Diabetes screening and health promotion : evaluation of a pharmacy based campaign and of related activities

This thesis is based on the evaluation of pharmacy-based screening concepts for cardiovascular risk factors (particularly for type 2 diabetes and dyslipidaemia) and of related health promoting activities. Type 2 diabetes mellitus and the metabolic syndrome including hypertension and dyslipidaemia are major public health concerns, and projections of future effects are alarming. These metabolic disorders are linked to an increased risk of cardiovascular disease. Type 2 diabetes is one of the most costly and burdensome diseases of our time and is a condition that is increasing in epidemic proportions throughout the world. Early detection and treatment of type 2 diabetes and metabolic syndrome can reduce the burden of complications. In addition, there is large evidence that weight loss and lifestyle changes in nutrition habits and physical activity have positive effects on the prevention of diabetes and cardiovascular disease. Community pharmacies are regarded as a suitable setting to promote awareness, screen high-risk patients, and to deliver health promoting counselling to persons at risk for diabetes and cardiovascular disease. However, triage guidelines for diabetes and lipid screening in community pharmacies and appropriate cut-off points for measurements in capillary blood are missing. In addition, measurements used in pharmacy-based screenings for diabetes or cardiovascular risk (such as blood pressure and blood glucose) are not validated. It was the goal of this thesis to develop and evaluate screening concepts for type 2 diabetes and dyslipidaemia including appropriate triage guidelines and cut-off points for community pharmacy practice as well as to investigate the influence on lifestyle behaviour of different types of counselling. The thesis consists of five projects: Project A investigated whether a white coat effect in blood pressure measurements (as known from physicians’ measurements) can be observed and quantified in community pharmacy practice. Up to date no such findings have been published. It was the aim of this study to validate blood pressure measurement in community pharmacy practice as hypertension is a major risk factor for cardiovascular disease and an important part of screening concepts. For this purpose blood pressure was measured in four different settings: pharmacy, outpatient clinic (measurement by a nurse), self-measurement at home and daytime ambulatory blood pressure monitoring. Pharmacy blood pressure was statistically significantly higher compared with daytime ambulatory blood pressure monitoring in both systolic and diastolic values. In contrast, only diastolic values of outpatient clinic blood pressure were statistically significantly higher compared with daytime ambulatory blood pressure monitoring. In addition, a total of 16% of the participants showed a white coat hypertension, defined as elevated pharmacy blood pressure (≥140/90 mmHg) and normal daytime ambulatory blood pressure (<135/85 mmHg). Thus, the results of this study have shown that white coat effect and white coat hypertension exist in community pharmacy practice and are at least similar to the effects in an outpatient clinic. In Project B, a sequential screening concept for type 2 diabetes to be used in community pharmacy practice was evaluated. Triage guidelines and appropriate cutoff points for capillary blood glucose have been elaborated in an interdisciplinary and multi-institutional collaboration. A large pharmacy-based national diabetes screening campaign called “Stopp Zucker – Jetzt testen!” provided the possibility to evaluate the sequential screening concept. Community pharmacies participating in this campaign offered a free of charge diabetes risk assessment with consecutive capillary blood glucose measurement. Readiness for lifestyle change has been assessed based on the transtheoretical model (Prochaska) of behaviour change. During five weeks of spring 2002, a total of 94124 persons were screened for previously undiagnosed type 2 diabetes in 530 pharmacies of the German speaking part of Switzerland. The campaign attracted a large number of Swiss German speaking adults (2.4% of the total population) and the sequential screening concept could successfully be implemented into pharmacy practice. Of the generally elderly population screened, a total of 6.9% were suspected to have type 2 diabetes showing abnormal blood glucose values in the screening. A large proportion (71.5%) of the screened population had at least two risk factors but showed normoglycaemia. This provided an opportunity to provide targeted counselling towards health promoting lifestyle change. In the context of a pilot study, project C developed triage guidelines and cut-off points for dyslipidaemia which were evaluated in a regional screening campaign for metabolic syndrome in 30 community pharmacies. The results suggested that screening for the coincidence of ≥2 values of lipid profile above normal with ≥2 other risk factors for cardiovascular disease is the more promising approach than is exclusive screening for ≥1 or even ≥2 abnormal lipid values without coincidence with other cardiovascular risk factors as this would lead to large referral rates to physicians. On the other hand, if a single value of the lipid profile is elevated on the level requiring drug treatment, even without coincidence with other risk factors, referral is required. In project D, the changes in lifestyle behaviour and body weight after counselling in community pharmacies during the national diabetes screening campaign were investigated. Three different counselling intensities were compared: Standard (nonspecific recommendations towards lifestyle change), intensive (additional specific advice to reduce body weight), and standard plus referral to physician for persons at high risk for type 2 diabetes. Three months after screening a stratified sample of 3800 randomly chosen overweight individuals at risk for type 2 diabetes were addressed with written questionnaires to assess changes in body weight and lifestyle. Half a year and one year later the assessment was repeated. All counselling groups showed a significant weight loss three months after screening (0.6-1.9 kg; p<0.001). One year later a further significant weight reduction was observed. This reversed the general trend in the common population. Lifestyle changes in physical activity and/or nutrition habits were reported by 72.5% of all persons. Reported lifestyle changes as well as weight loss were most pronounced in the population at high risk for type 2 diabetes. The findings of this study showed that the immediate and targeted counselling after screening for type 2 diabetes in community pharmacies can result in significant and sustainable lifestyle changes and weight loss in overweight individuals. However the uncontrolled design of this project did not allow for stringent conclusions. Therefore, project E investigated the effect of a telephone-based counselling on body weight and lifestyle of overweight persons in a randomised controlled trial. Subjects for this study were recruited out of individuals who participated in the national diabetes screening campaign and provided informed consent for further investigations. After baseline assessment with a written questionnaire, subjects were randomly selected for intervention and control group. Within three months three telephone-based counselling sessions of 15 minutes were provided to the intervention group. Changes in lifestyle and body weight were assessed three months after counselling and another half year later with two evaluation questionnaires. Three months after telephone-based counselling the intervention group showed a significantly higher weight loss than the control group (-0.37% vs. +0.09%; p<0.05). Half a year later differences in weight loss were not significant anymore. However, a greater proportion of subjects in the intervention group progressed at least to the next higher stage of change in the transtheoretical model regarding physical activity (27.0% vs. 21.3%; p<0.05) and reported lifestyle changes in nutrition habits and/or physical activity (80.5% vs. 62.9%; p<0.001). Thus, the results of this study have shown that a three times 15 minutes telephone-based counselling is able to result in measurable weight loss and significant lifestyle changes in overweight individuals. Best modalities and, because of seasonal interference, the best point in time of a telephone-based counselling need further investigation. In conclusion this thesis showed that: • Screening for cardiovascular risk in community pharmacies benefits from a sequential procedure: First an assessment of all risk factors including blood pressure, second capillary blood glucose measurements with retest in case of borderline results and with measurement of lipid profile if possible and finally counselling of persons at risk to initiate lifestyle change. • The elaborated and evaluated triage guidelines with the cut-off points for diabetes and for lipid screening appear to be appropriate and can be recommended for community pharmacy practice. • A total of 6.9% of the population screened in the national diabetes screening campaign were suspected to have type 2 diabetes showing abnormal blood glucose values. This rate is representative for the population screened but due to selection effects not for the general Swiss population. • Blood pressure measurements in community pharmacies are as reliable as those of other health professionals. They are subject to a white coat effect, also known from measurements by physicians and nurses. • After screening for cardiovascular risk pharmacists should offer targeted counselling to persons at risk according to the readiness to change their lifestyle. • Health promoting activities provided in community pharmacies or by nurses through telephone-based counselling can have positive effects on lifestyle behaviour and therewith on public health

Change of body weight and lifestyle of persons at risk for diabetes after screening and counselling in pharmacies

To investigate the effects of pharmacy based counselling on changes in lifestyle and body weight