Consumer Engagement in

Self Management and

Prevention of Diabetes

Global Snapshot

People living with diabetes:

- over 371 million world wide

- 63 million in India

- 92 million in China (* 114 million)

4 out of 5 cases are in low / middle income countries

Next 20 years - Africa will have the highest % increase

Diabetes killed 4.8million people in 2012 – more than

HIV and TB combined

Australian Perspective

More than 1.5 million Australians have diabetes

Over 1,100,000 Australians actually diagnosed

280 Australian’s diagnosed everyday

2 million at high risk (pre-diabetes)

32% of preventable hospital admissions are diabetes

related

Set to become No 1 burden of disease

Australian Perspective

Type 1 diabetes – 120,000

Type 2 diabetes – 950,000

Insulin treated – 202,000

Gestational diabetes – 25,000 per year

May be one person with silent, undiagnosed type 2

diabetes for every person diagnosed.

Prediabetes (high risk) – more than 2 million

The Seriousness

• 2-4 times more likely to develop cardiovascular disease

(heart attacks and strokes)

• Most common cause of blindness in adults

• Leading cause of kidney failure

• Limb amputation – four times the risk

• Depression and mental well being

• Erectile dysfunction

National Burden of Disease

Type 2 diabetes

HOMA=homeostasis model assessment.

Adapted from Holman RR. Diabetes Res Clin Pract 1998;40(suppl 1):S21―5.

Type 2 diabetes is a progressive condition

-c

ell f

uncti

on (

% o

f norm

al by H

OM

A)

Time (years)

0

20

40

60

80

100

―10 ―8 ―6 ―4 ―2 0 2 4 6

Time of diagnosis

?

Pancreatic function

= 50% of normal

Type 2 diabetes

• Insulin resistance

• Beta cell degradation leading to relative insulin deficiency

• 50% will require insulin therapy within 6-10yrs of

diagnosis. Some immediately on diagnosis.

• Serious and complex

• But….people blamed for getting type 2 diabetes!!

• Stigma and distress

Gradual loss of glycaemic control occurs despite various oral treatment regimens M

ed

ian

Hb

A 1

c (

%)

Lifestyle only (n = 200)

Chlorpropamide (n = 129)

Glibenclamide (n = 148)

Metformin (n = 181)

0 2 4 0

6

7

8

9

6 8 10

Years from randomisation

Upper limit of normal 6.2%

ADA goal 7%

Overweight Patients With T2DM in the UKPDS

ADA=American Diabetes Association.

Adapted from UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:854-865.

Saydah SH et al (2004) JAMA. 291: 335-342.

US

ad

ult

s w

ith

T2

DM

(%

)

Vascular disease risk factors

0

10

20

30

40

50

60

HbA1c Level <7.0% BP <130/80 mmHg Total Cholesterol

Level <200 mg/dL All 3 Factors at Goal

T2DM = Type 2 diabetes

BP = blood pressure

NHANES III (n=1204) 1994

NHANES 1999-2000 (n=370)

Achieving treatment goals is difficult

Improving self-management…

‘…will have a far greater impact on the health of the population than any improvement in specific medical treatments’

(World Health Organisation, 2003)

8,760 hours spent alone with diabetes

Looking beyond HbA1c, at the person

• 70-82% worry about complications

• 58-69% feel hopeless when they think about complications

• 51-66% feel diabetes controls their life

• 30-60% experience diabetes-related distress

• 10% experience clinical levels of depression

• In type 1, 20% have impaired awareness of hypoglycaemia

• In type 2, 28% unwilling to use insulin if prescribed

• On average, diabetes impacts negatively on quality of life

International guidelines recommend

• ‘Emotional well-being [as] part of

diabetes management’ (ADA, 2006)

• Routine monitoring of

psychological well-being

‘…should be integral part of

routine care’ (IDF, 2005)

• Structured education as an

‘…integral part of management’ (IDF, 2005)

International Diabetes Federation, 2005

Rationale for structured education

• Self-management = cornerstone of successful diabetes

outcomes

• Effective self-management often requires

a radical change in behaviour

• Health professionals perceive they are offering adequate

education

– Mostly 1:1; problem-focused; lacking theoretical basis

• Few people with diabetes feel they have the skills they

need and quality of life is impaired

• Structured education is equitable, effective, evidence-

based, scalable and cost-saving

CASE STUDY: DAFNE

What is DAFNE?

• structured self-management

education program for T1DM

– skills training to replace insulin by

matching it to CHO on a meal-by-meal

basis: “the end of the diabetic diet”

– adult education principles to facilitate

new learning

– emphasis on building confidence &

appropriate independence

– 5-day outpatient group program

(6-8 people) in secondary care

• Delivered by 2+ trained educators

(DSNs & dietitians)

dose adjustment for normal eating

OzDAFNE am

• Dose Adjustment For Normal Eating

• Evidence based 5-day intensive program for adults with type 1 diabetes

• Strong focus on carbohydrate counting and insulin dose adjustment

• Insulin is matched to lifestyle not the other way round

• Teaches self management skills regarding exercise, illness, alcohol, eating out, travel

• Principles are very similar to pump therapy

• Can self refer

CASE STUDY: DESMOND

What is DESMOND?

• structured self-management

education program for people

newly diagnosed with T2DM

• Underpinned by strong

philosophy of care and

psychological / educational

theory

• Delivered as 1 day or 2 ½ days

• Delivered by 2 trained

educators

• Delivered in Primary Care

Insulin pump therapy

• Type 1 diabetes

• Continuous rapid acting insulin infusion

• Cost involved around $8000 for pump, $15-20/month for consumables (NDSS)

• Can be updated after 4 years

• PHI will cover cost of pump, if member for over 1 year

• Advantages: more flexibility, stable control

• Be willing to test BGL frequently

• Worn for 24 hours but can be disconnected for up to two hours

A New National Diabetes Strategy

Prevention, Prevention, Prevention

Primary Prevention

Prevention of unhealthy food and physical activity

environments through public health initiatives, whole of

community programs, social marketing.

•Front of pack labelling

•Reducing marketing and promotion of junk food to kids

•Food reformulation

•Promote active living

•Active transport

- Nelson Mandela

“There can be no keener

revelation of a society's

soul than the way in

which it treats its

children.”

Knowledge

Motivation

How Best to Make Change?

Educate

Implore

Medicate

Operate

The

Individual Less Obesity?

Disastrous Defaults (examples)

• The economics of food

• Food marketing

• Portions

• Too much access

• Too little access

RWJF $100

million/yr vs.

Child

Marketing

January 4!

• Single greatest source of added sugar

• Poor calorie compensation

• Sugar may be addictive

• Gratuitous addition of caffeine

• Completely empty calories

Why Soft Drinks?

• Rock solid proof of harm

Coke and Kerry Armstrong

Coke Campaign

Coke campaign

Complaint re Misleading and

Deceptive Conduct

The campaign creates the overall impression that ‘Coca-Cola’ is not an unhealthy product. We consider these claims and this impression to be false and misleading. In fact, evidence shows that consumption of sugary soft drinks such as ‘Coca-Cola’ is associated with increased energy intake, weight gain, and risk of medical problems. Evidence also shows that consumption of black cola drinks like ‘Coca-Cola’ contributes to the development of dental caries.

Therefore, in our view, Coca-Cola’s conduct:

· is misleading and deceptive in breach of section 52 of the Trade Practices Act; and

· constitutes the making of false and misleading representations in breach of section 75AZC(1)(a) and (e) of the Act.

Optimal

Defaults

Economics

Legislation

Environment

Regulation

The

Individual Less Obesity?

Prevention – High Risk

Prevention for those at high risk (pre-diabetes) through

innovative national programs (and international links).

•2 million Australians with pre-diabetes

•Strong evidence base

•Life! Program in Victoria

•Loss of federal funding ($200m+over 4 years)

Prevention of Complications

Prevention of the serious complications and

hospitalisations related to diabetes (blindness, kidney

disease, heart attacks, strokes, amputations).

•32% of preventable hospital admissions

•Coordination of care ($449m program scrapped)

•Improved self management

•Quality of life and wellbeing

Creating national standards for structured education programs

• evidence-based, with specific aims and

objectives

• a structured, theory-driven curriculum with

effective supporting materials

• delivered by educators trained in education

theory

• quality assured, reviewed by independent

assessors and with outcomes regularly

audited

CASE STUDY: DAFNE

What is DAFNE?

• structured self-management education program for T1DM

– skills training to replace insulin by matching it to CHO on a meal-by-meal basis: “the end of the diabetic diet”

– adult education principles to facilitate new learning

– emphasis on building confidence & appropriate independence

– 5-day outpatient group program (6-8 people) in secondary care

• Delivered by 2+ trained educators (DSNs & dietitians)

dose adjustment for normal eating

CASE STUDY: DESMOND

What is DESMOND?

• structured self-management education program for people newly diagnosed with T2DM

• Underpinned by strong philosophy of care and psychological / educational theory

• Delivered as 1 day or 2 ½ days

• Delivered by 2 trained educators

• Delivered in Primary Care

Cost Effectiveness of Delivering

the DESMOND Intervention

(Diabetes Education and Self-

Management for Ongoing and

Newly Diagnosed) for People

Newly Diagnosed with Type 2

diabetes

BMJ on line 2010

Structured education is cost-effective

• DESMOND:

– ‘Real world’ cost per patient

£76 (~AU$120)

– Incremental cost per QALY

£2,241 (~AU$3,600)

• DAFNE:

– ‘Real world’ cost per patient

£354* (~AU$570)

– Incremental cost per QALY

£2,237 (~AU$3,600)

* Based on 6 courses per year; £300 for 15 courses

National Diabetes Services

Scheme (NDSS)

National Self Management Support

• ATSI

• CALD

• Youth and Transition

• Diabetes in Pregnancy

• Mental Health and diabetes

• Older people and diabetes

• e-Health

Consumer Engagement in

Self Management and

Prevention of Diabetes