A national diabetes care and education programme: the Ghana model

An account is given of how a national diabetes care and education programme was developed in Ghana, a developing country, through international collaboration of medical schools, industry and government health care institutions. The approach is by way of trained diabetes teams consisting of physicians, dietitians and nurse educators at two tertiary institutional levels (teaching hospitals) who in turn trained teams consisting of physicians, dietitians or diettherapy nurses, nurse educators and pharmacists at regional and district/sub-regional levels to offer care and education to patients and the community. In three years all regional and about 63% of sub-regional/district health facilities had trained diabetes health care teams, run diabetes services and had diabetes registers at these institutions. Additionally a set of guidelines for diabetes care and education was produced. All programme objectives with the exception of one (deployment of diabetes kits) were met. Distances to be travelled by persons with diabetes to receive diabetes care had been reduced considerably. The success of the project has given an impetus to the collaborators to extend the programme to the primary health care level. The continuing prohibitive prices of diabetes medications and supplies however, could be addressed by removing taxes on such supplies. The Ghana diabetes care model, a 'top-down' approach, initially involving two diabetes centres is recommended to other developing countries, which intend to incorporate diabetes care and education into their health care system.

Facilities and resources for diabetes care at regional health facilities in southern Ghana

In the fall of 1995, each of the five provincial hospitals in southern Ghana was visited and facilities and resources for diabetes care assessed. In addition, health facilities and standards of care questionnaires were completed. Only Korle Bu Teaching Hospital run a diabetes clinic and had diabetologists. Only two facilities had an eye specialist or trained dietician. None of the five facilities had a trained diabetes educator or chiropodist. Except for sphygmomanometers, basic equipment for clinical care were lacking. Basic biochemistry tests were available at all facilities. Creatinine clearance and 24-h urine protein, glycated haemoglobin, fasting triglyceride, total cholesterol and HDL cholesterol were available at only one centre. None of the facilities measured C-peptide, islet cell antibody and urine microalbumin. None of the facilities had chronic haemodialysis service. Insulin supply was erratic at two institutions. Three regions had active diabetes associations. The facilities and system of diabetes care in southern Ghana revealed in this study are far from satisfactory. Training of health care personnel in diabetes management and education may enhance diabetes care despite the existing constraints. Furthermore, the development of international and regional guidelines for facilities and resources may facilitate implementation of international resolutions and clinical practice guidelines.

Combination of very-low-calorie diet and behavior modification in the treatment of obesity

Very-low-calorie diets (VLCDs) cause rapid weight loss. However, weight regain is rapid upon discontinuing the VLCD unless lifestyle is altered. The addition of a behavioral-modification (BMOD) program improves the long-term outcome. The major components of a BMOD program to alter lifestyle are education about nutrition and eating habits with alteration of amount and patterns of eating, institution of an aerobic activity program designed to increase energy expenditure, training in self-awareness and assertiveness, and training in coping techniques for long-term alteration of lifestyle. By retrospective chart review, we evaluated two VLCD programs at the same institution. One program gave 12 wk of BMOD before a 12-wk course of VLCD (Program 1), then scheduled individual visits regularly thereafter. The other program used simultaneous VLCD and BMOD in a 26-wk treatment course (Program 2), consisting of 2 wk of stabilization on 5020 kJ/d (1200 kcal/d), 12 wk of VLCD, and 12 wk of transition to a low-calorie solid food diet. Follow-up was obtained at 1 y in both groups. Maximum weight loss was similar, but subjects in Program 2 regained about one-third of the lost weight versus approximately 10% in Program 2. A third program of preceding BMOD followed by a low-calorie diet (Program 3) gave similar weight maintenance at 1 y as Program 1. Prospective studies are needed to determine if BMOD simultaneously with or preceding VLCD promotes better long-term weight maintenance. These data confirm the benefits of long-term follow-up for maintaining weight loss.

Alternatives to the exchange system for teaching meal planning to persons with diabetes

Although the most well known, exchange lists are not the only meal-planning approach for persons with diabetes. This paper outlines the steps in the nutrition education process, including initial and continued education stages, and presents six alternative approaches for individualizing meal planning. These include the High Carbohydrate-High Fiber Exchange System, Calorie/Fat Counting, Total Available Glucose, the Point System, Month of Meals, and Individualized Sample Menus. The approaches are rated according to emphasis on weight loss, glucose control, and ease of learning and according to type of diabetes. A complete resource guide is provided.

Psyllium fiber reduces rise in postprandial glucose and insulin concentrations in patients with non-insulin-dependent diabetes

The ability of psyllium fiber to reduce postprandial serum glucose and insulin concentrations was studied in 18 non-insulin-dependent diabetic patients in a crossover design. Psyllium fiber or placebo was administered twice during each 15-h crossover phase, immediately before breakfast and dinner. No psyllium fiber or placebo was given at lunch, which allowed measurement of residual or second-meal effects. For meals eaten immediately after psyllium ingestion, maximum postprandial glucose elevation was reduced by 14% at breakfast and 20% at dinner relative to placebo. Postprandial serum insulin concentrations measured after breakfast were reduced by 12% relative to placebo. Second-meal effects after lunch showed a 31% reduction in postprandial glucose elevation relative to placebo. No significant differences in effects were noted between patients whose diabetes was controlled by diet alone and those whose diabetes was controlled by oral hypoglycemic drugs. Results indicate that psyllium as a meal supplement reduces proximate and second-meal postprandial glucose and insulin concentrations in non-insulin-dependent diabetics.

Nutrition management for individuals with noninsulin-dependent diabetes mellitus in the 1990s: a review by the Diabetes Care and Education dietetic practice group

Noninsulin-dependent diabetes mellitus (NIDDM), or Type II diabetes, is characterized by two primary defects: insulin resistance and insulin secretion. The two major goals of management of NIDDM are to achieve near normal metabolic control and to prevent/delay the microvascular and macrovascular complications of diabetes. Nutrition, exercise, and, if necessary, medication are the three primary treatment modalities used in NIDDM. Treatment regimens need to be individualized and developed with consideration for diabetes management goals and quality-of-life issues. Lean individuals with NIDDM should be encouraged to maintain their body weight and modify food composition and eating pattern to minimize glucose excursions. The primary treatment goal for an obese individual with NIDDM is weight loss. The process of teaching nutrition and meal planning involves developing a cooperative alliance, gathering information, setting realistic goals, intervention, and maintaining change. Nutrition intervention involves providing information in stages, beginning with "survival skill" information and progressing to in-depth information. The dietitian's responsibility is to promote continuity of learning by introducing new ideas and concepts and altering the learning environment. Dietitians can expand their role in the 1990s to that of a diabetes educator taking a leadership role to ensure that the individual with NIDDM receives comprehensive and individualized care.