1 MINISTRY OF EDUCATION AND TRAINING MINISTRY OF PUBLIC HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY NGUYEN VAN LANH THE SITUATION OF DIABETES, PRE-DIABETES TO THE KHMERIN HAU GIANG PROVINCE AND AN EVALUATION OF THE EFFICIENCY OF SOME INTERVENTIONAL METHODS Major in: Hygiene Sociology and Health Organization Code: 62 72 01 64 SUMMARY OF MEDICINE PhD THESIS HA NOI – 2014 PROJECT WAS FINISHED AT NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Supervisor 1.Reader A/Prof PhD Nguyen Van Tap 2.Reader A/Prof PhD Nguyen Duc Trong Referee 1: A/Prof PhD Ngo Van Toan, Hanoi Medical University Referee 2: Prof PhD Le Van Nghi, Military Medical Academy Referee 3: A/Prof PhD Do Thi Khanh Hy, Central Hospital of Gerontology Thesis will be defended at Academic Committee of the Institute discussing at National Institute of Hygiene and Epidemiology Date :…… Month:……Year: 2014 For further information about thesis at National Library National Institute of Hygiene and Epidemiology Library ABBREVIATION BMI Body Mass Index Chỉ số khối thể CDC Center of Disease Control Trung tâm kiểm soát dịch bệnh Mỹ Cs Et al Cộng ĐTĐ Diabetes Đái tháo đường EASD European Association for the Study of Diabetes, Hiệp hội nghiên cứu đái tháo đường Châu Âu ESC European Society of Cardiology Hội tim mạch Châu Âu FFAs Free fat acides Các axit béo tự FINDRISC Finnish Diabetes Risk Score Thang điểm nguy đái tháo đường Phần Lan GDNG Impaired Glucose Tolerance (IGT) Giảm dung nạp glucose HA Blood Pressure Huyết áp HATT Huyết áp tâm thu HATTr Huyết áp tâm trương HbA1c Hemoglobine A1c Hemoglobine A1c HDL.C High Density lipoprotein cholesterol Lipoprotein gắn cholesterol có tỷ trọng cao IDF International Diabetes Foundation Liên đoàn đái tháo đường quốc tế LDL.c Low Density lipoprotein cholesterol Lipoprotein gắn cholesterol có tỷ trọng thấp MCT Body Fat Mỡ thể MNT Visceral Fat Mỡ nội tạng NPDNG Oral Glucose Tolerance Test Nghiệm pháp dung nạp glucose NXB Publisher Nhà xuất OR Odd ratio Tỷ số chênh RR Risk ratio Tỷ số nguy TG Triglycerid THCS Junior High School Trung học sở THPT Senior High School Trung học phổ thông THA Hypertension Truyền thông – giáo dục sức khỏe TT- GDSK TCYTTG World Heath Organisation Tổ chức y tế giới Yếu tố nguy YTNC TĐTĐ Tăng huyết áp Prediabetes Tiền đái tháo đường INTRODUCTION Diabetes is not a contagious disease, has an upward trend It effects on the health of working-age people in all over the world In 2003, there are 171,4 million people suffered from diabetes, it is predicted to be double in 2030 Every day, there are about 8700 people die because of diabetes The prevalence of diabetes is different from each continents and areas In Singapore, the rate is 8,6%, Malaysia is 3,1%; that of Kampomg Cham, Cambodia (2005) of over 25-year-old people is 11% In Viet Nam, Ngo Thanh Nguyen said that, at Bien Hoa (2011), the prevalence of diabetes of over 30-year-old people is 8.1%, including, the diagnosis is about 69,1% Huynh Nhan Hai, (2012), at Vinh Long, the prevalence of diabetes is 19,4%, type diabetes is 7,4% Diabetes is still a burden to economic and society However, the disease can be prevented and managed to have treatment, if it is consulted and treated early Moreover, a balance diet and proper exercises can help reduce the risk of prevalence and complication In Hau Giang, a rice production place of Southwest Vietnam, still a poor province in urbanization Khmer make up 22% of the population They have their own habit, particulars; but have narrow knowledge about diabetes and how to prevent it Through a survey at Nga Bay County Town, in 2009, it is found that the prevalence made up 11,8% and it trends to increase However, there is no research related to the prevalence of diabetes of the Khmer in our country It is essential to determine the prevalence of diabetes, pre-diabetes of the Khmer, find proper methods to prevent the disease Moreover, it is to determine the risk of disease for Khmer and have methods to help medical station to manage diabetes It is shown through the following purposes of the research project: To determine the rate of pre-diabetes, diabetes and some factors related to diabetes of Khmer from 45 years old to over at Hau Giang Province in 2011 To evaluate the effect of some preventive methods of diabetes of Khmer from 45 years old to over at the research area New points of science and reality value of the topic - It is a research which can determine the prevalence of diabetes of the Khmer - It can determine the prevalence of pre-diabetes of the Khmer in community - It can determine some factors related to type-2 diabetes of Khmer, proof that the intervention of educational communication can change behaviors and manage diabetes treatment at medical station At the same time, having a combination with Khmer clinic staff, mass organization and religious authorities in the local area to organize prevention work of diabetes in the community THESIS’S STRUCTURE The thesis includes 139 pages with 41 tables, diagrams, graphs and pictures Including: pages of Pose problems, 33 pages of overview, 30 pages of subjects and research methods, 36 pages of research results, 35 pages of discussion, pages of conclusion and page of petition There are 130 references, in Vietnamese (64), in English (66) CHAPTER OVERVIEW 1.1 Overview of diabetes 1.1.1 Concepts of type-2 diabetes According to American Diabetes Association (ADA), in 2006, “Type diabetes is a metabolic disorder that is characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency” According to International Diabetes Foundation (IDF), in 2010, “Diabetes is a group of metabolic disorders of carbohydrate metabolism characterized by high blood glucose levels and usually resulting from insufficient production of the hormone insulin or an ineffective response of cells to insulin Type-2 diabetes is characterized by insulin resistance and relative insulin deficiency, one of the two dysfunctions can occur at the time of clinical symptoms of diabetes” “Pre-diabetes is a condition of glucose transformation deficiency which includes Impaired Fasting Glucose – IFG and Impaired Glucose Tolerance – IGT” 1.1.2 Diagnosis and classification of diabetes 1.1.2.1 Diagnosis of diabetes: Standards for diagnosis of diabetes and blood sugar disorder of WHO – IDF in 2008 updated in 2010 and the diagnosis standards of ADA/WHO in 2010: - Diabetes Fasting blood glucose ≥ 7mmol/l (≥ 126mg/dl) Random blood glucose or after 2-hour glucose tolerance (≥ 11,1 mmol/- ≥200mg/dl l), Or the patient was diagnosed and being treated diabetes Or the concentration of HbA 1c ≥ 6,5% - Pre-diabetes Impaired glucose tolerance (IGT): fasting blood glucose is from 5,6 - < mmol/l and (100 < 126 mg/dl) Or blood glucose after 2-hour glucose tolerance is from 7,8 - < 11,1 mmol/l (140 - < 200 mg/dl), or Impaired Fasting Glucose (IFG) Impaired Fasting Glucose is from 5,6 - < mmol/l and/ or after 2hour glucose tolerance is under 7,8 mmol/l Or the concentration of HbA 1c is from 5,7% - < 6,5% - Normal Fasting blood glucose is < 5,6 mmol/l 1.1.2.2 Classification of diabetes According to American Diabetes Association and European Diabetes Association - Type diabetes: the beta cells are destroyed by the immune system and no longer secrete insulin It can be divided into two categories: structure with and without autoimmune It does not depend on cytoplasmic antibodies - Type diabetes: It is characterized by insulin resistance, relative insulin deficiency, and increased production of glucose by the liver, abnormal fat transformation Obesity caused from visceral fat or central obesity - Other specific types: Diabetes due to absent beta cell function or absent insulin action due to genetics - Gestational diabetes: occur while being pregnant 1.1.3 Factors related to Type diabetes In recent years, people have proved that there are many factors related to diabetes According to American National Institute of Health, factors that can cause Type diabetes include: - People ≥ 45 years old, 90-95% suffers from Type diabetes - Overweight (BMI ≥ 23 for Asian people) male pattern obesity (waist size ≥ 90 cm to male and ≥ 80 to female, high WHR) - Blood pressure 140/90 mmHg or higher - Have a family prehistory of diabetes - Woman had a prehistory of gestational diabetes or gave big child (≥ 4kg) - People who have trouble with impaired fasting glucose or impaired glucose tolerance - Having high rate of cholesterol or triglycerides - Less physical activities Besides that, people also record other factors such as: high rate of beer consumption or smoking are also be the causes of diabetes 1.2 Intervention model to prevent diabetes The Resolution 42.36 of WHA has introduced a development of Diabetes Prevention Program within national level, engagement of countries to prevent diabetes United Nations (2006) published the Resolution UN61/225 on the prevention of diabetes with the message: Developing policies to treat, prevent and taking care of diabetes International Diabetes Foundation (IDF) has designed a national diabetes prevention program which focuses on enhancing the awareness of community through communication and education Level-1 prevention is to reduce the prevalence of diabetes It is also to change the behaviors and to have early detection of the disease to reduce complications, fatality and enhance the quality of life for people In Viet Nam, Ministry of Health has developed some programs for preventing some infected diseases in the period of 2010-2020 with the purpose to reduce the prevalence and death of diabetes With the following activities: Organizing communication to change behaviors: to propaganda to enhance the awareness of people about the risk of diabetes to prevent Specifically, it is to change bad behaviors, help people to know how to prevent and detect diabetes Therefore, they can avoid complication Organizing evaluation in the community: Previous studies affirmed that diabetes can be managed and prevented We have intervened to prevent diabetes for Khmer at medical station by method as follows: Change our diet: it is recommended to change our habit to reduce the disorder of blood lipids including the decrease of fat, cholesterol, the increase of protein with low fat, fiber To reinforce physical activities: doing exercise regularly can prevent Type diabetes because exercising help reducing the resistance of insulin It is also easy to transform glucose to reduce plasma glucose A scientific Exercising can fresh our mind, reduce stress and avoid insulin resistance An increase of physical activities can reduce the risk of obesity and eliminate some factors caused diabetes It is encouraged to lessen drinking hard and stop smoking CHAPTER SUBJECTS AND RESEARCH METHODS 2.1 Subject The Khmer who are 45 years old and over, living in Hau Giang Province within the study period 2.2 Location: Residents live in: Long My, Chau Thanh A District and Vi Thuy District, Hau Giang Province 2.3 Period: From 09/2011 to 10/2013 The first period is for investigation and the second period is for intervention research (2 years) 2.4 Research methods 2.4.1 Cross-sectional descriptive study and community intervention 2.4.2 Cross-sectional descriptive study - Sample size With single random sampling formula: p(1-p) N = Z²(1-α/2) x x DE d² Including: Z(1-α/2) = 1,96, with the accuracy of 95% d=0,03 is selected odd Design coefficient DE = p = 0,15 p is the rate of diabetes and pre-diabetes under the study on Khmer in Cambodia in 2005 n = 1100 - Sampling: Random sampling of districts /7 districts, county town, Hau Giang Province are: Long My, Chau Thanh A District and Vi Thuy District Two communes will be selected from each district, Sample size is 1100 people /4792 people /6 communes The list of Khmer who are over 45 years old will be selected from each commune which corresponds with k 2.4.3 Community intervention + The research sample size is calculated by the following formula - n: Minimum sample size for each group (intervention and control group) - p1: Estimation rate of pre-diabetes, diabetes for the intervention group is 0,2 - p2: Estimation rate of pre-diabetes, diabetes for the control group is 0,2982 - α: Statistical significance with the accuracy of 95% (α=0,05) - β: Probability of the II error With β=0,2 - Z² (α,β) = 7,9 10 The rate of pre-diabetes , diabetes desired 10% reduction compared to pre-intervention ( 29.82 % ) The rate of pre-diabetes , diabetes mellitus after intervention was 20 % So ( p2 ) is estimated to 0,2982 % , due to the rate pre-diabetes , diabetes does not change or less change Placing into the above formula, we have the minimum sample size is 302 So, the sample size after 2-year taking intervention at communes has the smallest n with 302 in the community of 45-year-oldand-over Khmer At the control commune, we also choose the smallest sample size 369 to investigate after taking intervention Sampling: taking random sampling at the two intervention communes are Cai Tac and Bay Ngan of Chau Thanh A District For that of control group are Vi Thuy Commune and Vinh Trung Commune of Vi Thuy District 2.4.4 Organization of intervention Model “Commune medical station in diabetes prevention for Khmer” - Interventional actions It includes activities for intervention, prevention of pre-diabetes and diabetes as follows: (1) develop resources and network at medical station which is under the interventional model; (2) Educating community health through communication; (3) consulting to change behaviors; (4) doing exercises; to monitor for early detection and to manage the work of examining and treating at commune medical station (5) - To evaluate the efficiency of intervention model Efficiency index (CSHQ) │p1 – p2│ CSHQ (%)= x 100 │p1│ p1 is the rate of pre-intervention p2 the rate of post-intervention The efficiency of intervention (HQCT) HQCT (%) = CSHQ intervention – CSHQ control 2.5 Officials in charge Graduate student is the project’s director, directly manage, coordinate with the staff of Health Department, District medical center, medical office, commune medical station, collaborator of hamlet medical station 2.6 To minimize research errors 14 Table 3.15 The relationship between health indexes Number of people OR Variable Total suffering % P 95% CI from diabetes Belly size Normal 918 105 11,4 0,6 0,03 0,3-1,1 High 182 26 14,3 Visceral Normal 853 72 8,4 3,4 0,01 fat 2,3-4,9 High 247 59 23,9 Body fat Normal 507 35 6,9 0,9 0,04 High 593 96 16,2 0,9-1,0 WHR Normal 787 84 10,7 1,4 0,04 1,0-2,1 High 313 47 15 BMI =23 has the risk of diabetes as 2,3 as that of people who have BMI