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.