People with diabetes have a high frequency of presenting chronic complications. The Diabetes Control and Complication Trial (DCCT) and the United Kingdom …
HCP/HCN/DIA/66/1-058-03
Original: Spanish
CAMDI I Workshop: Diabetes Surveillance and Control
Ecuador, El Salvador, Guatemala, Honduras Nicaragua
San Salvador, El Salvador, 8-9 March 2000
Division of Disease Prevention and Control
Program on Non-Communicable Diseases
Pan American Health Organization /
World Health Organization
| |
Introduction
Diabetes is worldwide health problem It is estimated that the number of
people with diabetes will reach the figure of 65 million by 2025
People with diabetes have a high frequency of presenting chronic
complications Premature mortality risk is higher in people with diabetes
than in their non diabetic peers The Diabetes Control and Complication
Trial DCCT and the United Kingdom Prospective Diabetes Study UKPDS have
influenced the objectives of diabetes care, since those studies
demonstrated that a tight
control of blood glucose and blood pressure can
improve the prognosis of diabetes, reducing premature mortality and the
frequency of some long-term complications
Under the auspices of the Program of Noncommunicable Diseases of the
Division of Disease Prevention and Control of the Pan American Health
Organization PAHO a regional workshop on diabetes surveillance and
control was held This workshop took place in the Hotel Camino Real, of San
Salvador, El Salvador, 8-9 of March 2000, with the involvement of Honduras,
Nicaragua, Guatemala, Ecuador, and El Salvador This activity is part of
the Initiative of Diabetes for the Americas DAY of PAHO and is linked to
the Declaration of the Americas on Diabetes DOTA
General Objective
Commence and coordinate activities of diabetes epidemiological surveillance
and control of diabetes in participating countries
Specific Objectives
1 Determine the feasibility of a survey on diabetes, hypertension,
obesity, and its risk factors
2 Study the possibility of compiling data on various aspects of
diabetes, including the direct and indirect costs and co-morbidity
as hypertension and other chronic
complications of diabetes
3 Evaluate the needs for the implementation of a national diabetes
program
4 Strengthen cooperation among countries in the field of surveillance
and control of diabetes
First Day
During the morning there was a plenary session The list of the
presentations are included on the agenda of the workshop Copies of the
presentation are available in the Program of Noncommunicable Diseases of
PAHO, Washington DC
Group Activity
Subject: Critical needs for diabetes surveillance and control in the
subregion
Objective: Propose activities to carry-out diabetes surveillance and
control in the participating countries
Suggested Subjects
Definition of the problem
Objectives of diabetes surveillance and control
Diagnostic criteria
Registries of people with diabetes
Mortality from diabetes
Diabetes care programs
Education of the general population
Diabetes advocacy
Health systems and diabetes
Availability of insulin, drugs and other critical supplies
Facilitators: Dr Mario Valcarcel, Dr Christine Karkashian, Dr Alberto
Barceló
On the
first day, three groups were created for the afternoon activities
The first group was formed by the representatives of Guatemala and Ecuador,
the second by the representatives of Honduras and Nicaragua and the third
group by the participants of El Salvador
Development
During the afternoon session, each group carried-out three activities:
The first activity was a Brainstorming Session For this activity,
each group was asked to identify the greatest number of problems
related to the current situation of diabetes in each of their
respective countries A special form was created for this purpose in
which participants wrote down their ideas up to 21
The second activity consisted of a Multivoting establishing
priorities Session This technique aids in the reduction of the
quantity of identified problems during the brainstorming session For
this activity, the members of each group were asked to choose the four
most important problems of the original list of problems
During the third activity of that afternoon, groups were asked to
apply a Nominal Group Technique to prioritize the four most important
problems of the list Once each person has given a score from 1 to
4 to each selected problem a final countdown is down for the over all
group , and the list is sorted by level of importance
The last activity of the day included a presentation of the list of
problems identified and prioritized by each group
Results of the First day
Result of Group 1
El Salvador
Diabetes not given priority status at the Ministry-of-Health level
Lack of human resources trained for primary, secondary, and
tertiary care multidisciplinary team
Lack of health education and promotion at all levels
Insufficient budget for the development of a diabetes program
Results of Group 2
Ecuador and Guatemala
There is no support from government to establish a health policy on
diabetes
Lack of application of norms for the prevention, treatment and control
of diabetes
Lack of information about incidence/ prevalence of diabetes
Lack of resource availability for the treatment and control of
diabetes at the state-supported health-care level
Results of Group 3
Nicaragua and Honduras
Lack of a national
medical-care program for people with diabetes
Lack of an integrated approach in diabetes management of diabetes at
the primary medical-care level
Deficient diabetes surveillance system
Lack of coverage of health services and medicines
The prevalence of diabetes is unknown
Second Day
Subject: Introduction to a plan of action
Objective: Development of a proposal for diabetes surveillance and control
Description of the work methodology, as well as the location in time and
space of the proposal
Suggested Topics: Selection of one or more topics on the basis of the
results of the first days work
Facilitators: Dr Christine Karkashian, Dr María del Carmen Daroca, Dr
Alberto Barceló
Development
There was a wrap-up session for the presentations of the day before
Participants were asked to created a plan of action or proposal to address
the issues/problems identified by their groups the day before They were
asked to remain in the same groups as the day before
Results of the Second Day
Workshop: Diabetes Surveillance and Control
Group 1
Action Plan Exercise
End purposes
Prevent risk factors and the development of
complications of DM
Change the attitudes and improve skills of the multidisciplinary
personnel regarding the management of DM
Objective 1
Promote and dissemination of knowledge on the importance of DM to the
overall society, with emphasis on special population groups children,
women, etc
Objective 2
Raise the awareness of the authorities on the economic and social costs of
diabetes
Objective 3
Support the organization and education of the diabetic patients and their
families
Objective s4
Incorporate into the program of studies of DM knowledge on healthy
lifestyles
Objective 5
Incorporate in the training curriculum of the health care team
multidisciplinary the comprehensive management of DM
Training of health care personnel multidisciplinary in DM and
development of continuous education programs
Target population
1 National and local authorities
2 Civil society, patient children, and their family
3 Health teams multidisciplinary
4 Industry and private enterprise
Activities
1 Prepare a communications media plan
2: Prepare and disseminate the situation analysis of the DM
To make forums, seminars, etc, to
convey the diabetes
situation, involving the communications media
3 Promote and strengthen groups and associations of persons with
diabetes and their families
4 Train leaders in the field
5 Coordinate with the Ministry of Education the incorporation in the
curriculum, information on healthy lifestyles
6 Incorporate within the framework of Healthy Schools Escuelas
Sanas the introduction of contents on diabetes risk factors and
prevention
7 Coordinate and provide technical support for the universities
regarding the inclusion of contents on prevention and integrated
management of DM
8 Prepare and set up programs for continuous education for health care
workers in DM
9 Train and motivate educators in DM
10 Involve the private business and industry in the management and
control of DM
11 Supervise and evaluate the processes and measure the impact of the
educational programs
Workshop: Diabetes Surveillance and Control
Group 2
Exercise of Plan of Action
General Objective
Establish in every country a Diabetes Management National Program
Specific Objectives
1 Define the policies
and strategies of inter-institutional
coordination, implementation, evaluation and monitoring systems
2 Establish the standards for primary, secondary, and tertiary
prevention
3 Promote a comprehensive approach for the management of persons with
Diabetes Mellitus
Plan of Action
1 Create an inter-institutional group, responsible for preparing the
proposal of a national program on diabetes This group should be
composed of representatives of a variety of sectors involved in the
management and control of diabetes
2 Establish mechanisms of coordination among the inter-institutional
groups of the countries of the region in order to standardize the
diabetes management and control programs in each country/region
3 Identify sources of technical support and financing and promote its
cooperation for the implementation of the National Diabetes Program
4 Achieve effective functioning of the management of the National
Diabetes Program focal point within the Ministries of Health of each
countries
5 Obtain a compromise from the participants in each group regarding the
development and sustainability of
the proposed actions in this
workshop and their continuos involvement in the process
Workshop: Diabetes Surveillance and Control
Group 3
Exercise of Plan of Action
Proposal of a diabetes prevalence study of diabetes mellitus and
development of policies for its prevention, control, and management
Problem 1
Lack of knowledge/information on the prevalence of diabetes
Deficient epidemiological surveillance system
Objective
Establish the prevalence of diabetes mellitus and its risk factors in each
country of the region
Methodology
Study Design: The study will be conducted including persons of 18 years and
older, in urban and rural areas of each country, taking into account the
existing regional differences The sample will be selected using cluster
sampling and will be stratified in accordance with sex, age, and
socioeconomic level Pregnant women will be excluded from the study
Methods
Survey on diabetes and its risk factors, including dietary habits and
level of physical activity
Test of glucose oral tolerance, using 75 g of anhydrous glucose Blood
glucose will be measured in fasting and two post-prandial hours using
the micromethod The levels of glucose that will be used to make the
diagnosis are those established by WHO
Anthropometry: measurement of weight and height to calculate Body Mass
Index, and measurement of the abdominal circumference
Measurement of antecubital blood pressure left arm utilizing
digital manometers For the hypertension diagnosis the criteria
established by WHO will be used
Lipids profile: the concentration of total cholesterol,
triglycerides, and HDL will be measured using the micromethod
The subjects should have 14 hours of fast prior to taking the sample
Problem 2
The creation of health policies in diabetes is not a priority for the
government and the Health Ministries
Objective
Propose to the governments of the region to define as priority the
development of policies aimed at the prevention, control, and management of
diabetes mellitus
Indicators
Number of governments that have defined policies
Economic resources allocated to these policies
Cost/benefit of the development of these policies
Hypothesis
Sensitization of the authorities and related institutions by
policy
adoption
Analysis of Interested Parties
The participants were grouped in order to carry-out an analysis of
interested parties Each group analyzed the plan of action that had been
previously prepared They were asked to identify a list of stakeholders and
to designate a value regarding the level of importance in this process and
their perceived attitude against/in favor of the proposed plan of
activities In the following section the results per group are summarized
Group 1
Problems: Lack of promotion and education on diabetes in every level
Lack of human resources trained for primary care
| |Groups |Power |Value |Effect |
|A |Government |5 |1 |5 |
|B |Ministry of Health |4 |2 |8 |
|C |Communications Media |5 |1 |5 |
|D |Association of Persons with Diabetes |3 |3 |9 |
|F |Universities |4 |0 |0 |
|G |Pharmaceutical Industry |4 |1 |4 |
|H |International Organizations |5 |2 |10 |
|I
|Service Club |2 |2 |4 |
|J |Scientific Societies |2 |3 |6 |
|K |Diabetes health care staff team |2 |3 |5 |
Group 2
Problems: 1 The prevalence of diabetes is unknown
2 The governments do not give priority to diabetes
| |Groups |Power |Value |Effect |
|A |Ministry of Health |5 |3 |15 |
|B |Association of Persons with Diabetes |3 |1 |3 |
|C |Medical Associations or Societies |3 |2 |6 |
|D |Pharmaceutical Industry |4 |2 |8 |
|E |Population to Study |4 |3 |12 |
|F |Food Industry |2 |1 |2 |
|G |NGOs |5 |2 |10 |
Group 3
Problem: No National Program for the Management and Control of diabetes in
place
| |Groups |Power |Value |Effect |
|A |Ministry of Health |5 |1 |5 |
|B |Universities |2 |-1 |-2
|
|C |Pharmaceutical Industry |1 |1 |1 |
|D |Medical Associations |1 |-1 |-1 |
|F |Patient Associations |2 |1 |2 |
|G |Communications Media |5 |1 |5 |
|H |Social Security Institutions |2 |1 |2 |
|I |NGOs |2 |2 |4 |
|J |International Organizations |5 |2 |10 |
Conclusions
During the two days in which the workshop was developed, the participants
discussed several aspects related todiabetes surveillance and control The
representatives of the participating countries illustrated with their
presentations the importance of this issue in the different national
contexts Important talks/lectures on a variety of topics were offered
including: the importance of education in the management of diabetes and
the inclusion of gender in the management of the disease
In addition, several problems related to diabetes were identified These
were ranked and at the end, the following regional priorities were chosen:
1 Studies of Prevalence of Diabetes
National Diabetes Programs
The participants participated in discussions and other individual and group
activities in order to continue with the plan of action defined in the
workshop of San Salvador
Coordinators for the Diabetes Projects
A coordinator or contact person for each country was selected who will be
responsible to offer updates of the development of the plan of action
created by each group The following list includes the names of those
responsible for each country and the organization to which they are
affiliated:
|El Salvador |Dr Nery Eduardo Ruiz Pimentel, Hospital Rosales, Phone: |
| |288-3092 |
|Nicaragua |Dr Martha Pastora, Ministry of Health, Facsimile 289-4202 |
|Guatemala |Dr Mauel Ramírez, INCAP and Dr Patricia Orellana, |
| |ministry of Health |
|Honduras |Dr Gustavo Zúñiga, Ministry of Health, FEDIABETES |
|Ecuador |Dr Byron Cifuentes |
|PAHO |Dr Alberto Barceló, Washington DC |
References
Aschner P, King H, Triana de Torrado M,
Marina Rodriguez B 1992
Glucose intolerance in Colombia A population-based survey in an urban
community Diabetes Care 16 1: 90-XX
De Sereday M Di Toro C, Correa A, Nusinovich B, Kapelushnik D 1979
Encuesta de prevalencia de diabetes: metodologia y resultados Bol Off
Sanit Panam 86: 293-305
Escobedo de la Pena J, Islas S, Lifshitz-Guinzbergh AL, Mendez JD,
Revilla C, Vazquez-Estupinan F 1998 Higher prevalence of diabetes in
hypertensive subjects with upper body fat distribution Rev Invest Clin
50: 5-12
Figueroa JP, Fox K, Minor K 1999 A behaviour risk factor survey in
Jamaica West Indian Med J 48 1: 9-15
Gagliardino JJ, Olivera EM, Barragan H, Hernandez RE 1995 Diabetes
Mellitus e Hipertension Arterial Aspectos clínicos y epidemiológicos en
la ciudad de La Plata Medicina Buenos Aires 55: 421-430
Guzmán Monterroso ZM, Palencia Prado JH 1999 Prevalencia de Diabetes
Mellitus en el departamento de Solola Trabajo presentado en la Primera
Reunión Científica Conjunta GLED-EDEG, Programa Científico, Buenos Aires
Harris MI 1990 Non-Insulin-dependent diabetes mellitus in black and
white Americans Diabetes and Metabolism Reviews 6: 71-90
Hernandez
RE, Cardonet LJ, Libman C, Gagliardino JJ 1984
Prevalence of diabetes in an urban population of Argentina Diabetes 81:
18-20
Jimenez JT, Palacios M, Canete F, Barrio Canal LA, Medina U,
Figueredo R, Martinez S, Melgarejo MV, Weik S, Kiefer R, Alberti
KGMM, Moreno-Azorero R 1998 Prevalence of diabetes mellitus and
associated cardiovascular risk factors in an adult urban population in
Paraguay Diabetic Medicine 15: 334-338
King H, Aubert RE, Herman WH 1998 Global Burden of Diabetes, 1995-2025
Diabetes Care 21: 1414-1431
Knowler WC et al 1978 Diabetes incidence and prevalence in Pima Indians:
a 19-fold greater incidence than in Rochester, Minnesota American
Journal of Epidemiology 108: 497-505
Lerman IG, Villa AR, Llaca Martinez C, Cervantes Turrubiatez L,
Aguilar Salinas CA, Wong B, Gomnez Perez FI, Guttierrez Robledo
LM 1998 The prevalence of diabetes and associated coronary risk
factors in urban and rural older Mexican populations J Am Geriatr Soc
46: 1387-1395
Malerbi DA, Franco LJ 1992 The Brazilian Cooperative Group on The
Study of Diabetes Prevalence Multicenter Study of the Prevalence of
Diabetes Mellitus and Impaired Glucose
Tolerance in the Urban Brazilian
Population Aged 30-69 yr Diabetes Care 15 11 1509-XX
Miller GJ; Maude GH; Beckles GL 1996 Incidence of hypertension and
non-insulin dependent diabetes mellitus and associated risk factors in a
rapidly developing Caribbean community: the St James survey, Trinidad J
Epidemiol Community Health 50 5: 497-504
Mouter JP, Kangambeza-Nouvier P, Donnet JP, Pileire B, Echvege E,
Patterson AW 1990 Diabetes Mellitus and Public Health in Guadeloupe
W I Med J 39: 139-XX
Proctor, T 1995 The Essence of Management Creativity New Jersey:
Prentice Hall International
Raggobirsingh D, Lewis-Fuller E, Morrison E 1995 The Jamaican Diabetes
Study A Protocol for the Caribbean Diabetes Care 18 9: 1277-XX
Rawlinson, JG 1981 Creative Thinking and Brainstorming New York:Wiley
and Sons, Inc
Scholtes, P, Joiner, B, and Streibel, B 1996 The Team Handbook 2nd
ed Wisconsin: Oriel Inc
Sociedad Ecuatoriana de Endocrinología 1998 Recomendaciones de Consenso
para Ecuador sobre el Diagnóstico y Manejo Básico de Diabetes Mellitus
Tipo 2 Quito: SSE
VanGundy, AB 1987 Creative Problem-Solving Connecticut: Greenwood
Press
West KJ, Kalbfleisch
JM 1966 Glucose tolerance, nutrition and diabetes
in Uruguay, Venezuela, Malaya and East Pakistan Diabetes 15: 9-18
White F, Vega J, Aedo C, Jadue L, Robles S, Salazar R, Delgado I
1998 Proyecto de demostración en educación en diabetes Informe Final
Organización Pan Americana de la Salud Eli Lilly
World Health Organization 1999 Definition, diagnosis and classification
of diabetes mellitus and its complications Report of a WHO Consultation
WHO/NCD/NCS/992 Geneva: WHO
Annex 1: Participatory Techniques Summary
Brainstorming Technique
Multivoting Technique
Nominal Group Technique
The session includes three main activities:
1 Brainstorming Session
2 Multivoting Session
3 Nominal Group Technique
I Brainstorming Session
This type of technique is used to achieve a spontaneous, abundant, and
creative generation of ideas or solutions to a subject/problem presented to
a working group It is fundamental that four main rules be observed at all
times during the session Furthermore, these same principles should be
observed during the multivoting and nominal technique sessions
Rules of Participation
The success
of the session depends on the observation and maintenance of
these four rules of participation throughout the of teamwork process
1 Suspend all types of criticism or judgmental remarks: This rule requires
that every participant including the leader of the group refrains from
voicing any criticisms or judgmental remarks about what other people say
during the brainstorming session No criticisms or self-criticism is
permitted among the participants of the session Any person that criticizes
someone elses ideas example that idea seems a little silly he or she
will be explicitly requested to suspend this type of behavior
2 Free thinking: This rule suggests that all the barriers or inhibitions
are left behind during this session The participants should allow
themselves to be spontaneous and creative, offering all sorts of ideas even
those that may not seem to make a lot of sense All the ideas are permitted
and duly noted
3 Quantity over quality: In this type of exercise what is important is to
achieve the greatest number of ideas without taking into account their
quality Any idea is important regardless of its quality The participants
should feel comfortable and motivated to say any
idea that comes to mind
without feeling restrained by the lack of merit of these ideas
4 Cross-fertilization of ideas: This rule suggests that the participants
can create their own ideas based on the ideas of other participants In
other type of sessions this type of behavior may not be considered
appropriate or polite to steal somebody elses ideas However, for
this type of session it is accepted and even encouraged in order to
generate the greatest number of ideas possible If the idea of a
participant stimulates the idea of another participant both ideas should be
written down It is important to strengthen this rule among the
participants of the session in order to avoid competition or rivalry
between of the members of the group The cross-fertilization of ideas makes
possible the exchange and enrichment of different ideas among the
participants of the group, in an environment of collaboration and total
acceptance
These rules should be written and explained to the participants of the
group A written copy of the rules should be available at all times during
the session Any participant who does not follow the rules, should be
warned by the leader or another participant and will
be informed as to
which rule of participation he/she is not following It is fundamental that
the implementation and strict adherence to this rules takes place because
the integrity and the effectiveness of the session depends on them
Instructions for the Brainstorming Session
Every participant should have the following information in advance:
1 The problem/topic selected for the session
2 Relevant information related to the discussion topic
3 Copy of the participation rules
4 The exact hour and place where the session will take place
Each group should consist of approximately five to seven people and a group
leader
At the beginning of the exercise the topic of discussion should be
presented again to the group participants, also review the rules of
participation, and re-define the topic of discussion if necessary A
practice session is encouraged 5 minutes of brainstorming session on a
simple, non-controversial topic of discussion For example, different
forms in which a stew can be prepared, or different ways you can build a
birdhouse, etc
Written Brainstorming Session: The exercise requires that each participant
works in silence and that no discussion
or comments of any of the ideas
take place during this phase of the session Each person should work
individually Practical jokes, observations, etc in this phase of teamwork
should not be permitted
Method
1 Every participant gets a form, a table with three column and 7 lines, in
which they will write down identified problems
2 Each member should write as quickly as possible 3 problems/ideas in the
first row of the table
3 When all the participants have finished writing their ideas, the ideas
are placed in a box which will be placed on top of the working table,
and every participant should take out at random from the box or
container a new sheet If a participant finishes before the other people
in the group, he/she should wait in silence
Option: pass the sheet of paper to the person sitting to the right hand
side of him/herself The leader must decide which option will be used
4 On the next round, each person will pick at random a new sheet, and
write 3 more problems Participant may use the ideas written before on
the sheet by a different person, to come up with new ideas cross-
fertilization principle
5 This process goes on until the seven
lines of the form are completed
This exercise lasts for approximately 30 minutes
Break for 10 minutes
6 When the participants return, each participant takes a sheet of paper
First, each person will take turns reading ideas identified in the form,
and cross-out those that are redundant Each new idea should be written
in a flipchart and will be hung on the wall so that all the
participants may see it
This exercise lasts for approximately 20 minutes
II Multivoting Session
This technique is used to reduce the number of ideas generated at the
brainstorming session
During this session, a selection of the most important identified
ideas/problems will be done This technique will help to reduce the number
of ideas generated during the session to a more manageable number of
approximately 4 to 5 ideas/problems chosen by the group
Method
1 A list with the all problems identified during the brainstorming
session is taped on the wall
2 Each participant votes in silence for those ideas/problems that he/she
considers more important Every participant can vote for as many
problems/ideas he/she
wants
5 After voting, the group facilitator calls out loud each idea in the
list one by one At this point, participants are asked to raise
their hand when an idea they have selected/voted is being called A
total score is obtained for each problem/idea
6 Only the ideas/problems with more number of votes are selected for a
second round of voting, and written down on a new sheet f paper You
can also draw a circle around the selected problem from the original
sheet of paper in the flip chart
7 A second voting round takes place with only the problems with more
number of votes During this second round of voting, each participant
can vote for a maximum, that cannot exceed half of the total of the
ideas pre-selected in the previous round For example, if in the
previous round 20 ideas were chosen, every participant cannot
vote/select more than 10 ideas in this second round, and not more than
five in the third round, etc
8 Repeat exercise until 4 or 5 final ideas are obtained These four or
five final ideas are the ideas/solutions selected by the group
time available for this
exercise 40 minutes
Break for 10 minutes
III Nominal Ordering Technique
During the third group activity ideas are arrange in order of importance
Method
1 Write the 4 or 5 ideas selected during the previous session in a piece
of paper and make a copy for each members of the group
2 The form should be presented in the following way:
A Idea _____
B Idea _____
C Idea _____
D Idea _____
3 Each participant will be asked to write a number from 1 to 4 next to
each problem in the list, that will indicate his/her perceived degree of
importance of the problem Note that the higher the number eg, 4 the
more important the idea Example: Number 4 indicates the most important
problem, 3 the most important second, 2 the following most important and
1 the least important
Example
A Idea _____ 3
B Ideas _____ 4 more important
C Ideas _____ 2
D Ideas _____ 1 less important
4 The voting sheets are given to the group leader and a total score is
computed for each problem with the votes of each member
Example
A 2, 3, 2, 4,1 12
B 1, 4, 2, 3,1 11
C 31 33, 4 14
D 4, 2, 4, 1, 2 13
5 The group re-organizes the list of problems in order of importance
A More important third
B More important room
C More important
D More important second
Once the most important ideas/problems have been identified and arranged in
order of importance, the team and leader is of the group s can use this
information for the development of a strategic plan or for a cause - effect
diagram
The usefulness of these types of techniques is that they allow for the
creation of an enormous quantity of information by the work group, in a
very creative and spontaneous fashion In addition, they allow to select
and give priority to those ideas that the participants considered to be
more important for their countries/regions If a plan is developed from the
ideas selected using these techniques, these activities are more likely to
be supported by the participants in the group, since they were part of the
process
Annex 2: Final Evaluation of the Workshop
In general, the participants were very
excited about the workshop and
worked with a great deal of enthusiasm
The following graph shows the scores given by the participants in the
workshop evaluation A10 point scales was used 10 excellent, 0 deficient
These are some of the opinions obtained as responses to the open-ended
questions of the evaluation These were as follows:
1 Very important because it is going to allow us to develop concrete
programs in each of our countries
2 Excellent event, especially if there is a continued effort by the
countries representatives to develop the proposed plans of action
3 Dynamic and effective work group techniques that made it possible to
maintain the interest through the different working sessions This
will allow for the continuity of the project and to conduct the survey
of prevalence of DM in the participating countries
4 The logical framework was probably handled without the necessary
rigor, due to the limited time
5 Greater definition of follow-up strategies
6 The methodology was new for almost all the participants That brought
difficulties The results could have been expressed more concretely
for each
country
Annex 3: List of Participants
|No |Name |Institution |Telephone/e-mail |
|1 |Lucy Villagra |HALF, Managua, |villagra@nicaraoorgn|
| |Gutiérrez |Nicaragua |i |
|2 |Martha Shepherd |PAHO/WHO CIN |2894202 |
|3 |Roberto Sempertegui O|PAHO/ECU |rsempert@opsecuorgec|
|4 |Alejandro Mayer |Diabetic Asoc de ELS |260-5682 |
|5 |Miguel Ernesto Elas |MSPAS ELS |miguelas@yupimailcom |
|6 |Gustavo Zuniga |MS - TEGUCIGALPA |237-3160 |
|7 |Ruben Palm |FundDiab Honduras |239-9373 |
|8 |José Rolando Hernández|MSPAS ELS |221-1618/222-3324 |
|9 |Byron Cifuentes |FEDIABETES-ECU | |
|10 |Manuel Ramírez |INCAP-GUT |mramirez@incaporggt |
|11 |María Isabel Jule de |ASOCDIAB ELS |260-5682 |
| |Hernández | | |
|12 |Enrique Aguilar |MPH ECU |593-2-566197 |
|13 |Ruth Vega of |PAHO/WHO/ELS
|rmanzano@oporgsv |
| |Apple-tree | | |
|14 |Patricia Orellana |MSPASGUT |orellanapp@pronetnet|
| | | |gt |
|15 |Rolando Hernández |AsocSalvDiab ELS |260-5682 |
|16 |Gladys Ana of Cortéz |AsocSalv-Diab ELS |agal@saltelnet |
|17 |Miguel Machuca |PAHO/WHO HOND | |
|18 |Rosario of Takes out |HOSPROSALESELS |jlsaca@insatelsacom |
| | |MSPAS | |
|19 |Nery Edgardo Ruíz |MSPASHOSPROSALESELS|222-5866 |
|20 |Navy Antonio Panameño |AsocSalvDiab ELS |260-5682 |
|21 |Romero Mauricio |PAHO/WHO/ELS |mromero@elsops-omsor|
| | | |g |
|22 |Mario Valcárcel Novo |PAHO/WHO EL SALVADOR |mvalcarcel@opsorgsv |
|23 |Raúl Armando Palomo |MSPAS, El Salvador |221-0978 |
|24 |Julio Garay Ramos |MSPAS, El Salvador |julioels@hotmailcom /|
| | | |221-0978
|
|25 |Marta Dinora A De |MSPAS, ASADI,El |223-9947 |
| |Maza |Salvador | |
|26 |María Elena de |MSPAS, ASADI, El |mecastelar@citnet |
| |Castelar |Salvador | |
|27 |María of the Carmen |PAHO/WHO-Bolivia |mdaroca@bolopsorg |
| |Daroca | | |
|28 |Rafael Baltrons |MSPAS ELS |295-1357 |
| |Orellana | | |
|29 |Dinorah of Mace |Asoc Salv Endocrino|225-3377 |
|30 |Laura Branches |MSPAS ELS |221-0978 |
|31 |María Mercedes de |MSPAS ELS |221-0966 |
| |Padilla | | |
|32 |Alberto Barceló |PAHO/WHO-Washington DC|barceloa@pahoorg |
|33 |Christine Karkashian |PAHO/WHO-Washington DC|karkashc@pahoorg |
Annex 4: Agenda
Wednesday, 8 March 2000
8:30-8:40 Opening by Mr Gladys de Cortez, Subdelegate for
Central
America, Region SACA/IDF
8:40-8:50 Welcome by Mr Alejandro Meyer, President of ASADI
8:50-9:00 Allusive words to the event by Dr Horacio Toro, PAHO/WHO
representative, El Salvador
9:00-910 Official inauguration by Dr José Francisco López Beltrán,
Minister of Health
9:10-9:20 Brief personal presentation of the representatives of each
country
9:20 Plenary Session:
President: Dr Mario Valcarcel, PAHO, El Salvador
Facilitator: Dr Miguel Machuca, PAHO, Honduras
Subject: Current situation of diabetes in the Americas
Objective: Describe the principal problems that affect
surveillance and control of diabetes in the Americas
9:20-09:40 Presentation: Diabetes in Latin America and the Caribbean Dr
Alberto Barceló
9:40-10:00 Presentation: The example of Bolivia Survey of Diabetes,
Obesity, and Hypertension in Bolivia Dr María del Carmen
Daroca
10:00-10:20 Coffee and pupusas
10:20-11:20 Round table: Current situation of diabetes
Moderator: Dr Mario Valcarcel, PAHO, El Salvador
a El Salvador, Dr
Roberto Cerrito, ASADI
b Nicaragua, Dr Lucy Villagra, Ministry of Health
c Guatemala, Dr Patricia Orellana, national authority of
Noncommunicable
d Honduras, Dr Ruben Palma, president of the Federation of
Prevention of Diabetes in Honduras
e Ecuador, Dr Byron Cifuentes Alvear, president of Ecuadorian
Diabetes Federation
f
11:30-12:30 Teamwork
Subject: Critical needs for surveillance and control of diabetes
in the subregion
Objective: Propose activities to carry out for diabetes
surveillance and control in the participating countries
Suggested Subjects: Definition of the problem Objectives of
surveillance and control of diabetes Diagnostic criteria The
registries of people with diabetes Mortality from diabetes The
programs for attention in diabetes The education of the general
population Advocacy in diabetes The systems of health and
diabetes Availability of insulin, drugs and other critical
supplies
Facilitators: Dr Mario Valcarcel, Dr Christine
Karkashian, Dr
Alberto Barceló, Dr María of the Carmen Daroca
12:30-14:00 Luncheon
14:00-16:00 Continuation of the teamwork
16:00-17:00 Plenary Session
Presentations of results of the teamwork
President: Dr Miguel Machuca, PAHO, Honduras
Facilitator: Dr Patricia Ruiz, PAHO, Guatemala
Thursday, 9 March 2000
9:00 Plenary Session
President: Dr María of the Carmen Daroca, PAHO, Bolivia
Facilitator: Dr Roberto Sempertegui, PAHO, Ecuador
Subject: Current situation of the education in diabetes in El
Salvador
Objective: Describe the programs for education in diabetes of
the Salvadorian Association of Diabetes
9:00-9:20 Presentation: Education in Diabetes Mr Ana Gladys A de
Cortez
9:30-9:50 Round table: The Gender in the Health Care of Diabetes:
Nicaragua and El Salvador
Moderator: Dr Christine Karkashian, PAHO, Washington
Nicaragua, Gilma Tinoco, PAHO
El Salvador, Mr Laura Ramos, Ministry of Health
10:00-10:30 Teamwork
Subject: Introduction to a plan of
action
Objective: Development of a proposal for diabetes surveillance
and control of diabetes Description of the method of work, as
well as the location in time and space of the proposal
Suggested Subjects: Selection of one or more subjects on the
basis of the results of the teamwork of the first day
Facilitators: Dr Mario Valcarcel, Dr Christine Karkashian, Dr
Alberto Barceló, Dr María of the Carmen Daroca
10:30-10-50 Coffee and pupusas
11:00-12:30 Continuation of the teamwork
12:30-14:00 Luncheon
14:00-17:30 Plenary Session
President: Dr Miguel Machuca, PAHO, Honduras
Facilitator: Dr Manuel Ramírez, INCAP, Guatemala
Teamwork presentation
17:30-18:00 Closing remarks
———————–
The knowledge of the diabetes prevalence in Latin America and the Caribbean
is limited There are many countries in the region where diabetes has never
been studied Most of the diabetes surveys conducted in Latin America and
the Caribbean were conducted many years ago Others, like Colombia
and Cuba
have monitored risk behavior as part of their surveillance systems Figure
1 shows results of population surveys in the Americas In Canada, the
reported diabetes prevalence was 4 among adults The highest diabetes
prevalence rate has been documented among the Pima Indians of Arizona in
the United States Hispanics, Caucasians and African Americans living in
the United States have shown prevalence rates of 8, 7 and 4
respectively In Jamaica diabetes prevalence was reported at 175 in 1995
Other studies in the Caribbean reported diabetes prevalence rates of 145
in Cuba, 6 in the Dominican Republic and 6 in Guadeloupe A small study
in Guatemala showed a prevalence of diabetes of 7 among adults Studies
conducted in Peruvian adult volunteers reported a diabetes prevalence rate
of only 2 Surveys in Argentina, Paraguay, Uruguay, Brazil and Colombia
showed diabetes prevalence rates between 7 and 8 Recent studies conducted
in Chile and Bolivia documented diabetes prevalence of 7 and 8
respectively The lowest prevalence rate of diabetes in the Americas was
reported among the Mapuche Indians of Chile in 1985 0 males and 02
females This ethnic group was studied recently reporting a low
prevalence
of diabetes 2
Table 1: Diabetes, hypertension and obesity by gender Bolivia, 1999
|Variable |Total Number|Male |Female |Both |
| | | | | |
| | | | | |
|Diabetes |2533 |68 |76 63-89|72 |
|Mellitus | |52-85 | |61-83 |
| | | | | |
|Hypertension |2533 |215 |178 |196 |
| | |191-240 |156-200 |180-213 |
| | | | | |
|Overweight |2530 |566 |647 |607 |
| | |532-599 |623-670 |584-629 |
Diastolic blood pressure 90 mm Hg y
Systolic blood pressure 140 mm Hg
BMI24
In Bolivia, a survey of diabetes, hypertension, and obesity was conducted
A total of 2,533 people from four sites El Alto, La Paz, Santa Cruz and
Cochabamba participated Prevalence of diabetes was 72 6,1-83 The
results of this survey have been used to design an intervention program to
improve
medical care for people with diabetes
Table 3: Annual direct cost per person with Type 2 diabetes Ecuador, 1999
|Rubro |Cost in US |
|Laboratory |3200 |
|Medicines |26516 |
|Glucose monitoring test |9600 |
|Medical care |4800 |
|Total |44116 |
Official statistics showed that in Ecuador, in the last 30 years, a
progressive increase in diabetes mortality has occurred, mainly among
people older than 45 years An increasing trend has also been seen in the
number of hospitalizations caused by diabetes chronic complications
Diabetes will become the most frequent disabling chronic disorder that
affects the Ecuadorian population in the next decades Ecuadorian Society
of Endocrinology
Table 4
Values for Diagnosis of Diabetes Mellitus and Other Categories of
Hyperglycaemia
|Normoglycemia |IFG or IGT |DM |
|FPG 110mg/dl |FPG126mg/dl and |FPG 126mg/dl and |
|2hPG 140mg/dl |126mg/dl
IFG |2hPG200mg/dl |
| |2hPG 140mg/dl and |Symptoms of DM and random |
| |200mg/dl IGT |plasma glucose concentration |
| | |200mg/dl |
|A diagnosis of diabetes must be confirmed, on a subsequent day, by |
|measurement of FPG, 2-h PG or random plasma glucose if symptoms are |
|present The FPG test is greatly preferred becose of ease administration,|
|convenience, acceptability to patients and lower cost Fasting is defined |
|as no caloric intake for at least 8h This test requires the use of a |
|glucose load containing the equivalent of 75g anhydrous glucose dissolved |
|in water DM, diabetes mellitus; 2-h PG, 2-h postload glucose |
These criteria were published by the World Health Organization WHO and
the American Diabetes Association ADA
In Guatemala, the Instituto del Seguro Social a government institution
conducted a cross-sectional study to determine the prevalence of type 2
diabetes mellitus in a sample of 400 inhabitants of an indigenous
population living in Sololá Participation in the study was in a volunteer
basis
among people aged 35 years and older Blood samples were taken to a
random sample of participants Diagnosis of diabetes was based on the WHO
diagnostic criteria A total of 28 cases of diabetes were identified, that
represented a prevalence of 7 Only 37 reported to have previous
knowledge of being diabetics Diabetes was more prevalent among men of 45-
49 years of age and among women of 35-39 years of age Even though the
sample was small and that participation was voluntary and not a random
sample, this study is an indication that diabetes could be a health
problem in Guatemala
Source:awoosh.com
