Objectives

1. To assess the effectiveness of a community-based DSME program in improving physiologic measures (HbA1c, lipid profile, blood pressure, BMI) and health behaviors (regular exercise, smoking cessation, foot examination, and self-efficacy) among diabetic patients.
2. To determine if patient factors such as age, sex, duration of diabetes, family history of diabetes, and educational attainment affect response to the DSME Program.

Methods and Results

Phase I involved comprehensive community assessment by determining knowledge, attitudes and practices using locally validated questionnaires and conducting focused group discussions. Data from 156 participants showed low overall knowledge score with a mean of 42.71%, lowest in the self-monitoring subscale. Most respondents did not believe in the seriousness of diabetes.

Phase II constituted a prevalence survey of diabetes, pre-diabetes and metabolic syndrome in the rural community. Using a two-stage cluster sampling method, a total of 365 residents participated. Each participant underwent an interview, physical examination and determination of fasting blood sugar, oral glucose tolerance test and lipid profile.

The diagnosis of diabetes and impaired glucose tolerance in this study was based on venous plasma glucose testing using the World Health Organization (WHO) Criteria. Diabetes mellitus (DM) was defined as fasting plasma venous glucose of = 7.0 mmol/L (126 mg/dl) or a plasma venous glucose of greater than or equal to 11 mmol/L (200 mg/dL) 2 hours after a 75 gram oral glucose load.

Pre-diabetes is defined as having either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). IFG was defined as a fasting plasma venous glucose in the range of 5.6-6.9 mmol/L (100-125 mg/dL), while participants who had a fasting plasma venous glucose of 7.8 – 11 mmol/L (140-199 mg/dl) 2 hours after a 75 gram oral glucose load were diagnosed with impaired glucose tolerance (IGT).

Our results showed that 9% were known diabetics while an additional 10% were newly-diagnosed diabetics, giving an overall diabetes prevalence of 19%. Pre-diabetes was also prevalent at 26%. Metabolic syndrome was found to be present in 38% of the residents surveyed. This alarming diabetes prevalence provides greater impetus to initiate self-sustaining DSME programs to assist in the control of diabetes and prevention of complications.

Phase III is ongoing. Program participants are diagnosed diabetics in the community. They will be randomly allocated either to receive the 12-week DSME program (intervention group) or traditional care (control group). Fourteen diabetics have volunteered to be peer educators. Among these 14 are a barangay captain (village leader), a community nutrition scholar, and a nursing student. They underwent a 2-day workshop, where they were taught the content and manner of delivery of the IDF modules. The actual DSME program will be taught to small groups of 10–15 people, 3-4 hours per week, incorporating strategies to enhance self-efficacy. IDF educational modules were modified and translated to the Filipino language. Data from the intervention and control groups will be compared initially and at 3 and 6 months after the initiation of the program.

Phase IV aims to tackle diabetes prevention among high-risk community residents identified during Phase II as well as prevention of diabetes complications among known diabetics.

Summary

This long-term, self-sustaining diabetes program aims at reducing the burden of diabetes particularly in the rural community. The investigators envision a program that will serve as a “model of community diabetes care” throughout the Philippines by providing culturally-appropriate and comprehensive diabetes care. Special thanks to the community of San Juan, Batangas, who have allowed us to participate in their care.