Peer-led Diabetes
Prevention Program for
TASC in Melbourne
Nabil Sulaiman
“International Congress on CDSM, Melbourne
Nov 2008”
Aims of Peer-led
Develop an evidence based,
culturally appropriate peer-led
diabetes prevention resources and
program for TASC
Trial the program
Evaluate the program
Methodology- how?
Design: Pre and post intervention
trial (action research methods)
•
•
•
•
•
Advisory Group
Peer- leaders
Diabetes prevention program
Participants
Evaluation
Methodology- how?
•
•
12 peer leaders recruited from TASC
•
•
2- full days training of leaders
Program was developed (food, exercise,
group dynamics ..etc)
Each leader engage 10 people
Program components
•
•
•
•
•
Principles of peer-led program
Role of diet, physical activity and stress
Group facilitation, engaging
Motivational techniques and chronic
disease self-management
Leaders were paid for their training time,
recruitment of participants and
implementing the program.
Outcome Indicators
•
•
•
Changes in knowledge and attitudes
Changes in behaviours
Changes in body weight and waist
circumference
Data collection
•
Questionnaire and interviews:
knowledge, attitudes and behaviour
"Three-day Food Diary" and physical activity”
•
•
Weight, waist circumference were
measured
Pedometer to act as incentive for walking
RESULTS (N= 94)
Gender: females (73%)
Age: 47% (40-45 y) and 25% (>55 y )
COB:
 Turkey (45%)

Iraq (39%)

Lebanon (12%)
Obesity: 50% (BMI=30+)
Knowledge of risk of diabetes?
• 54.8% said yes post intervention
compared to 29.8% pre-intervention
(p=.069).
Why do you think you are at risk factors of DM?
80
72.3
71.3
68.1
70
64.9
59.6
60.6
58.5
56.4
60
54.3
51.1
48.9
50
48.9
45.7
40.4
%
38.3
PRE
40
POST
28.7
30
20
11.8
8.5
10
0
Have you done anything to lower risk during last 3 months
(P<0.001)
79.6
80
60.9
70
60
50
%
39.1
40
No
Yes
20.4
30
20
10
0
No
Yes
PRE
POST
39.1
20.4
60.9
79.6
Lifestyle changes after program
•
•
•
•
•
•
89% in food preparation
79% dietary intake
82% shopping
81% feeling of well being
79% physical activity
69% body weight
Mean walking time last week pre and
post intervention
Exercise
Pre
Post
P-value
Walking
180
258
0.007
Moderate
249
269
0.722
Vigorous
161
185
0.85
Weight and Waist
• Weight (kg): significant reduction in
weight [mean weight pre=78.1,
post=77.3; Z score=-3.415 (P=0.001)
• Waist circumference (cm):
mean pre=99.5cm, post =96.5
Z=-2.569 (P=0.010)
Effectiveness of the program
using 10-points scale
•
•
68% gave 9 or 10 points
18% gave 7 or 8 points
•
2% gave 5 points (undecided)
•
2% gave 3 or 4 points
What are the main reasons for not taking
any actions to lower your risks?
Reasons
Pre
Post
p-value
No time to
cook
37.2%
20%
0.004
Like to eat
fast food
24.5%
11.1%
0.029
What did you like?
77% appreciated the information
69% the skills learned
63% the support provided
95% learned healthy eating skills
70% maintaining healthy weight
75% how to loose weight
73% value regular exercise
48% information access and
42% attitudinal change
Source of diabetes knowledge








Doctors (92%)
Television (70%)
Friends (54%)
Nurses (35%)
Brochures (35%)
Family (36%)
Internet (29%)
Ethnic media (29%).
Comparison with other studies
Meta-analysis of 11 RCTs in CALD:
1. Improved HbA1c 3m after intervention
2. Weight Mean Difference -0.3% at 3m
and 0.6% at 6m
3. Knowledge scores improved at 3m
4. Healthy life style improvement at 3m
Hawthorne K, Robles Y, Cannings-John R, Edwards S. Culturally appropriate health
education for type 2 diabetes in ethnic minority groups. Cochrane
Systematic Revies 2008 (3)
Database of
Conclusions
Limited intervention
• Administered by trained peers equipped
with culturally appropriate education
• Native language
Significant improvement in:
• knowledge and attitudes
• limited changes in lifestyle behaviour
• The changes were maintained three
months after the intervention.
Conclusions
• The peer-led DPP was effective in
improving knowledge and changeing
behaviour
• The program could be replicated in
other CALD
Diabetes Research
Initiatives in Sharjah,
UAE
Nabil Sulaiman
nsulaiman@sharjah.ac.ae
n.sulaiman@unimelb.edu.au
Diabetes Supercourse, Alexandria 12 Jan 2009
Sharjah Diabetes Study
 Background
 Why the study
 Methods
 Preliminary results
 Conclusions
 Recommendations
Environmental and
behavioral changes
New dietary habits (what and how
we eat),
Lack of physical activity,
Overweight/ obesity, and
Stresses of urbanization and
working condition
will lead to further rise of CVD and
diabetes, and their risk factors.
Summary
Diabetes is a major and complex
health problem worldwide.
Prevalence in UAE (24% & IGT18%) is
the 2nd highest in the world
Onset of the disease in the GCC is
early in late 20s
With early Dx and appropriate Mgt
diabetics can live better and longer
Sharjah Diabetes
Study
N. Sulaiman, Dh. Al Badri, N. Sajwani, S. Saleh, D.
Young
1 Nabil
Sulaiman, 2Dhafir Al Badry, 2Najla Sajwany, 1Amal Hussein, 1Saba Saleh, 2Doris Young
(1Department of Family and Community Medicine, University of Sharjah,
2 Ministry
of Health UAE, 3Department of General Practice, University of Melbourne)
METHODOLOGY
PRELIMINARY RESULTS
Background
 Diabetes is a major and complex health problem worldwide.
 Diabetes prevalence in UAE is the 2nd highest in the world, reaching
about 24% in UAE nationals.
 The prevalence of pre diabetes is reported to be about 18%.
 With early identification and appropriate management, people with
diabetes can live better and longer
The study design is a cross sectional baseline survey of patients with diabetes
attending Primary Medical Care Centers in Sharjah during 2007/08.
 Gender: 65.4% (n= 227) females and 34.6% (n=120) males
 Nationality: UAE 83.9%, Pakistan 3.5%, Egypt 2.6%, others 10% including
Palestine, Lebanon, Yemen, Iraq, Poland , Syria, Iran and Sudan.
1.
2.
3.
4.
5.
Aim
 Participants: 347 diabetic patients were interviewed and their medical records were
cheeked
Data Collection
Research Assistant attended diabetes mini clinics at Riffa and Asit
centres and diabetes clinic at Al-Qassimi and Kuwaiti Hospitals:
Patients were invited to participate
Patients were interviewed using structured questionnaires
Their data were extracted from medical records
Data cleaning and analysis was performed using SPSS
 Marital Status: 8.9% single, 87.9% married, divorced 1.4% and 1.4% widowed.
 Consanguineous Marriage: 16.4% (n=57)
 Occupation: : 47.3% housewife, 28.2% clerks, 6.3% students, 0.6%retired.
 Family History: 23.1% (N=80) had a positive family history of diabetes.
 Smoking: 3.2% (n=11) current smokers, 3.2% (n=11), ex-smokers, never smoked
93.1% (n=323).
To improve diabetes management, control and quality of life of patients
with diabetes in UAE
Objectives
Diabetes
1. Establish an electronic database for diabetic patients in Sharjah
Diabetes Control Indicators
2. Audit their medical records to identify gaps in management.
3. Pilot test known EB intervention to investigate their appropriateness to
Sharjah



4. Determine barriers and facilitators to the implementation of the
intervention
Duration (mean)
Males
(N=120)
7.1 ± 4.9
Females
(N=227)
8.5 ± 7.4
BMI (kg/m*m)
30.9 ± 6.0
27.8 ± 5.3
9.9 ± 4.3
9.4 ± 3.7
26.4%
31.4%
Fasting B Sugar
(mmol/l)
Diabetes
complications%
body weight and waist circumference from medical records
knowledge and attitudes towards healthy eating using physical
activity questionnaire and
Biochemical indicators such as AbA1c and cholesterol, lipids,
blood glucose and urine test
Current Diabetes management method
Diabetes in family
200
250
Current Diabetes management method
150
None
Diet only
Tablets only
Insulin only
100
Diet & Tablets
Diet & Insulin
Diet, tablets & Insulin
Unknown
Others
50
Missing
Frequency
Frequency
200
150
100
50
0
Yes
No
0
Not sure
None
Diabetes in family
Diet only
Tablets
only
Insulin only
Diet &
Tablets
Diet &
Insulin
Diet,
tablets &
Insulin
Unknown
Others
Current Diabetes management method
Self monitoring
CONCLUSIONS
250
1. Diabetes Mellitus is common problem in primary medical centers in Sharjah.
Frequency
200
2. There is gap in self-management education including self monitoring,
manifested by high levels of obesity and lack of physical activity.
150
3. Diabetes control in Sharjah measured by HbA1c could be improved compared
with international guidelines.
100
4. Measures to improve control may include employing Diabetes Nurse
Educators to assist doctors at the medical centers to train patients as well as
CME courses for doctors working at the centers.
50
0
Yes
No
Self monitoring
This project was funded by the University of Sharjah. For information please contact Dr Nabil Sulaiman, HOD Family and Community Medicine, The University of Sharjah E-mail: nsulaiman@sharjah.ac.ae or
n.sulaiman@unimelb.edu.au
Sharjah Diabetes Study
Aim
To improve diabetes management,
control and quality of life of
patients with diabetes in UAE
Sharjah Diabetes Study
Objectives
Identify gaps in diabetes
management
Determine barriers and facilitators
to implementation of known
interventions
Pilot test known EB intervention in
Sharjah
Study Design
Cross sectional baseline survey
of patients with diabetes
attending Primary Medical
Centers in Sharjah during
2007/08.
Data Collection
Research Assistant attended diabetes
mini clinics at Riffa and Wasit centres
and diabetes clinic at Al-Qassimi and
Kuwaiti Hospitals:
Patients were invited to participate and
interviewed using questionnaires
Their data were extracted from
medical records
Data cleaning and analysis was
performed using SPSS
Diabetes Control Indicators
Medical Records:
Biochemical indicators such as HbA1c
and cholesterol, lipids, blood glucose and
urine test
Weight and waist circumference
Patients questionnaire:
Knowledge and attitudes


healthy eating
physical activity
Preliminary Results
Sample: 347 patients
Gender: 65.4% females
Mean age 53.2 (14.6)
BMI 29.8 (5.9)
Nationality
UAE 83.9%,
 Pakistan 3.5%,
 Egypt 2.6%,
 Others: 10% (Palestine, Lebanon, Yemen,
Iraq, Syria, Iran and Sudan)

Diabetes in Families
Diabetes in family
250
Frequency
200
150
100
50
0
Yes
No
Diabetes in family
Not sure
Marital Status
Marital Status
87.9% married
 8.9% single
 2.8 divorced/widowed

Consanguineous Marriage: 16.4%
(n=57)
Gender difference
Diabetes
Duration (mean)
Males
(N=120)
7.1 ± 4.9
Females
(N=227)
8.5 ± 7.4
BMI (kg/m*m)
30.9 ± 6.0
27.8 ± 5.3
Fasting B Sugar
(mmol/l)
Diabetes
complications%
9.9 ± 4.3
9.4 ± 3.7
26.4%
31.4%
HbA1c:
78% of patients has HbA1c
(>7%)
BP:
57% have high BP
Management Methods
Current Diabetes management method
200
Frequency
150
100
50
0
None
Diet only
Tablets
only
Insulin only
Diet &
Tablets
Diet &
Insulin
Diet,
tablets &
Insulin
Current Diabetes management method
Unknown
Others
Complications (83)
26 (Eye glaucoma, laser surgery)
74 (feet ulcer, loss of sensation)
2 (Kidney: protein urea or albumin
urea)
4 (loss of toe/ foot)
6 (angina, heart attack)
Self monitoring
Self monitoring
250
Frequency
200
150
100
50
0
Yes
No
Self monitoring
Self Management
I can exercise several times a week
(25% strongly agree)
I can not exercise unless I feel like
exercising (28% strongly agree)
I can recognize when my blood sugar
is too high (27% strongly agree)
Self Management
I can do what was recommended to
prevent low blood sugar (24% SA)
I can figure out what self treatment
when blood sugar gets high (29% SA)
I can fit my diabetes self treatment
routine into my usual lifestyle (26% SA)
CONCLUSIONS
Diabetes Mellitus is common
problem in primary medical centers
in Sharjah.
High levels of obesity
Low physical activity
Gap in self-management education
including self monitoring,
manifested by high levels of obesity
and lack of physical activity.
Recommendations
Diabetes management in Sharjah
could be improved compared with
international guidelines
Measures to improve control:




Diabetes Nurse Educators
Patient’s self management education
Peer-led or peer-support models
CME for doctors at PHC centers
Thank You