השפעת הטיפול הפרטני מול קבוצתי בחולי סוכרת סוג 1 במרפאת סוכרת שלישונית ד"ר ג'ואל זינגר מרכז רפואי רבין, ב"ח בילינסון מכון אנדוקריני

Death

Diabetes medication

HbA1c

Hba1c at 12-14 months

Hba1c at 2 years

Weight

Weight 12-14 months

Diabetes knowledge

Systolic Blood Pressure

Triglycerides

Ester Boteach RN,MPH, Shula Witkow RD,MPH and Ilana Harman-Boehm MD The Effect of Interventional Group Therapy on Glucose Control and Weight Loss in Obese "Non-compliant“ Patients with Type 2 Diabetes Mellitus Ester Boteach RN,MPH, Shula Witkow RD,MPH and Ilana Harman-Boehm MD Introduction Group interventions have been shown, overall, to be effective in the management of people with diabetes. Their efficacy in the sub-group of patients considered "non-compliant" remains to be demonstrated. Type 2 diabetic patients defined as "non-compliant" are often characterized by overweight, high doses of hypoglycemic agents and/or insulin, poor glucose control and insufficient knowledge of their disease despite repeated individual instruction by the clinic staff. Objective: To study the effects of interventional group-therapy delivered by a nurse-dietician diabetes educator team on blood glucose and weight control in a group of non-compliant type 2 diabetes patients. Methods: 20 uncontrolled overweight diabetic patients, members of the local Israel Diabetes Association chapter in Beer-Sheva and 8 spouses, were enrolled in a group therapy program run by a nurse and a dietician, both diabetes educators. At enrollment all participants signed a written agreement to attend most meetings, uphold the rules of the group and pay a symbolic fee. 10 weekly sessions took place, each lasting 2 hours. Each interactive session included weight, waist and hip measurements. The topics covered included general knowledge of diabetes, practicing self-management, hypoglycemic agents, diet therapy including snacking and eating during holidays, physical activity under different circumstances, emphasizing activities for partially disabled patients, fighting negative thoughts, personal assessment of glycemic control and overcoming obstacles to better control. Blood samples were taken at meeting 1 and 10 for HbA1C. In order to better mirror the effects of their own habits, each participant kept a daily diary of food and physical activity and graded his weekly progress in each of three treatment modalities: diet, activity and medication adherence on a scale of 1-low to 5-high. Each session ended with a smile elicited by a weekly cartoon on the topic discussed. At the last meeting the attendants were asked to state which habits would be permanently adopted and which not. Table 1: Patient Data at Baseline Figure 1: Changes in Weight (Kg) at the End of Intervention Period Figure 3 :Changes in HbA1C at the end of intervention period Figure 4: Changes in Waist Circumference at the end of intervention period Figure 5: Changes in Hip Circumference at the End of Intervention Period Figure 6: Example of our way to get a smile at the end of each meeting. I wished I had her Metabolism Summary: 15 diabetes patients attended most meetings. They were heterogeneous in terms of age, gender, duration of disease, hypoglycemic agents and motivation for in HbA1C, weight, BMI, waist circumference, hip circumference, were 0.96 ± 0.9%, 3.2 ±2.4 Kg. 1.14±0.8, 4.3±4.3 cm and 4.4±4.9 cm respectively. The doses of oral hypoglycemic agents as well as daily insulin were lowered. Conclusions: Interventional group therapy performed by experienced diabetes educators, resulted in marked improvement of glycemic and weight control. The power of the group appeared to be a strong determinant of the behavior of the individual.

Protocol Patients with type 1 or type 2 diabetes mellitus attending Diabetes Clinic Randomized to group visits or personal visits by the same physician for 1 year

Outcomes Composite outcome: HbA1c, Weight, Blood pressure differences at 1 year Secondary outcome: PAID, WHO QoL, Concerns about diabetes questionnaires scores differences at 1 year General Practitioner visits number at 1 year

65 patients agreed to participate and signed informed consent ( T2DM N=38, T1DM N=27) Group visits were scheduled once every 4 months Personal visits according to availability and needs T2DM patients and T1DM patients were scheduled in different group visits

Every group visit was 1.5 hours long 30 mn were the physician did a file and lab review while the nurses took anthropometric measures and short education tools when needed 45 mn group visits with patients & physician: free discussion 15 mn with short personal visit to give the consultation letter for the GP

Table 2B. Comparison between control and study group in Diabetes Type 1. P value n Mean SD N . WHO 11 17.1 28.4 16 4.25 23.1 .21 Paid 8 -.2 .2 15 .1 .4 .03 PMDC severe .6 .71 PMDCCont diff ,2 ,1 1.0 .89 PMDC inf .8 .93 PMDCeffDiff .06 .60 .80 .31 Weight 7 -2.4 4.2 14 1.2 .15 BMI -.8 1.4 -.1 HbA1C -.4 .7 .14 SBP 5.5 15.2 9.2 15.4 .59 DBP 1.5 9.7 5.2 8.4 .36 NonHDL -8.3 17 12 20.6 .29 LDL GPDiff 9 -5.2 10 -1.2 8.1 .22 Average Diff -3.6 6.0 8.5 .51 Admit Diff .45 .32 GP year 17.3 7.1 14.1 4.7 .19 Avevisityear admityear -.42 .70 1.3 .49

Conclusions Group therapy seems to be as safe as personalized therapy in patients with diabetes type 1

Clinical inertia & Personal Conclusion The physician part: don’t confuse me with facts Changing treatment paradigm in chronic disease to improve the life of people with diabetes is a very slow process