advisor to Memisa, Brussels, Belgium.

Guy Kegels is Senior Lecturer at the Institute of Tropical Medicine, Antwerp, Belgium.

BRIDGES project Mobile phone Diabetes Self-Management Support: a multi country analysis of its implementation in existing Diabetes Self-Management Education programmes in the Democratic Republic of Congo, Cambodia and the Philippines

Acknowledgement This project is supported by BRIDGES. 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. National Diabetes Education Program.

Guiding principles for diabetes care: for health care professionals. NDEP. USA, 2009.

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Integrated efforts

optimal diabetes Ming-xia Yuan and Shen-yuan Yuan

The prevalence of diabetes is estimated to be 11.6% in the Chinese adult population, which represents up to 113.9 million Chinese adults with diabetes or a third of the world’s diabetes population. The prevalence of diabetes is higher in older age groups, in urban residents and in persons living in economically developed regions. Among people with diabetes, only 25.8% received treatment for diabetes and only 39.7% of those treated had adequate glycaemic control.1,2 These numbers suggest that China has overtaken India as the epicentre of the global diabetes epidemic.3

relatively untapped resource pool. Once organised, GPs could deliver better care for a broader base of people living with diabetes in China. There is a growing realisation that integrated efforts between specialists and GPs may be the ideal way to ensure optimal outcomes of management for diabetes.

The study This ongoing BRIDGES supported project is implementing and evaluating a community-hospital integrated management system for type 2 diabetes 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

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key for

care in China

the risk of microvascular and macrovascular complications.5 However, translation of these interventions to real-life settings remains a major challenge in China. In the 2006 nationwide Diabcare-China surveys,6 only 26.8% of patients with type 2 diabetes reached HbA1c ≤6.5% (International Diabetes Federation criteria) and 41.1% of people with diabetes reached an HbA1c <7% (American Diabetes Association criteria).

The proportion of patients with “poor control” (HbA1c >8%) was 28.3%. In addition, only 22.4% of patients achieved a BP goal of below 130/80 mmHg and the proportion of patients achieving high density lipoprotein (HDL) levels >1.1 mmol/L and triglyceride (TG) levels <1.5 mmol/L was 60.9% and 40.7% respectively.

The quality of diabetes management in Beijing is similar to data collected nationwide. National reports from community centres show diabetes care status is even worse with approximately 10% of people with type 2 diabetes having achieved an HbA1c ≤6.5%. More importantly, only 2.7% of people with diabetes obtained optimal glycaemic,

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blood pressure, and serum lipid control in Shanghai,7,8 the largest city (by population) in the world. It is evident that more intensive care is required for people living with diabetes in China.

More specifically, the following issues require attention: ■G Ps need further expert guidance, including training on updated diabetes guidelines in practice.

■ Preventive measures are required for controlling multiple risk factors associated with diabetes.

■P roactive systems for surveillance and support are needed to enhance current diabetes management.

General practitioner training Training for community GPs is provided by tertiary hospital specialists and developed by the project’s principal investigators along with an Expert Committee. The Expert Committee consists of ten experts from relevant professional fields including Endocrinology, Cardiology, and Ophthalmology as well as 20 endocrinologists from tertiary hospitals.

Training modules include group training class, interactive workshops and specialist outpatient services in the community. Specialists assist GPs in DiabetesVoice 37

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clinical practice twice per week for the entire trial.

A total of 150 GPs are participating in the training programme. Specialists supervise a specific community and a fixed number of GPs, who in turn are responsible for a fixed number of participants.

All levels of the trial organisation are linked via a web-based electronic monitoring platform, allowing participant records (such as HbA1c data) to be shared quickly and easily. The web-based platform also facilitates the rapid flow of information and professional feedback from specialists to GPs and patient participants.

participants with type 2 diabetes. Five urban districts were chosen over suburban regions because the urban economic conditions offer a sufficiently stronger medical infrastructure to carry out the study. Participants were randomised into either the intensive-care group or the control group.

Trial management To achieve good target control, management adjustment strategies on guidelines,9 continued to be applied by a collaborative team consisting of participating tertiary hospital specialists and the programmeâ&#x20AC;&#x2122;s community GPs. Further, to ensure Patient recruitment the integrity and quality of data collection, a superGreater 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 recare 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

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every four months. The researcher meetings provide: updated follow-up data, summary of endpoint events, lectures by the principal investigators, and GP generated oral presentations.

Preliminary results By analysis, 9.4% in the intensive-care group and 8.4% in the control group met all the HbA1c, BP, and LDL-C target values at the baseline (p=0.35).

People with diabetes who were treated by community GPs in training showed a significant improvement 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.

Ming-xia Yuan and Shen-yuan Yuan Ming-xia Yuan is Chief-Physician and Vice-Director at the Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.

Shen-yuan Yuan is Professor at the Department of Endocrinology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.

BRIDGES project Promotion of community-hospital integrated model for diabetes management in Beijing

Acknowledgement This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

To date, the community-based care system has proved to be an effective approach, although results will not be complete until the study ends in December 2014.

Public health significance Optimal target control of glycaemia, BP and lipids should significantly reduce the risk of chronic complications, improve quality of life for people living with diabetes and lessen the financial burden for diabetes care. However, the challenge to maintain continuous optimal diabetes management during the long-term is considerable.

Sustainability plan Results and experiences gained in this study will be used on a wider scale in Beijing and in more regions in China. Further exploration and followup studies across larger communities will continue for the next five years, ten years or longer.

References 1. Ning G, Zhao W, Wang W, et al. Prevalence and control of diabetes in Chinese adults. 2010 China Noncommunicable Disease Surveillance Group. JAMA 2013; 310: 948-59 2. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Engl J Med 2010; 362: 1090-101.

3. Hu FB. Globalization of Diabetes. The role of diet, lifestyle, and genes.

Diabetes Care 2011; 34: 1249-57.

4. G oyder EC, Drucquer M, McNally PG, et al. Shifting of care for diabetes from secondary to primary care, 1990-5: review of general practices. BMJ 1998; 316: 1505-6.

5. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000; 321: 405-12.

6. Pan C, Yang W, Jia W, et al. Management of Chinese patients with type 2 diabetes, 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.

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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 have diabetes in Brazil, the fifth largest country in the world.

Prevalence of diabetes in 2013 exceeded 9% and it is estimated that diabetes is responsible for more than 80,000 deaths each year.1 The increase in life expectancy of the global population, combined with a poor diet and a sedentary lifestyle are contributing to higher rates of type 2 diabetes and Brazil is no exception.

Maintenance of near normal blood glucose levels is crucial to the prevention of the microvascular and macrovascular complications of diabetes. Actively involving people with diabetes in their own care is the cornerstone of good diabetes management.

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This requires effective, ongoing education and support, and should match the individual’s ability and capacity to learn.

Including individual lifestyle and culture in diabetes education is also important for success.

For various reasons, including mobility challenges, there is frequently poor adherence to lifestyle modification activities.

The Brazilian Health Ministry2 has proposed a goal to train healthcare professionals and thereby transform and increase knowledge in current diabetes care practice. The Health Ministry is seeking development of competencies in the field of healthcare communication – essential for establishing a valued

link between professionals and healthcare service users.

The study This BRIDGES project team organised diabetes education into multiple strategies: operative groups, home visits and telephone monitoring, all of which were designed to enhance self-care practices related to diet and physical activity. The project was carried out in four “basic health units” in Belo Horizonte, Brazil with 240 participants living with type 2 diabetes.

Professional workshops Educational workshops were strategically chosen for the development and training of participating healthcare professionals.

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The workshops were designed to update best practices about diabetes care and adaptation of healthy lifestyle habits. A problem-posing methodology was used in tandem with healthcare participant experience and knowledge as a starting point.

During the workshops, discussions addressed educational practices and knowledge about diabetes, nutrition, and physical activity. The healthcare participants highlighted their experiences in caring for people with diabetes, focusing on defining and differentiating professional

conduct. They were also encour- people living with diabetes was aged to reflect about self-care ed- also encouraged. ucation. Each workshop lasted approximately two hours.

In group education for behavioural interventions, the particiThere was a marked interest in pants discussed primary needs: the importance of teamwork to dietary management, exercise, promote successful education taking medication as prescribed, activities for people living with monitoring of blood glucose diabetes. The professional work- levels and knowing what action shops emphasised the develop- to take when problems arise. ment of a systematic approach to Participants agreed that helping diabetes education as well as the people prioritise diabetes and asimportance of respecting indi- sume co-responsibility for behavvidual needs, values and beliefs. iour change associated with diet Additionally, the need to use and physical activity were crucial appropriate language to address components for success. Various different management themes for diabetes themes (Figure 1) were presented to groups of thirteen by a nurse and a dietician through interactive and recreational activities. Healthcare professionals (physician, nurse, physiotherapist, occupational therapist and dietician) were instructed on posture, language and positive communication.

Participants being taught how to stretch and exercise at home

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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 professional trainees began. It was assumed that real-life educational interventions utilised as part of the programme would provide a greater opportunity for firsthand professional experience.

Home visits were scheduled to

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help the professional trainees better understand how to advance improved behaviour change and self-management skills for the local population with diabetes.

Success in changing specific aspects of healthcare professional behaviour was intended to promote more efficient and effective consultations. For guided diabetes self-management to progress, a positive healthcare provider and patient relationship has shown to be a key factor. Here was an opportunity to observe the effect of professional diabetes educational training on the health status of people living with diabetes.

The home visits enhanced the development of a bond between people with diabetes and the healthcare professional trainees in part based on the group training experience. Visiting the individual participants living with diabetes in their home environments gave the trainees an opportunity to provide diabetes guidance with a deeper understanding of individual circumstances. Home visits also provided diabetes education to people with limited access to primary healthcare services.

Professionals were trained to use the Conversation MapTM for home visits, which is a highly visual and interactive diabetes educational tool created by Healthy Interactions in collaboration

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Figure 1. Diabetes education group.

THEME Healthy nutrition

IMPORTANCE ■ Food plan

FACILITATING TECHNIQUES ■ Exchanging recipes ■ Tasting

Practicing self-care and developing autonomy

Changing lifestyles

■F ood record

■ Encouragement of self-care practices

■ Reading texts and reflecting on them

■ Acceptance of the disease

■ Writing poems

■ Health promotion

■ Recreational dynamics

■ Physical activity

■ Group dynamics

■ Proper diet

■ Presentation of objects

■ Autonomy

■ Writing poems

Belo Horizonte-MG, 2012

with the International Diabetes Federation, and supported by Lilly Diabetes. The Conversation MapTM visual is a 3-foot by 5-foot colourful picture or metaphor for teams to navigate during diabetes sessions. The Conversation MapTM education tools are aligned with the patientcentred model, which focuses on empowerment, independence and individually defined needs.

It enables participants to integrate concepts of diabetes and relate health information from personal experience, resulting in a greater awareness and acceptance of changing needs for life with diabetes.

Health professionals were also trained to use telephone monitoring as a method to encourage adherence to daily treatment regimens as well as help investigate personal difficulties with self-care practices. Teaching people with diabetes how to prevent acute and chronic complications of diabetes, and helping them decide the best way to improve metabolic control was emphasised. Many participants used the telephone calls as an opportunity to express personal challenges with their need to do more physical activity and adhere to dietary restrictions.

Some of the people with diabetes expressed feelings of anguish, too.

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Practitioners utilised this time to better connect to the emotions people with diabetes often have and develop trust, essential for good practice.

The idea of combining several educational interventions, such as monitoring physical activities gave people with diabetes a choice for engagement. The opportunity for alternative contact outside working hours Summary In summary, preparing health- and avoiding unnecessary visits care professionals to be motivat- to the healthcare service proved ed, skilled and better equipped to to be beneficial. help people overcome the barriers associated with improving The programme was effective at diabetes self-care appears to be changing a range of behaviours a promising strategy. Custom associated with diabetes and bettailoring is critical and specific ter glucose control, including: details for success include pro- ■ I mprovement of dietary habits and physical activities. viding the necessary conditions for learning, facilitating group ■ E nhanced diabetes knowledge meetings with short intervals, and awareness. and constant encouragement.

■M ore positive attitude attached to living with diabetes.

The expansion of behavioural interventions in the educational The effectiveness of the diabeprogramme fulfilled the objective tes education programme study of actively engaging healthcare was executed largely by theoretiprofessionals with diabetes. cal and methodological choice,

centred on a dialogical and reflective educational practice for diabetes healthcare professionals.

It is expected that the results of this study can be utilised by additional healthcare units in Brazil.

Every attempt should be made to identify ways to improve control of diabetes through the enhancement of self-care activities.

Heloisa de Carvalho Torres, Ilka Afonso Reis and Mariana Almeida Maia Heloisa de Carvalho Torres is Professor at the Nursing Department in Universidade Federal de Minas Gerais in Belo Horizonte, Brazil.

Ilka Afonso Reis is Professor at the Statistics Department in Universidade Federal de Minas Gerais in Belo Horizonte, Brazil.

Mariana Almeida Maia is Nurse at the Universidade Federal de Minas Gerais in Belo Horizonte, Brazil.

BRIDGES project Evaluation of the diabetes education programme for people with type 2 diabetes in primary care, Belo Horizonte, Brazil

Acknowledgement This project is funded by BRIDGES. 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.

Participants learning about healthy diet

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2. Ministério da Saúde. Plano de Ações Estratégicas para o Enfrentamento das doenças crônicas não Transmissíveis (DCNT) no Brasil, 20112022. Ministério da Saúde. Brasil, 2011.

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Education to change the course of diabetes in the Caribbean Errol Morrison, Shelly McFarlane, Cliff Riley and Novie Younger-Coleman

The International Diabetes Federation (IDF) estimates that over 382 million people currently live with diabetes globally. This accounts for 11% of the adult population and is projected to increase to near 592 million by 2035.

The data reveals that over 80% of persons living with diabetes are from developing countries. The IDF estimates that one in every ten adults in the North America and Caribbean Region has diabetes.1 In 2013, over 178,520 adult Jamaicans (20-79 years) were reported to have diabetes with prevalence rates estimated at 10.6%.

This represents a 2.8% increase between 2008 and 2013.2 It is well known that diabetes and its complications are a leading cause of adult morbidity worldwide. The increasing prevalence 44

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of diabetes and its associated complications present significant socio-economic, medical and scientific challenges. Additionally, the aetiology and pathophysiology of the disease are markedly different among people living with diabetes across the region and therefore dictate different prevention strategies, diagnostic screening and treatment methods. Currently diabetes is the third leading cause of death in the Caribbean.3 This is further compounded by high net migration rates of healthcare professionals in the region, particularly nurses.

Implementing culturally sensitive diabetes education This BRIDGES supported project seeks to implement a culturally sensitive, peer/lay diabetes education programme for

adults with type 2 diabetes in six Caribbean countries. The programmeâ&#x20AC;&#x2122;s primary objective is to empower community health workers (CHWs) with essential tools in a region where such diabetes patient educational services are not typically provided. The effectiveness of the programme is expected to enhance individual self-management skills, thereby improving blood glucose control for people living with diabetes in the participating countries. The programme is utilising the newly developed and culturally specific Community Empowerment through Diabetes Self-Management Education Training guideline.4 Further, the long-term goal of the study in conjunction with the ministries of health for participating countries and the Pan American

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Health Organization (PAHO) is 1. Train and educate six country to increase diabetes awareness, coordinators and 12 CHWs. knowledge and improve selfUsing the peer/lay education care behaviours of people with curriculum, the CHWs carry diabetes in the region. The study out the community based diaprogramme will be completed in betes education to participants February 2015. living with diabetes.

2. Measure progress by monitoring Currently diabetes HbA1c, waist circumference (adiposity), and blood pressure. is the 3rd leading Participants living with diabetes cause of death in completed standardised the Caribbean. self-care and quality of life Conducted in six Caribbean counquestionnaires, which were also tries (Jamaica, Grenada, St Lucia, part of the evaluation process.

Barbados, Belize and Antigua), 3. Empower regional communithe study will test the applicabilties and CHWs with training to ity, versatility and effectiveness increase awareness and knowlof the educational programme. edge of diabetes and self-care behaviours.

The effectiveness of the lay programme will be determined by evaluating the impact on patient Study methodology participant outcomes. Overall, To date, the project has completed the project aims to improve and the training of the CHWs and is increase the level of knowledge and awareness of diabetes and self-management at the community level. Other specific activities and objectives include:

in the final stages of assessing the curricula. The programme intervention has been delivered to 115 study participants living with diabetes. Demographic data and baseline characteristics, including HbA1c, blood pressure, and waist circumference were obtained from a total of 237 participants (115 intervention and 122 control).

Quality of life and self-care questionnaires were administered and evaluated to all participants at baseline. Additionally, all 12 CHWs have been responsible for conducting data entry for patient demographic and biomedical measures with the tablets provided by the study programme. This information is uploaded each week to a password-protected folder and transported from the field in a secure manner to the coordinating site, where a

Low-cost educational activity: footwear demonstrations in Antigua

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statistician downloads the field Barbados) showed no statistically data for analysis. significant difference in change from baseline. Complete data will The programme curriculum is not be available until the project’s based on four modules: Diabetes end in February 2015.

Basics and Medication; Nutrition and Psychosocial Issues; It is important to note that across Physical Activity; and Diabetes all six participating countries subComplications. Currently, a jects with diabetes who received major proportion of the pro- diabetes education stated that gramme’s CHWs from each of the they are grateful for the support participating countries has suc- because they have been “strugcessfully implemented 75% of the gling” to manage diabetes for curriculum for people with diabe- many years. One comment from tes. The self-care questionnaires a male participant in St Lucia readministered to the participants flects the toll type 2 diabetes has with diabetes are maintained on the uninformed individual, with excel workbooks, unique to “Since I was enrolled last October, each participant. Each CHW has I lost two toes; I wish I knew then conducted at least two sessions what I have learned from the first with their respective intervention session. I would have been in betgroups covering Modules 1 and 2 ter control of my 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 adaptacue cards were adapted from the tion for the CHWs use of tablets Conversation MapTM Education provided to facilitate real-time data tools. Simple low-cost activities, entry at the point of collection. such as footwear demonstrations Additionally, the CHWs showed and presentations related to mod- a preference for collecting data on ifying food portions, have been paper rather than inputting the employed by the facilitators for data on the tablets. This is a clear demonstrative purposes. indication that the transition to electronic devices from the paper and pen approach among CHWs Preliminary results Preliminary results based on pri- can pose challenges or lead to demary and secondary outcomes lays in data entry and analysis. The for 38 participants in three coun- transition is being addressed via tries (Antigua, Grenada, and monthly team meetings via Skype.

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Errol Morrison, Shelly McFarlane, Cliff Riley and Novie Younger-Coleman Errol Morrison is President of the University of Technology, Kingston Jamaica and President of the Diabetes Association of Jamaica.

Shelly McFarlane is Research Fellow in the Epidemiology Research Unit, Tropical Medicine Research Institute at University of the West Indies, Mona, in Kingston, Jamaica.

Cliff Riley is Associate Professor and Associate Dean of Graduate Studies at the College of Health Sciences, University of Technology, Kingston Jamaica and Board Member at the Diabetes Association of Jamaica.

Novie Younger-Coleman is Biostatistician in the Epidemiology Research Unit, Tropical Medicine Research Institute, University of the West Indies, Mona, Kingston, Jamaica.

BRIDGES project Implementation of a culture sensitive peer /lay diabetes education program for adults with type 2 diabetes in six English speaking Caribbean countries by 2015

Acknowledgement This project is supported by BRIDGES. 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. Wilks R, Younger N, Tulloch-Reid M, et al.

Jamaica Health and Lifestyle Survey 2007-8.

Tropical Medicine Research Institute, University of the West Indies. Mona, 2008.

3. L owe H. Caribbean Herbs for Diabetes Management: Fact or Fiction? Pelican Publishers. Kingston, 2012.

4. P an American Health Organization (PAHO), Diabetes Association of Jamaica (DAJ), Ministry of Health – Jamaica. Community Empowerment through Diabetes SelfManagement Education Training. 2012.

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Health coaching increases self-esteem and healthy smiles Ayse Basak Cinar and Lone Schou

Promoting oral health is essential in order to prevent and reduce the negative consequences of type 2 diabetes and to maintain good health.1 Periodontal inflammation in early old age tends to be associated with mortality in older age2 and people with diabetes are more likely to have periodontal disease than people without diabetes.3 Besides sharing common biological mechanisms, type 2 diabetes and oral diseases,4,5 also called lifestyle diseases, share the same lifestyle related risk factors such as poor dietary habits or smoking.

Project overview This BRIDGES project aims to assess the impact of Health Coaching (HC) on diabetes and oral health

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management among people with type 2 diabetes in Turkey and Denmark. In principal, HC focuses on transformation and maintenance of positive health behaviours by person-centred empowerment. It is directly associated with positive lifestyle outcomes including smoking cessation and improved management of obesity and diabetes.

HC creates awareness about individual values and empowers people to transition towards a healthy lifestyle. The HC process enables people with diabetes to adapt and change health behaviours for long-term compliance. In this study, coaching focused on empowerment for daily diabetes health-related practices, and compliance, and oral DiabetesVoice 47

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health related self-care regimes. Health-related capacity skills, self-monitoring skills and taking responsibility for health and quality of life were also targeted. Participants set up their own goals and action plans with supervision of their health coach. Coaching sessions were individualised and tailored to expectations, challenges, and progress of the person living with diabetes.

The health coach focused on empowering people with diabetes for daily health-related practices.

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 article, represent gratitude for the HC opportunity and an increased sense of empowerment. One 6069 year-old participant living with diabetes for 14 years discussed how he had improved his lifestyle habits, but wished for regular oral health service.

Another participant in her 50â&#x20AC;&#x2122;s who has lived with diabetes for 12 years expressed how the coaching had given her a fresh start.

consent and filled out questionnaires including background, psychosocial and behavioural information. The last current medical reports (HbA1c, fasting blood glucose, HDL, LDL, triglyceride) were drawn from the hospital.

Following the oral examination, participants were allocated to HC or formal Health Education groups.

The intervention included two phases (initiation 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 At the baseline visit, participants provided informed

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Participants set up their own goals and action plans, focusing on improvement of lifestyle and clinical DiabetesVoice 49

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measures, under the supervision of the coach. Each coaching session was utilised as the foundation for the next coaching session, and influenced progress towards the achievement of target goals. Duration for face-to-face coaching sessions was between 2060 minutes. Sessions covered needs, expectations, challenges, and progress of the person living with diabetes. Telephone monitoring also supported progress of the participants.

A Wheel of Health (Figure 1) was administered during the initial HC session to explore values, establish priorities, and set goals. Participants reported how satisfied they were (0%-100%) recently and how satisfied they would like to be in the future. Participants were then asked to define each domain on the Wheel of Health and choose a specific goal and action plan. Although the coach regularly asked participants to explore goals in relation to oral health and diabetes care, participants were free to select any additional goals such as stress management.

Figure 1. An example for Wheel of Health, each domain defined by person living with diabetes

100%

100% Physical Exercise

Diet/Weight

0% Oral Health

100%

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Examples: Stress management Socialising

The Health Education group received standard lifestyle advice referring to oral healthcare practices, diet and physical exercise. One dentist provided Health Education interventions and group participants were supported by the same educational brochures as the HC group.

Qualitative outcome variables and results After cessation of the intervention, participants in the HC group were asked to answer semi-structured questions to evaluate the HC intervention and its impact on their life. A selection of those are featured below: By the year 2012, Turkey 60-69 aged male with a diabetes history of 14 years “I have adopted healthy eating habits and regular tooth brushing. I didn’t know how oral health was important for my diabetes. Additionally I lost some of my teeth and I suffered from bleeding of my gums. I wish there was an oral healthcare service at diabetes polyclinics.”

50-59 aged female with a diabetes history of 2 years “I learned everything about oral health and diabetes management by coaching sessions. My psychology is much better. My life has completely changed in a positive direction. Before the coaching sessions, my life was a misery and hopeless.”

50-59 aged male with a diabetes history of 14 years “My self-esteem has increased by the coaching sessions. I felt and recognised that I was worthy as a person during these sessions. All the negative thoughts about living with diabetes were erased by these sessions.”

By the year 2014, Denmark 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 rebuilt my life.”

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70-75 aged male with a diabetes history of 10 years “I am now more physically active (going swimming, walking) and drinking more water and less alcohol.

I changed and adopted these new habits because I have recognised that I want to do better during the coaching sessions. I changed the wrong behaviour and replaced it with the healthy one.”

Health Coaching may be used as an effective common health promotion approach for better management of diabetes and oral health.

Summary Dentists, physicians and diabetes educators undergo extensive education and training to learn “what is best” for people with diabetes. However, traditional 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 oral health.

Ayse Basak Cinar and Lone Schou Ayse Basak Cinar is Assistant Professor at Section 1, Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.

Lone Schou is Head of Section 6 (Section for Global Oral Health), Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.

BRIDGES project Smile healthy with your diabetes: a translational randomized trial of culturally specific health coaching intervention for patients with diabetes (phase II Denmark)

Acknowledgement We express our deepest thanks to our collaborators in Turkey (Prof Nazif Bagriacik, Asst Prof Mehmet Sargin, Head Nurse Sengul Isik, Prof Inci Oktay) and Denmark (Christian Dinesen, Prof Maximilian de Courten). Many thanks are due to our study patients for their participation and cooperation.

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 Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 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. S andberg 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. G enco RJ, Grossi SG, Ho A. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. J Periodontol 2005; 76: 2075-84.

5. N ishimura F, Kono T, Fujimoto C. Negative effects of chronic inflammatory periodontal disease on diabetes mellitus. J IntAcadPeriodontol 2000; 2: 49-55.

6. C inar 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. C inar 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]

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Education helps decisionaffordable, healthy food Bettina Tahsin

Barriers to successful diabetes self-management in low-income populations include reduced access to healthy food along with limited awareness of healthy eating. In the United States, it is a public health paradox that those at the highest risk for obesity and type 2 diabetes are the most food insecure, meaning unable to consistently afford or have access to enough healthy food to meet their nutritional needs.1 One challenge faced by healthcare providers serving low-income populations is reducing the health risks posed by the consequences of these barriers. Can education and counselling empower lowincome patients with type 2 diabetes to make healthier food choices within their means and improve their health?

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Control of type 2 diabetes is heavily influenced by dietary choices. A frequent complaint of low-income individuals with diabetes is that by the end of the month all they can afford are cheap high-carbohydrate snack foods. Without money left for healthy, low-carbohydrate, lowcalorie vegetables, this dilemma is a recipe for obesity and poor diabetes control. Can targeted, additional diabetes education help deter this trend?

cally targeted to the needs of a low-income, ethnically diverse population in the US suffering from obesity and uncontrolled type 2 diabetes.

The core principles of diabetes nutrition management are universal: carbohydrate and portion control, meal timing and coordination with medications, and weight management. What that actually looks like on the plate and how that is managed day-today is unique to each individual.

Control of type 2 Food and cultural preferences, diabetes is heavily and ability to buy appropriate foods that will keep people with influenced by diabetes healthy must be condietary choices. sidered. Our study focused on Study these universal principles while The study focuses on imple- also making it very specific to menting a diabetes nutrition the needs and challenges of our education curriculum specifi- population.

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making for and control

The study setting is the diabetes clinic and lifestyle centre in the Fantus Clinic, the primary outpatient clinic of the Cook County Health and Hospitals System (CCHHS), located in Chicago, Illinois, USA. CCHHS is a network of hospitals and community clinics servicing a primarily lowincome, ethnically diverse population at high risk for developing chronic diseases. Those overweight or obese make up 80% of the patient population. Ethnically, close to half of the CCHHS patient population is African American, one third Hispanic and the remaining reflective of Chicago’s urban diversity.

participants with type 2 diabetes lose weight and better manage their diabetes. Participants in the study were patients seen in the Fantus clinic’s Network Diabetes Program (NDP), a diabetes clinic devoted to helping those with uncontrolled diabetes achieve The purpose of this study is to greater diabetes control. NDP is evaluate whether additional class- staffed by endocrinologists, nurse es in nutrition and basic cook- practitioners, nurses, registered ing could help obese, low-income dieticians, and pharmacists, all

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with specialised diabetes training, experience, and certification.

The site for the intervention classes is the Therapeutic Lifestyle Center (TLC), which is adjacent to the diabetes clinic. Conducting the intervention in the lifestyle centre is one of the advantages of the study programme compared to other hospital and community settings in low- and middleDiabetesVoice 53

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income countries. Our lifestyle centre includes a virtual kitchen and a mock grocery store plus additional classroom and exercise areas. While the study focused exclusively on nutrition, exercise was encouraged as part of a healthy lifestyle.

In total, 98 patients who have type 2 diabetes and an HbA1c ≥ 7% and obese (BMI ≥ 30) are being recruited from the diabetes centre.

Participants are randomised into either the control group, who receive their usual care at the diabetes centre, or the intervention group, who receive their usual care plus the additional classes.

Each group of eight participants going through the intervention attends a series of eight one-hour classes over the course of six months, followed by a two-hour grocery store tour. Classes are bi-weekly the first two months and then monthly for the next four months. At the end of the six months, participants are assessed for weight, blood glucose control, and other markers of overall health.

The eight classes, taught by a registered dietician/certified diabetes educator, follow the basics of diabetes nutrition management and focus on foods commonly eaten by the participant population. In this study to date, 67% are African American, 14% Hispanic, 11% Asian, and 8% White. The classes include: 1. L abel reading for diabetes teaches which foods raise blood glucose, appropriate portion sizes, and how to assess food content by using the nutrition facts label.

2. Meal planning for diabetes discusses how the Plate Method, which includes half a plate of non-starchy vegetables, quarter plate of starchy foods, quarter plate of protein, plus a fruit and milk, can be used to both accommodate dietary preferences while also supporting good blood glucose control.

3. Eating to lose weight emphasises appropriate portion control and dietary strategies that will provide a healthy plate of food and also promote weight loss.

While the study focused exclusively on nutrition, exercise was encouraged as part of a healthy lifestyle.

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4. Eating on a budget translates dietary principles into costeffective strategies for eating healthy on limited means.

5. Feeling full on less covers the benefits of eating whole foods for more fibre and greater satiation.

6. Heart-healthy fats addresses dietary that support good heart health, a primary concern in diabetes.

7. Eating to control blood pressure combines both sodium restriction and increasing vegetables for more potassium to improve hypertension.

8. Eating out applies the strategies already discussed to maintain healthy dietary control while dining out.

A grocery store tour at a budgetconscious supermarket concludes the programme and serves to put into practice healthy food selection on a budget.

Preliminary results To date, three groups of the planned six groups to participate in the intervention have already completed the study and several interesting results have emerged.

Compared to their control group counterparts, the intervention group participants have improved blood glucose control, as measured by their HbA1c results. For instance, participants in one of the intervention groups decreased their average HbA1c by June 2014 • Volume 59 • Special Issue

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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 diabetes make healthier food choices within their means can provide positive outcomes and a chance for better futures.

Bettina Tahsin

People with diabetes learning about healthy and unhealthy food choices, Chicago, USA

0.7% compared to a decrease of 0.2% in participants in its paired control group. Those intervention patients with their diabetes solely managed by oral medications also achieved greater weight loss with an average 9.6 kg weight loss versus only 1.2 kg weight loss in its paired control group. However, intervention patients managed on insulin had a more difficult time with weight

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loss, reflecting the challenges of insulin and weight control. But even these patients had improved blood glucose when compared to the control patients, reflecting a better understanding of matching carbohydrate content with insulin dosing.

Overall, participants who consistently attended classes demonstrated better understanding of

Bettina Tahsin is Research Dietician and Diabetes Educator at Cook County Health and Hospitals System, Chicago, Illinois, USA.

BRIDGES project Medical lifestyle centre community healthy eating initiative to improve diabetes outcomes

Acknowledgement The project’s principal investigator is Leon Fogelfeld, MD, the Chair of the Division of Endocrinology, Cook County Health & Hospitals System, Chicago, Illinois, USA. The author is the study coordinator and educator for this project, which is supported by BRIDGES. This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 1. S eligman HK, Jacobs EA, Lopez A, et al.

Food insecurity and glycemic control among low-income patients with type 2 diabetes. Diabetes Care 2012; 35: 233-8.

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Everything you ever needed to know about gestational diabetes Valerie Holmes and Claire Draffin

Gestational diabetes mellitus (GDM) is glucose intolerance that begins or is first identified during pregnancy. GDM is associated with increased perinatal morbidity.1 In the long term women with GDM have a seven-fold risk of developing type 2 diabetes in later life compared to pregnancies with normal blood glucose levels.2 Recent research has centred on investigating the effect of treating GDM on pregnancy outcome, and defining the diagnostic criteria for GDM. This research has led to the recent recommendations from the International Association of Diabetes and Pregnancy Study Groups (IADPSG) for diagnosis of GDM.3 Prevalence of GDM has increased in recent years, along56

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side an increased prevalence of type 2 diabetes in the background population. Additionally, the adoption of IADPSG criteria has even further increased GDM prevalence almost three-fold in some populations.4 A need for novel educational resources Women currently diagnosed with GDM are referred to antenatalmetabolic clinics for specialist medical and obstetric care from multi-disciplinary teams. Much of the information a woman with GDM receives is direct from healthcare professionals during her initial consultation. Apart from some locally produced leaflets, very few user-friendly supplementary materials are

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available to women newly diagnosed with GDM. Patient education is a crucial step and a better understanding of GDM will influence 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: ■L earn about the associated risks of GDM to pregnancy and for the future.

■A dapt to a GDM specialised diet and lifestyle.

■ Self-monitor blood glucose and meet individualised targets.

■A dminister insulin, if necessary.

Furthermore, changes to the diagnostic criteria for GDM impact the workload of diabetes teams caring for women in settings where services are already stretched. Novel approaches are urgently needed to support healthcare professionals in the delivery of education to women diagnosed with GDM during pregnancy. An educational tool such as a DVD will help ensure that women with GDM adapt to their new diagnosis as quickly as possible, reduce stress and anxiety and re-establish some semblance of normality. This type of information should be driven by the needs of the target audience.

in partnership with women diagnosed with GDM and healthcare professionals. We hypothesise that this DVD will alleviate anxiety and improve measure of glucose homeostasis for women with GDM during pregnancy and provide diet and lifestyle advice for the prevention of type 2 diabetes in later life.

Study design This is a two-phase project. Phase one was the development of the educational DVD under the direction of healthcare professionOur hypothesis als adhering to National Institute The hypothesis of this project is for Clinical Excellence guideto develop an educational DVD lines.5 Input from women with

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GDM was incorporated to ensure the DVD meets the needs of its target audience. Focus groups of women with GDM explored their anxieties, needs and knowledge in order to direct the tone, key messages and format of the DVD. Findings from focus groups confirmed that the development of user-friendly educational resources was warranted and suitable for women with GDM from different ethnic backgrounds. In particular, women were keen for a resource such as a DVD to be available during the early stages of diagnosis when they have so many unanswered questions.

They valued the documentary DiabetesVoice 57

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production style, which included real women living with GDM telling their stories. Focus group participants felt this helped them realise that they were not alone.

Women were keen to hear the views of healthcare professionals and wanted more information about what having gestational diabetes means for the baby.

They also wanted to know what impact it might have on their delivery as they felt this was not always explained in pregnancy clinics. It was important to women that the resource focused on the benefits of starting insulin, allaying fears in relation to administering and tolerating the drug. Women were also eager to learn about the future risk of type 2 diabetes.

Feedback received from women who watched the DVD has been positive.

Women with GDM participated in the development phase of the DVD, and viewed the prototype in focus groups. Their feedback was incorporated into the final editing of the DVD. The resulting 46-minute DVD features five women with GDM sharing their views and experiences alongside an evidence-based commentary.

the impact of this DVD on maternal anxiety and stress, glycaemic control, diabetes knowledge, and maternal and neonatal outcomes in a multicentre randomised controlled trial. The trial commenced in January 2013 in three antenatal metabolic clinics in Northern Ireland and Manchester. Women who had just been diagnosed with GDM for the first time were invitThe DVD consists of three main ed to participate. They were ransections: domised to one of two treatment ■W hat is gestational diabetes? groups: usual care plus DVD or ■L iving with gestational diabetes usual care only. The study has ■L ife after gestational diabetes now fully recruited, with 150 women enrolled. Follow-up is The DVD also provides addi- ongoing and results will be availtional features offering women able by the end of 2014. step-by-step guidance on how to monitor blood glucose; how to While we do not have results inject insulin; how to eat healthy from the trial to report as yet, foods and how to determine feedback received from women whether weight-loss is required who watched the DVD has overafter pregnancy. The DVD has all been positive: been produced in English, Urdu, ■ “Thought DVD was fantastic, Somali and Arabic. Phase two of very glad I took part.” 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 clinic 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 participants and staff that the GDM educational DVD has filled a knowledge gap, and that it helps

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women with GDM better understand their condition and management of GDM. Clinic staff also commented that the DVD is a valuable resource to assist with patient education, and one that could be used for group education sessions.

Public health significance This project has substantial public health significance, particularly in the context of rising prevalence of GDM and type 2 diabetes globally. Women with GDM have an increased risk of developing type 2 diabetes in later life.2 Diagnosis of GDM in pregnancy presents both women and healthcare professionals with a golden opportunity to intervene in the progression to diabetes.

However, despite clear guidelines on postpartum screening and follow-up,6 uptake of postpartum glucose testing is low, due in part to low attendance at follow-up appointments. Providing women with comprehensive information on long-term lifestyle modification during the antenatal period may maximise the potential presented by GDM. It may also encourage follow-up in the postnatal period.

Sustainability After the project completion, we envisage that the DVD could be “adopted”, reproduced and further translated for use in healthcare settings in different

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countries. This tool is suitable for use by patients for individual support, or may be considered as an educational aid for group education. Adaption to other media formats such as podcasts and webcasts could maximise its impact on women with GDM. Knowledge transfer following a project such as this is key if we are to maximise the impact of the research. In a sister project we have recently converted our preconception counselling DVD to a website platform (http://go.qub. ac.uk/womenwithdiabetes). Here the goal is to increase awareness of the importance of planning for pregnancy for all women with diabetes, and provide guidance about preconception care for those women planning a pregnancy (funded by Diabetes UK and Public Health Agency, Northern Ireland). We envisage a similar approach on completion of this project.

Valerie Holmes and Claire Draffin Valerie Holmes is Senior Lecturer at the Centre for Public Health, Queen’s University Belfast, UK. Claire Draffin is Research Fellow at the Centre for Public Health, Queen’s University Belfast, UK.

BRIDGES project The development of an educational DVD for women with gestational diabetes: “Gestational diabetes: things you need to know (but maybe don’t)”

Acknowledgement The authors are the principal investigator (Valerie Holmes) and the researcher (Claire Draffin) of this project. Co-investigators on this project are: Prof Fiona Alderdice, School of Nursing and Midwifery, Queens University Belfast, Belfast, UK; Prof David McCance, Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK; Prof Chris Patterson, Centre for Public Health, Queen’s University Belfast, UK. Dr Michael Maresh, St Mary’s Hospital, Central Manchester University Hospitals NHS Foundation, Manchester, UK; and Prof Roy Harper, South Eastern Health and Social Care Trust, Ulster Hospital, Dundonald, UK. This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 1. C rowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352: 2477-86.

2. Bellamy L, Casas JP, Hingorani AD. Type 2 diabetes mellitus after gestational diabetes: a systematic review and metaanalysis. Lancet 2009; 373: 1773-9.

3. International Association of Diabetes and Pregnancy Study Groups Consensus Panel.

International Association of Diabetes and Pregnancy Study Groups Recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010; 33: 676-82.

4. W augh N, Royle P, Clar C, et al. Screening for hyperglycaemia in pregnancy: a rapid update for the National Screening Committee. Health Technol Assess 2010; 14.

5. N ational Collaborating Centre for Women’s and Children’s Health (Great Britain), National Institute for Clinical Excellence. Diabetes in Pregnancy: Management of Diabetes and its Complications from Preconception to the Postnatal Period. RCOG Press. London, 2008.

6. S jögren B, Robeus N, Hansson U. Gestational diabetes: a case-control study of women’s experience of pregnancy, health and the child. J Psychosom Res 1994; 38: 815-22.

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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 worldwide and the burden associated with diabetes complications poses a serious threat to global health and national health systems. Austria, a country of 8.47 million in Central Europe, is estimated to have a diabetes prevalence of 9.27%.1 Austria had an estimated 4,705 deaths due to diabetes in 2013; a rate of 12 citizens a day.1 Spending on diabetes as a percentage of Austria’s total health expenditure was 10% in 2011.2 The care of people with type 2 diabetes in Austria either takes place within the framework of existing disease management programmes (DMPs) or according to 60

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the practice of each doctor’s office.

To what extent diabetes services are offered may vary in accordance with the regional particulars as national regulations, medical fees, and availability of services.

Disease management and modern drug treatments have improved diabetes care but current therapies are far from effectively preventing micro- or macrovascular complications. There is a strong need to intensify lifestyle intervention and motivate patients to better manage diabetes.

peer support programme to improve diabetes self-management and achieve lifestyle changes, such as increased physical activity. World Health Organization (WHO) acknowledges “peer support” as an economical, flexible intervention for improving diabetes care and outcomes.3 Peer support models include face-to-face self-management programmes, peer mentorships and community health workers. Peers can provide coaching and leadership and often serve as role models for sustained behavioural change.

Peer support to improve diabetes care The programme The objective of this randomised The peer support programme controlled study is to evaluate a was offered to all patients en-

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rolled in the DMP of statutory health insurance in the province of Salzburg, Austria. Participants were recruited from the offices of local general practitioners. To assure concealment of allocation, all patients were cluster-randomised after completion of recruitment and allocation to groups. The control group received usual care according to the disease management programme.

Groups of eight to ten participants also met to talk about 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 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 group received additional support

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from physicians, diabetes nurse educators, dieticians, clinical psychologists and physical education trainers as required.

cholesterol, HDL-cholesterol, and triglycerides). Other secondary measures included lowering of global cardiovascular risk (UKPDS-Risk-Engine Version The primary outcome meas- 2.0), weight reduction (body mass ure was the difference in HbA1c index [kg/m²]) and self-reported change between intervention and smoking cessation. control groups after two years.

Secondary outcome measures The peer support programme comprised quality of life (EQ-5D- goal was to provide a founda3L index and EQ-5D visual ana- tion for diabetes groups that logue scale) and improved control would continue after the study of cardiovascular risk factors (sys- without further intervention by tolic and diastolic blood pressure, healthcare providers other than creatinine, total cholesterol, LDL- professional support as specified.

Diabetes peer group on a hiking tour in the Austrian Alps

Peer support activity in the Austrian Alps

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Results Of the eligible 77 general practitioner (GP) surgeries, 49 (63.6%) recruited 393 participants fulfilling all inclusion criteria. These participants were assigned to 41 peer groups (21 intervention groups [n=202] and 20 control groups [n=191]). A total of 56 participants withdrew consent before the intervention started.

At follow-up, an intention-totreat analysis revealed stable HbA1c values in the intervention group while a small rise could be seen in controls. The difference between groups was not 62

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significant. We also found no significant improvements in the intervention group compared to controls regarding the majority of the secondary outcomes.

Discussion Group peer support intervention utilised as an additional component of a traditional disease management programme for improving lifestyle behaviours associated with type 2 diabetes self-management is feasible. Theoretically peer support is a very promising approach, but the intervention in this study achieved only

marginally improved HbA1c values compared to the control-group. In addition, the programme did not significantly improve clinical outcomes, risk profile or quality of life after two years of observation. These findings are most likely due to the well-controlled baseline values (e.g. HbA1c 7.0% in both groups), leaving little room for glycaemic improvement.

The control group revealed the same increase seen in the United Kingdom Prospective Diabetes Study (UKPDS)4 and in this regard, stable HbA1c results for the intervention group can be

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interpreted as success. A larger sample size would be necessary to demonstrate this effect to be significant.

Another programme insight was the observed practice by participating GPs to mainly recruit well-controlled patients, even though they had been requested to invite all people with type 2 diabetes, regardless of glycaemic control. Thus, a selection bias of more motivated and better self-managed patients may have occurred. Additionally, the intensity of our intervention might have been too weak to demonstrate an effect on HbA 1c although increasing professional support would have conflicted with the programme’s concept of group based peer support. Our intervention was intentionally based on a lowintensity level of professional support. Due to withdrawal of consent, some groups were smaller than planned with a potentially negative impact on group dynamics. Our continuous contact with peer supporters and participants throughout the study allowed modifications based on participant feedback.

Increasing individual support according to the groups’ needs was also heeded. The programme intervention was offered at no cost to avoid exclusion of potential participants for economic reasons. Participants

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were on average older than 60 years, so external validity is limited and our results are not generally transferable to all diabetes patients.

Conclusion and further action A peer support programme may enable GPs to offer additional support to patients willing to get active and change their lifestyle.

Our intervention was successful in maintaining adequate HbA1c results versus the control group.

While peer support interventions may be seen to respond to the needs of people living with diabetes, so far there is little evidence in the literature proving its effectiveness.5 Peer support interventions may be appreciated by those seeking help and can be used to supplement treatment for patients motivated to improve behaviours related to diabetes.

However, current evidence does not support a major impact of peer support on the outcome of type 2 diabetes.6 Additional studies are needed to determine the effect of peer support in different populations, various peer intervention approaches and long-term outcomes and sustainability.

Tim Johansson, Sophie Keller, Henrike Winkler, Raimund Weitgasser and Andreas Sönnichsen Tim Johansson is Research Fellow at the Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

Sophie Keller is Research Fellow at the Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria.

Henrike Winkler is Lecturer at Paris Lodron University, Salzburg, Austria.

Raimund Weitgasser is Associate Professor and Head of Department of Internal Medicine, Clinic Diakonissen, Salzburg, Austria.

Andreas Sönnichsen is Professor of Family Medicine and Director at the Institute of General Practice and Family Medicine, University of Witten/Herdecke, Germany.

BRIDGES project Effectiveness of a peer support programme in disease management regarding improvement of metabolic control, diabetes management self-efficacy, quality of life and risk profile

Acknowledgement This project is supported by BRIDGES. BRIDGES is an International Diabetes Federation programme supported by an educational grant from Lilly Diabetes.

References 1. I nternational Diabetes Federation. IDF Diabetes Atlas, 6th edn. IDF. Brussels, 2013.

2. I DF Europe, FEND, PCDE, EURADIA. Diabetes The Policy Puzzle: Is Europe Making Progress?

Third edition. http://ec.europa.eu/health/major_ chronic_diseases/docs/policy_puzzle_2011.pdf 3. W orld Health Organization. Peer Support programmes in Diabetes. www.who.int/diabetes/ publications/Diabetes_final_13_6.pdf 4. P rospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998; 352: 854-65.

5. D ale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review.

Diabet Med 2012; 29: 1361-77.

6. S mith SM, Paul G, Kelly A, et al. Peer support for patients with type 2 diabetes: cluster randomised controlled trial. BMJ 2011; 342: d715.

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List of projects supported by IDF BRIDGES Australia ■ Stop diabetes: health related behavior and risk perception in women with lifestyle related metabolic diseases at high risk of diabetes Austria ■ Effectiveness of a peer support programme in disease management regarding improvement of metabolic control, diabetes management self-efficacy, quality of life and risk profile Brazil ■ Evaluation of the diabetes education programme for people with type 2 diabetes in primary care, Belo Horizonte, Brazil Cambodia, the Democratic Republic of Congo and the Philippines ■ Mobile phone Diabetes Self-Management Support: a multi country analysis of its implementation in existing Diabetes SelfManagement Education programmes in the

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Democratic Republic of Congo, Cambodia and the Philippines Cameroon/Guinea ■ Improving access to HbA1c measurement in sub-Saharan Africa Canada ■ Family Defeating Diabetes: a Canadian intervention for family-centred diabetes prevention following gestational diabetes in London, Calgary and Victoria Caribbean ■ Implementation of a culturally sensitive peer/lay diabetes education programme for adults with type 2 diabetes in six Englishspeaking Caribbean countries China ■ Pathway to health: a lifestyle intervention to prevent diabetes ■ Promotion of a community-hospital integrated model for diabetes management in Beijing

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■ A randomized translational study to examine the effects of shared care versus usual care in management of gestational diabetes in a three-tier prenatal care network in Tianjin, China ■ The impact of initiation of an Educational and Preventive Foot Care Centre for subjects with diabetes in Qingdao, China network in Tianjin, China Colombia ■ DEMOJUAN – Demonstration area for primary prevention of type 2 diabetes, JUAN Mina and Soledad, Barranquilla, Colombia Denmark ■ Smile Healthy with Your Diabetes: a translational randomized trial of a culturally specific health-coaching intervention for people with diabetes Ecuador ■ The impact of a demonstrative Educational and Preventive Foot Care Centre for subjects with diabetes in the first-line ambulatory healthcare center “CAA Cotocollao” pertaining to the National Social Security in Quito, Ecuador Egypt ■ The impact of an Educational and Preventive Foot Care Centre for people with diabetes in Alexandria, Egypt Fiji ■ Using community theatre to promote diabetes education and prevention in Fiji Haiti ■ Improving diabetes care in Cap Haitien, Haiti

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India ■A translational randomized trial of a culturally specific lifestyle intervention for diabetes prevention in India ■ Prevention of type 2 diabetes in women with gestational diabetes in urban India – a feasibility study Jordan ■ The Jordan Diabetes Micro-Clinic Project: community ownership and awareness to improve health and wellbeing Mali ■ A randomized trial of an intensive education intervention using a network of peer educators to improve glycaemic control of people with type 2 diabetes in Bamako, Mali Netherlands ■ Cardiovascular risk in people with type 2 diabetes: an innovative dynamic prediction model Pakistan ■ A translational randomized trial of culturally specific and cost-effective life style intervention for the prevention of type 2 diabetes in Pakistan (Pakistan Diabetes Prevention Program PDPP) ■ Bridging the knowledge-to-practice gap to control diabetes in a rural population in Pakistan Philippines ■ Family stress reduction and coping response training among Filipino people with type 2 diabetes in Quezon City, Philippines ■E ffectiveness of a community-based diabetes self-management education programme: a pilot study in San Juan, Batangas, Philippines

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South Africa ■ Effectiveness of a group diabetes education programme using motivational interviewing in underserved communities in South Africa Sri Lanka ■ “Diabrisk-SL”; Evaluation of risk factors in the development of type 2 diabetes and cardiovascular disease in a young urban population in Sri Lanka Thailand ■ A community-based diabetes prevention programme in Thai population Tunisia ■ Lifestyle intervention among overweight and obese schoolchildren: a pre- post-quasi experimental study with control group in Sousse, Tunisia United Kingdom ■ Gestational diabetes: things you need to know (but maybe don’t) – design, development, pilot and evaluation of a DVD for women with gestational diabetes USA ■ Feasibility of developing a training program for peer leaders in diabetes in Ypsilanti, Michigan, USA

■ Tailored intervention for inpatients: transitional diabetes care coordinator versus conventional care ■ Project SEED: support, education and evaluation in diabetes ■ Medical lifestyle centre community healthy eating initiative to improve diabetes outcomes ■ Motivational interviewing to maximize utilization of self-management education for adults with type 2 diabetes ■ Non-visual foot inspection for people with visual impairment Venezuela ■ Peer-led and telehealth interventions for diabetes prevention in Maracaibo, Venezuela Vietnam ■ Lifestyle intervention trial programme to prevent type 2 diabetes in the Northern province of Ninh Binh, Vietnam - a D-START project Vietnam ■ Programme for the detection and prevention of diabetes in people at high risk in a mediumsize city in Vietnam Zimbabwe ■ The establishment of an Educational and Preventive Foot Care Service for subjects with diabetes in Zimbabwe

More information on each project is available on www.idf.org/bridges

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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.

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More information on www.idf.org/bridges

BRIDGES is an IDF programme supported by an educational grant from Lilly Diabetes