Diabetes Education … Educology The magic capsule for primary and secondary prevention W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n 

Diabetes Education The magic capsule for primary and secondary prevention W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n DIABETES IS AN EPEDEMIC DISEASE ! IS IT A PREVENTABLE DISEASE ? WHAT ARE THE WAYS OF PREVENTION ? WHICH METHOD TO USE ? WHERE DO WE GO NOW ?

Historical story of diabetes prevention W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Celsus Ancient Greek scientist 500 B.C. Polyuria ? : He described a disease characterized by: Polyuria. Lack of pain. Weakness. Fluid output greater than fluid intake. Treat by: Diet containing a minimum amount of food. Regulated mode of life. De Medicina ( English translation).

Diabetes is preventable disease W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n The proven methods in prevention of diabetes are: 1.Lifestyle modification. 2.Drug use. 3.Future methods: Vaccine Genetic ?

Historical story of diabetes prevention W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Two early studies suggested that changes in life style can prevent diabetes: 1.Prevention of type 2 diabetes mellitus by Diabetologia 34, diet and physical exercise Effects of diet and exercise in preventing Diabetes care 20, NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes study 1997.

Historical story of diabetes prevention W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Four recent well designed randomized controlled trails: 1.Prevention of type 2 diabetes mellitus N Engl J Med 344, by changes in lifestyle among subjects with impaired glucose tolerance Diabetes prevention research group: N Engl J Med 346, Reduction in the evidence of type 2 diabetes with lifestyle intervention or Metformin 2002 Diabetes prevention research group: Diabetes care 23, The diabetes prevention program: baseline characteristics of the randomized cohort Diabetes prevention program: Diabetes care Design and methods for a clinical trial in the prevention in type 2 diabetes Prevention of pancreatic  cell function and Diabetes 51, 2002 prevention of type 2 diabetes by pharmacological prevention of type 2 diabetes by pharmacological treatment of insulin resistance in high risk Hispanic women 2002

The Finnish Study 2001 W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Number522 Age (mean)55 years BMI (mean)31 kg/m 2 Clinical conditionIGT Control group: Received brief diet and Exercise counseling Intervention group: Received intensive individualized instruction on weight reduction, Food intake, and guidance on increasing physical activity Duration (mean)3.2 years Lifestyle 58%

Diabetes Prevention Program (DPP) W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Number3,234 Age (mean)51 years BMI (mean)34 kg/m 2 Clinical conditionIGT Lifestyle group: Intensive nutrition and exercise counseling Treatment group: Two masked medications: 1.Biguanide Metformin. 2.Placebo. Duration (mean)2.8 years Lifestyle 58% Metformin 31%

The Troglitazone in Prevention of Diabetes (TRIPOD) W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Number235 Age (mean) Younger BMI (mean) 28 kg/m 2 Clinical conditionGDM Placebo group: Received Placebo Tested group: Received Troglitazone which is Withdrawn from the group Named Thiazolidinediones class Duration (mean)2.5 years Troglitazone 56%

STOP-NIDDM trail W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Number1,429 Age (mean)55 years BMI (mean)31 kg/m 2 Clinical conditionIGT Placebo group: Received Placebo Tested group: Received Acarbose from the group named  -glucosidase inhibitor Duration (mean)3.3 years Acarbose 25% To 36%

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Lifestyle in prevention of type 2 diabetes Education pill: reduce weight >5%. Fat <30% of energy consumption. Fiber intake >15gm per 1000kcal. Moderate exercise for 30 min/day. Education dosing: Seven sessions with nutritionist in 1 st year then One session every three months. Individual guidance on physical activity. Self-reported change in dietary and exercise Habits during the first year VariableIntervention groupControl groupP value Number 253 (%) Number 247 (%) Decrease fat consumption Increase vegetables consumption Decrease sugar consumption Increase exercise Success in achieving the goals of the intervention by one year VariableIntervention groupControl groupP value Number 253 (%) Number 247 (%) Weight reduction >5% Fat intake <30% Saturated fat intake <10% Fiber intake  15g/1000 kcal Exercise >4 hr/week N Engl J Med,, Vol. 344 May 3, 2001

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Public education The expected relation between: the level of public health education and the prevalence of diabetes. No data available to prove this because: 1.Public education standardization. 2.Multi-factorial disease. 3.Ethnic and cultural factor. 4.Long duration trials. 5.Life-style modification difficulty. Involvement level: Individual. Family. Community. Nation. Risk factors: Controllable vs non-controllable Health Education

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Which factors…? Uncontrollable: Age. Genetic. Ethnicity. Associated diseases: - Hypertension Controllable: Weight. Exercise. Associated disease: - Hyperlipidemia - Polycystic disease - Vaculopathy Risk factors for type 2 Diabetes Education effect Individual conditions: Age  45 yearsNo Overweight ( BMI  25 kg/m2 )Yes First degree relative with diabetesNo Habitual physical inactivity Yes Ethnic riskNo Pre-diabetes conditions: IGF or IGTYes History of GDM or big baby > 4 kgmYes Associated conditions: Hypertension  140/90 mmHgYes/No HDL  0.9 mmol/l  triglyceride 2.82 mmol/lYes Polycystic ovary disease (PCOS)Yes History of vascular diseaseYes Risk factors for type 2 Diabetes Education effect Individual conditions: Age  45 yearsNo Overweight ( BMI  25 kg/m2 )Yes First degree relative with diabetesNo Habitual physical inactivity Yes Ethnic riskNo Pre-diabetes conditions: IGF or IGTYes History of GDM or big baby > 4 kgmYes Associated conditions: Hypertension  140/90 mmHgYes/No HDL  0.9 mmol/l  triglyceride 2.82 mmol/lYes Polycystic ovary disease (PCOS)Yes History of vascular diseaseYes

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Education A share between doctors and patient Patient share is an important issue that need special training for the treating physician. Patient involvement in education is only 21% which change to 47% after training. Continuity and patient load was not tested which will affect the out-come. Therapeutic education of PatientsAssal, 2000

Diabetes Education according to the source W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Physicians are the highest in providing patients with diabetes education but they are the least effective. The most effective method is the special training classes with >75% effect but not practical. The role of diabetes educator (nurse) is as effective >75% and more practical. Others ie; teachers, volunteers…etc need to be evaluated. Massachusetts Results from the Behavioral Risk Factor Surveillance System (BRFSS) 1996

Education of physicians vs patients: W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n 401 intervention group focused on improving the skills and knowledge of general practitioners (EMC). 413 second intervention group focused on patients education and self management (DS). 105 reference group choosing patients from regular clinics (RG). Diabetic Medicine, 20, 846; 2003 Patient education and self management decrease HbA1c by 0.51% comparing to the reference group. Improving GPs skill and knowledge decrease HbA1c by 0.23% comparing to the reference group. The patient involvement through education in their management give extra 0.28% decrease in the mean HbA1c.

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Education program Reduce weight >5%. Fat <30% of energy consumption. Fiber intake >15gm per 1000kcal. Moderate exercise for 30 min/day. Knowledge Risk factors What to do Behavior Eating less Healthy diet Exercise plan Factors: Age distribution Problem size Illiteracy rate Cultural factor Health system Health beliefs Weight loss Healthy diet Physical activity Decrease Prevalence Decrease costs Model of Public Education

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Education program Certified educator. Education system. Same language. Education materials. Support group. Integrated into lifestyle. Assisted by local health care providers. Patients Knowledge Diabetes general Diabetes management Behavior Skill performance Compliance/Adherence Factors: Age Sex Duration of DM Culture Education level Language Health system Health beliefs Good control HbA1c Blood glucose Weight loss Decrease complications Decrease medical costs Model of Diabetes Education

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Definition: Science of drug effect on human body and its role in disease treatment. Material: Active compound. Efficacy: Effective according to the dose. Action: Short term. Side effect: May be. Cost: 4000 SR annually.* Acceptance: More accepted.** Definition: Using education as a tool for disease prevention or treatment. Material: Large verity of methods. Efficacy: More effective than drugs. Action: Long term. Side effect: None.Cost: 50 SR annually.* Acceptance: Less accepted.** Educology Pharmacology * The National Saudi Diabetes Registry ** Diabetic Medicine Vol 24, 1997.

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Age at education.Age at education. Literacy rate.Literacy rate. Culture effect.Culture effect. Easy administration.Easy administration. Can be done by any body.Can be done by any body. No side effect.No side effect. Accumulative effect.Accumulative effect. Effect loss with time.Effect loss with time. Educology Pharmacology Factors related to each method Age. Disease related. Indication. Different routes (bioavailability). Prescribe by physician. Side effect. Dose related. Effect with use only.

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Is Physician Advice (patient education) effective? Weight lossExerciseMedication Age:  65Reference group for age Sex: MaleReference group for sex Female Ethnicity: WhiteReference group for race Black Hispanic Other Diabetes care, Volume 26, Number 3, ; March 2003 Effective Non-effective EffectiveLess effectiveEffective

Physical activity W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n There is no difference between adults with or without diabetes in the percentage of insufficient physical activity This data indicate that there is a large space for exercise in both primary and secondary prevention. Therapeutic education of Patients Assal, 2000

Education is Knowledge and behavior W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Patient education: Have you heard about HbA 1c ? - Age group: % % >6513% - Younger patients have better education. - Type of diabetes effect. - The target group Patient behavior: How many times did you check your feet? None15% 1-2 times31% 3-5 times17% > 5 times37% Therapeutic education of Patients Assal, 2000

A Saudi twin families: W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n Mohamed and his twin Abdullah are76 years old, both have type 2 diabetes managed currently with insulin. Mohamed has 13 children while Abdullah has 17 children. Follow-up started 1989 with yearly OGTT. Mohamed’s family refused education on prevention but Abdullah’s family agree. Mohamed’s family Abdullah’s family

W e I g h t l o s sH e a l t h y d I e tE x e r c I s eS c r e e n I n g P o s t e rV I d e o - t a p eP r o c u r eL e c t u r e L o w p r e v a l e n c el e s s c o m p l I c a t I o n If you don’t know, you have to learn…… If you learn, you have to implement…… If you implement, you have to do it right …… If you do it right, it has to be always. Activity Diet Weight

Mass Education Eat healthy… Do exercise… Watch your weight.