Diabetes Prevention Program

“IMAGE EGYPT”

By

Eman A. SabetAssisstant professor

Sohag University

IMAGE EGYPT

Introduction

• The dramatic increase in newly diagnosed cases of T2D,

particularly in younger people, has resulted into a major

public health concern worldwide and especially in

low and middle-income countries.

• Several studies have demonstrated that prevention

programs can significantly reduce the risk of

developing diabetes.

• The development of T2DM is strongly associated with

being overweight, obese or physically inactive. Large

randomized controlled trials have shown that relatively

modest changes in lifestyle can reduce the risk of

progression to T2DM in adults with pre-diabetes by

around 50%.

• Consequently, promoting changes in physical activity

and dietary intake is now recommended in national and

international guidelines as a first line therapy for preventing T2DM

Introduction

• Currently Egypt stands among the top countries

worldwide with the highest diabetic population between

people age 20-74.

• This forms a severe load not only on the health status

of the community but also on the already

compromised health care budget of the country.

• Diabetes prevention - which proved to be successful

and cost effective in many parts of the world - is highly

needed in Egypt.

Egypt and Diabetes

• The European “IMAGE” project includes a European

guideline for diabetes prevention together with a practical

toolkit for the implementation of prevention programs.

• In this context, IMAGE developed an adequate education

program for health care professionals to prevent diabetes

as well as the establishment of quality standards.

• “IMAGE EGYPT” is the project designed by Prof. El-Sayed

and Schwarz . It was adapted to the local needs for

prevention of diabetes in Upper Egypt.

IMAGE EGYPT

• Previously to the clinical trial for evaluating the prevention

program, Egyptian health care professionals have to be

trained based on the adapted curriculum. After this local

training program (workshop), these so called prevention

managers (PM) the will be able to deliver preventive

intervention.

• The first training program was done in Luxor in 2013 for 10

persons from upper Egypt and is planned to be repeated in

the near future.

Assignment of prevention managers

• The purpose of this study is to evaluate the implementation

of a diabetes prevention program in an underdeveloped

part of Egypt.

• In respect to recommendations from the European IMAGE

project behavioral change methods – transferred by

specifically trained prevention managers - may lead to

improvement in metabolic control, expressed as a

reduction in waist circumference, blood pressure and

HbA1c as primary endpoints.

Rational for clinical trial

• Primary objectives

• To determine if a successful implementation of a diabetes

prevention program is associated with improved metabolic control.

• Secondary objectives

• Motivation of subjects to improve healthy lifestyle and change of

quality of life.

• Improvement of metabolic aspects as determined by the waist

circumference, Bp, HB A1c and lipid profile.

Objectives of IMAGE EGYPT Project

Original plan

Preparation phase

• What do you need?

1. Recruitment of working teams.

2. Find out target population in advance.

3. Agreement on strategic alliances.

4. Select suitable permises for intervention program.

5. Finances: Consider your funding needs and your funding sources.

Create a funding plan.

6. Ethics: Apply for necessary permissions and approvals for data

collection (local ethics committee, data protection authorities)

Preparation phase

1. Selection and training of the working teams

2. Screening of population to identify people at risk for

development of diabetes in different localities in Upper Egypt.

3. Motivation of high risk population to share in Interventional

program.

4. Preparation of educational material into Arabic and adapt it

to Egyptian social and cultural environment.

Screening teams• Each team received training from the prevention managers

about the aim of the project, methods of screening and

how to apply FINDRISK scoring system.

• Each session was preceded by pre- screening information to

the target population about the risk of type 2 diabetes

mellitus and its complications and possibility of its prevention

to motivate them to participate in the program.

Screening

• FINDRISK scoring system

Each session was

preceded by pre-

screening information to

the target population

about Diabetes risk and

possibility of its prevention

to motivate them to

participate in the

program

QUESTION ANSWER SCORE

Age (years) <45

45 - 54

55 - 64

>64

0

2

3

4

Body mass index <25

>25 - 30

>30

0

1

3

Waist circumference (cm) men <94, women <80

men 94 - <102, women 80 - <88

men >102, women > 88

0

3

4

Do you usually have at least 30 minutes

of physical activity at work and/or during

leisure time (including normal daily activity)?

Yes

No

0

2

How often do you eat vegetables, fruit or

berries?

Every day

Not every day

0

1

Have you ever taken medication for high

blood pressure on regular basis?

No

Yes

0

2

Have you ever been found to have high

blood glucose (e.g. in a health examination,

during an illness, during pregnancy)

No

Yes

0

5

Have any of the members of your immediate

family or other relatives been diagnosed

with diabetes (type 1 or type 2)?

No

Yes: grandparent, aunt,

uncle or first cousin

Yes: parent, brother, sister, or own child

0

3

5

TOTAL SCORE:

<7: low risk

7-11: slightly elevated risk

12-14: moderate risk

15-20: high risk

>20: very high risk

Scoring results• Using the FINDRISK scoring system. Type 2 Diabetes- high risk (T2D_HR) is

defined as a score >14 points in the FINDRISC questionnaire. Persons

with a very high score (20 and higher) have a high probability of

suffering from undiagnosed diabetes; exclusion of diabetes with an

oral glucose test was recommended.

• Subjects with a high FINDRISC score (>14) are the target group and

has an opportunity to participate in the intervention program

• Persons who have low score or moderate risk score received general

information about healthy diet and exercise benefits during screening.

Preparation of educational sessions

• Power-point presentations were prepared in Arabic, together with the

materials needed for booklets, brochures, letters, and SMS as well as

the questionnaires that were used during the workshops in every

session.

• The materials were adapted from the prevention module and

culturally adjusted according to population’s needs.

• An agreement should be obtained from certain lab. to perform pre-

and post- intervention laboratory investigations for all intervention and

control groups.

• In the original plan, 4 sessions are required:

Educational Tools1. Simplified power point presentations in Arabic.

2. Simple printed questionnaires, papers and pens.

3. Simple brochures.

4. Boards, pens.

5. Some healthy foods or drinks.

6. Discussions, brain storming…

Preparation of educational materials

Original plan

Implementation phase

Educational sessions• We introduced 2 funny people; Halima and Masud. They plan to do

exactly the same thing you are going to do during our journey to

change lifestyle to enjoy the upcoming years

Implementation phase

first educational sessionsObjectives:

Motivation of persons to change their life style.

Power point presentation; contents:

• Why we choose this group for attending these sessions?

• A simplified account on type 2 diabetes, its risk factors and complications.

• How can we avoid diabetes by change in life style?

• Figuring out your personal importance and expectations in respect to a

behavior change

• Thinking about your self-confidence to change habits

First educational sessionTraining questionnaires and discussions about:

• what would you like to do?

• what are your own causes to change your life style?

• Do you think it possible?

• How much it is important for you to change your life style?

• What is your level of confidence that you can change?

• What are your own points of strength and weakness?

Main Message

It’s not difficult but let’s start together; It’s never to late, any minor

change is beneficial.

Second sessionObjectives:

Motivate subjects to increase their physical activity.

How to Increase your level of physical activity without becoming an

athlete?

• Thinking about your willingness to become more physically active

• know key messages about the range of physical activity

• Setting your goals to create a successful action plan

• Preparing coping strategies and monitoring your progress

Message

You don’t need to be an athlete, but just move as much as you can.

How to be physically active?

Third sessionObjectives:

Motivate subjects to change their eating habits.

How to make healthier food choices and enjoy eating?

• Thinking about your willingness to adapt your eating and drinking

patterns

• know key messages about healthier food choices

• Setting SMART goats to create a successful action plan

• Preparing coping strategies and monitoring your progress

Message

• Most of the available food can be eat in a healthy manner; just

change methods of cooking, serving and balance amounts.

Fourth sessionObjectives

Maintenance and relapse managements.

• What did you do? Are there any obstacles or relapses you

encountered? How can we face it?

How to cope with risk situations and relapses?

• Revise your action plans

• Thinking about coping strategies and checking if they are working

• Looking for social support especially for the time after the course

Message

Give yourself sufficient time to adapt the new behavior, if you fail try

again, prepare alternative plans, let others help you. Try to have

measurable goals.

Contineous communication and support

• A page was created on Facebook and the attendants were invited to

follow it.

• Telephone calls and

SMS messages.

• Frequents visits

Original plan

Clinical Trial for the Evaluation of a

Diabetes Prevention Program in

Upper Egypt

Eman A. Sabet & Amanl Khalifa

Under supervision of

Prof. Adel A. El-Sayed

What did we learned from the

first implementation trial• We should choose groups who are easily accessible to

communicate with.

• If possible , better to choose a time outside the work time.

• We have to create more attractive methods during sessions.

• We should listen well to our clients and we should have

answers and solutions foe their problems.

• We may share them active sessions about physical activities

and healthy cooking.

• Others …..???