Maritime Health Research and Education-NET/Organisation

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Management[edit | edit source]

Minutes from Board meetings[edit | edit source]

MAHRE-Net-Name-Orcid-Institution-Mail[edit | edit source]

https://en.wikiversity.org/wiki/%27%27%27CONTENTS_OF_THE_16_WEEKS_COACHING%27%27%27

Abstract[edit | edit source]

Seafarers and fishermen have an increased risk for diabetes and hypertension as part of the metabolic syndrome including overweight and obesity. Pre-diabetes increases the risk of developing type 2 diabetes, heart disease, and stroke. In Spain, 22% of those with overweight and 41% of those with obesity have diabetes. The fishermen have 2 times higher risk for diabetes compared to the seafarers. Thankfully, you can reverse the damage of pre-diabetes and we can help you. In view of the good research results from the coaching prevention non-maritime areas e.g.[1] [2] [3][4][5]. We are challenged to try-out using similar methods including Coaching with our partners in the maritime medical clinics as an extension of the ongoing prevalence study of Prediabetes and T2D. The study population of seafarers with newly diagnosed pre-diabetes in the maritime medical clinics. The purpose is to educate and support the seafarers so they by patient activation, efforts, knowledge self-management and self-esteem based on specific study materials on T2D for seafarers and supported by coaches to normalise elevated blood sugars and blood pressure and weight. We take the advantage that the seafarers have health examinations anyway biannually and that lots of training materials specifically for seafarers have been developed in the latest years, that reduce the costs, facilitates the study, reduces the number of non responders and increase the quality of the project by including coaches, with knowledge on the seafarers work, health and life and prevention on diabetes type 2. To try out for a start, one or more will give coaching for free over 16 weeks to an invited seafarer - or other professional - and report the experiences to adapt the project to bigger study populationn

INTRODUCTION[edit | edit source]

The program combines the biannual, mandatory clinical fit-for-duty health examinations for seafarers and fishermen in a Public Health perspective with biannual screening for Diabetes Type 2 and Hypertension and a pilot intervention project using Coaching support to the seafarers and fishermen who wants to join the trial and learn more about how they can prevent diabetes themselves.

Seafarers, have a great inequity in health at work with a higher risk of overweight, metabolic syndrome, diabetes type 2 and hypertension and a need for accurate early diagnosis and prevention.[6] [7] [8] [9] [10][11] While the objective one hundred years ago for the fit-for-duty medical examinations was mainly related to the safety for the seafarers and the ships, now the ILO guidelines inspire to include protocols related to the general health of seafarers beyond the fit-for-duty protocol. The focus on early diagnosis of Type 2 diabetes and hypertension seems to be a good choice for intervention based on the evidence that pre-hypertension and pre-diabetes mellitus Type 2 can be reversed by non-pharmacological and pharmacological measures, which is the background for our trial. [12] [13][14][15][16]


Statement of the Problem (scientific justification)

Seafarers, have a great inequity in health at work with a higher risk of overweight, metabolic syndrome, diabetes type 2 and hypertension and a need for accurate early diagnosis and prevention[17] [18] [19] [20] [21]. While the objective one hundred years ago for the fit-for-duty medical examinations was mainly related to the safety for the seafarers and the ships, now the ILO guidelines inspire to include protocols related to the general health of seafarers beyond the fit-for-duty protocol. The focus on early diagnosis of Type 2 diabetes and hypertension seems to be a good choice for intervention based on the evidence that pre-hypertension and pre-diabetes mellitus can be reversed by non-pharmacological and pharmacological measures, which is the background for our proposed trial[22] [23][24][25][26].

Justification and Use of the Results (final objectives, applicability)

Based on a systematic review, a limited number of studies of lifestyle interventions in the maritime setting exist, the quality of them is generally modest and failed to demonstrate substantial health benefits for seafarers. None of them focussed on pre-diabetes.[27] In a 2 years follow-up of a primary intervention study of the metabolic syndrom (MS), among seafarer the prevalence of MS increased in this group of seafarers instead of an expected improvement. [28] In contrast to the deceiving results of primary lifestyle interventions, a systematic review focusing on diabetes type 2 showed significant positive effect of patient self-management behaviors, particularly physical activity, healthy diet, foot care and blood glucose self-monitoring [29] This is in agreement with the general conclusions previously that primary prevention of lifestyle diseases most often fail, while secondary prevention studies e.g. for T2D has good success rates[30].

Corresponding to our own experiences, other authors have observed that after receiving a prediabetes diagnosis, it is normal for patients to experience a wide range of emotions—from shock and fear to disbelief. While most of the patients didn't know that pre-diabetes can be reversible by their own efforts, this calls for education of the seafarers on how they they can do themselves with effect [31]. Further, the justification to focus on pre-diabetes is based on the evidence that pre-diabetes is potentially reversible if the right steps are taken in time which is possible for seafarers and other job categories with obligatory medical examination every two years. Since around year 2000 came studies to show the possibility to prevent T2D by early focusing on pre-diabetes and CDC launched the first national campaign to raise awareness of pre-diabetes in 2016.[32][33].However, the importance of pre-diabetes for early prevention of T2D is obviously not well accepted that might be why the T2D prevalence studies still disregard the possibility to start an effective early prevention looks like disregard of good medical practice[34][35]. A review study from 2019 concluded that undiagnosed prediabetes and T2D and the associated risk factors are prevalent in many regions in countries worldwide[36]. The lack of blood test with A1c for early screening and detection of pre-diabetes due to erroneous use of urine-sticks at the maritime health examinations was shown in our preparative papers for this study[37][38][39]. Now we aim is to help to establish good medical practice by using the A1c test adequately for early diagnostics of pre-diabetes and prevention by the use of personal coaching.

Theoretical Framework (argumentation, possible answers, hypothesis)

The evidence based hypothesis is that pre-diabetes can be turned to normal by the use of coaching prevention in non-maritime areas [1][2][3][4] that remains to be evaluated among seafarers and fishermen. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus. The Health Belief Model (HBM) has been widely used in pre-diabetes programs e.g. the English Diabetes Prevention Program has shown to be effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid level[40]. A systematic review aimed to compare the effectiveness of pharmacological and non-pharmacological interventions to reverse prediabtes to normal. Based on 54 studies included, the authors concluded that although several pharmacological approaches can reverse prediabetes, lifestyle modification provides the strongest evidence of effectiveness and should remain the recommended approach to address this condition[41]. An important hypothesis that has been rejected so far is that treatment with metformin is equally as effective as lifestyle intervention. However, there is evidence that lifestyle modifications is needed to prevent pre-diabetes and T2D for life time in comparison to metformin. Metformin is included in the Ship's Medicine Chest, which is useful for an acute pharmacological treatment on board, but not for long term prevention of pre-diabetes[42]. The effects of drug interventions are limited to the time of their use and do not permanently change the basic pathophysiology of insulin resistance or β-cell dysfunction. Lifestyle modification (LM) and medications (weight loss and insulin-sensitizing agents) successfully reduced diabetes incidence, while medication effects were short lived. The LM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed.[43] .Increasing access to digital health coaching may lead to more effective control of diabetes for under-resourced patients. Several studies demonstrates the potential to implement a personalized, digital health intervention to treat and manage T2DM through a lifestyle and behavioral approach to improve clinical outcomes.[44][45][46] To obtain significant effect, cut-off points of A1c and BMI for participation is chosen to be ≥ 39 mmol/L (≥ 5,7%) and BMI ≥ 25 [47]

Medical treatment and lifestyle changes.

Recently the GLP-1 agonist medicament (Wegovy) has increasingly been used for weight loss indicated for BMI > 27 with prediabetes and only indicated as an adjunct to low-calorie diet and increased physical activity for weight control, including weight loss and weight maintenance, in adults with a starting BMI (Body Mass Index) of ≥ 30 kg/m 2 (severe overweight) ≥ 27 kg/m 2 to < 30 kg/m 2 (overweight) and at least one weight-related comorbidity, such as dysglycemia (prediabetes). Metformin should also only be used together with lifestyle changes, diet and physical activity and only Patients where treatment with diet and exercise has been insufficient[48].

Research Objectives

The general aim is to educate and activate the seafarers so they by their own efforts, knowledge and empowerment supported by the coaches normalise their blood sugars, blood pressure and weight with an increased self-esteem. The study aims in specific to evaluate the effect of a 16 weeks diabetes health coaching in seafarers with new diagnosed pre-diabetes (T2D) and weekly self-administrated Glucometer- and blood pressure measurements on board and at home following their stepwise goals on physical training and healthy eating.

OBJECTIVES[edit | edit source]

The Diabetes Health Coaching study trial is designed to evaluate the effect of a 4 months diabetes health coaching intervention in seafarers with new diagnosed pre-diabetes mellitus (T2DM) on glycated haemoglobin (A1C) on the start and at the end and weekly self administrated glycometer, self-care behaviours. The purpose of this pilot study is to evaluate how the Coaching system functions.

METHODS[edit | edit source]

The eligibility criteria are: a) adults > 18 years of age; b) a diagnosis of T2DM pre-diabetes: A1C of 5,7%-6,4% (39-47 mmol/L) fasting blood glucose 100-125 mg/dl, c) All levels of Body Mass Index included, d) Ability to read, write and understand English or Spanish; e) Have telephone/internet access at home and on the ships and e) do not take diabetes medicine.

Table 1. Laboratory Blood Glucose test values in the clinics to decide who can participate
Blood Glucose A1C limits Fasting glucose limits
Normal ≤ 39mmol/L (5,6%) ≤ 100mg/dl
Pre-diabetes 39-47 mmol/L (5,7%-6,4%) 100-125 mg/dl
Diabetes ≥ 48 mmol/L (6,5%) ≥ 126 mg/dl

In 2024 xx patients in each of the participating maritime medical clinics, completing the elegibility criteria are asked to participate and randomised into the trial. Over one month or so, each clinic, selects xx matched pairs for age, gender, and ship type (fishing/merchant ship) and randomize them for the intervention and the control group. In this way the baseline characteristics of the participants are equally distributed across the intervention and control group and the information is given to the research group.

Table 2. Example of data from maritime clinic on prevalence, is the basis for the study
GEN AGE WORK SMO HTN A1c FG BMI BMI PHY FRU
M 23 SeaEngine Non-Smoker Stage 1 Pre 25,5 Overweight High None

When the seafarer accepts to participate, the data from the "prevalence study" form the basis for the intervention study, where the seafarer collects data every week on the recorded variables, that forms the basis for evaluating the effect of the trial and reporting the results internationally (evidence or data driven coching).

Table 3. Weekly meetings, seafarer and coach keep Excel records in the Intervention group. .
Date Med Kg Act Fruit FBS DIA BP SYS BP Study Smoke. Y/N At sea or home
Start. Nov None 95 low low 140 91 145 Y Y SEA
Goal 0 85 high high fine 85 135 Y N

Excel files for registration of data [49]. Each participant get "their own" Excel file deposited in the Coach's personal Google Drive, editable with the rights as Editors for the Seafarer to report the week by week data (automatic data saving) that is available for the Coach for comments in mails and collected for analysis for all 16 weeks at the end. "Start meetings" are held with the Coach and the participants in the Intervention group to be informed on the procedures of the trial one by one. The control group are informed that we want to observe what happens with them in 4 months without any specific intervention. Both the intervention group and the control group are asked to contact the same clinic or another clinic after 4 months to register A1C, weight and the other variables (Excel scheme[49]). The Diabetes Health Coaching study for Pre-diabetes (T2DM) will examine the effects of the intervention on clinical outcomes, self-care behaviours (maybe more physical activity) and errors in the program to be corrected. To try out for a start, one or more coaches will start to give coaching for free over 16 weeks with only one or more seafarers with no control group and report the experiences to adapt the project to bigger controlled study populations.

Table 4. Values for self-testing with Glucometer, using the finger prick method
Fasting 1-2 hours after meal Random *
Normal ≤ 126 mg/dl ≤ 200mg/dl ≤ 200mg/dl
Diabetes. ≥ 126 mg/dl ≥ 200 mg/dl ≥ 200 mg/dl

A fasting glycemia that is, without calorie intake for at least 8 hours. A "1-2 hours after meal" glycemia equal to or greater than 200 mg/dl two hours after eating. A random glycemia = not knowing when you get the latest meal equal to or greater than 200 mg/dL in a patient with symptoms

Table 5. Schedule for the 16 weekly mails online meetings with seafarer and coach
Week > 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 End
Intervention Clinic Mail correspondences every Monday and Zoom meetings every 4 weeks Clinic

(1) Start and end meetings at the clinic, first meeting is the obligatory medical heath examination.

The "International Maritime research based Diabetes2/HTN Coaching Program" (IMDCP) is designed to teach and support seafarers on how to prevent the development of manifest type 2 diabetes and normalise their blood pressure and personal weight. The program targets individuals with (HbA1c) A1c = 39-47 mmol/L (5,7%-6,4%) who are currently not taking medication for diabetes. For the diagnosis of diabetes, these values are considered as in Table 1.

Laboratory tests

The start lab analysis includes A1c, total


Methodology

Operational Definitions

Table 1. Laboratory Blood Glucose test in the clinics to decide who can participate
Blood Glucose A1C limits Fasting glucose limits
Normal ≤ 39mmol/L (5,6%) ≤ 100mg/dl
Pre-diabetes 39-47 mmol/L (5,7%-6,4%) 100-125 mg/dl
Diabetes ≥ 48 mmol/L (6,5%) ≥ 126 mg/dl

Type of Study and General Design

The Diabetes Health Coaching study is a multi-centre, before- and after study with 16 weeks WhatsApp/mail personal health coaching among seafarers with new diagnosed pre-diabetes through an educational, lifestyle and behavioral approach. When the inaugurating study with few participants shows to be useful the trial is intended to be followed by a larger before- and after study and possibly a randomized controlled trial. The educational training is composed of stepwise readings, videos and WhatsApp talks with goal settings by advice from the coaches for changes of food and drink, physical exercise and readings week by week. The information materials are composed of online maritime educational pages, also useful for other professions as well. Personal online Excel reporting scheme located in "Google Drive" is prepared for each seafarer to write down their learnings, comments and goals to be addressed by the health coaches. They work one-on-one to educate and motivate participants on making changes in their goals for health life with emphasis on knowledge, self-esteem, nutrition, exercise, and weekly, progressive goals. Along with weekly contacts from their coach and access to online tracking tools and educational materials, the participants receive weekly WhatsApps to support them in their lifestyle change and occationally Zoom meetings with the health coaches. There is an abundance of health apps in the market like "Glucose Buddy Diabetes Tracker" and the "Apple Health" just to mention a couple of them. Most of them are reported to be used in combination of personal coaching with no evaluations whether they support to reverse pre-diabetes.[50][51][52]

Universe of Study, Sample Selection and Size, Unit of Analysis and Observation, Selection Criteria.

The universe of the study is the global population of seafarers and fishermen that are legally obliged to pass the seafarers' medical examination every 2 years in the maritime medical clinics worldwide. The first samples selection of about n=25 from each country comes from maritime clinics in several countries. This program targets individuals diagnosed with pre-diabetes or diabetes with an A1C ≥ 5,7% (≥ 39 mmol/L) fasting blood glucose ≥ 100 mg/dl; Body Mass Index ≥ 25, who are currently not taking medication for diabetes, adults > 18 years of age; Ability and to read, see videos and write English or Spanish. Having a mobile phone, laptop and internet access at home and on the ships.

Selection of the participants with the best education

Education gives people the tools they need to lead fulfilling lives and makes it more likely a person can access quality healthcare, “[53]. The ship’s complement is a hierarchal structure that consists of its leader, the master, and the two department heads, the chief mate and chief engineer. Within each department, the mates and engineers make up the deck and engineer officers. At the next level in each department, we have the ratings; these are skilled and less-skilled persons who make up the team required to run the ship. [54]. Based on this we primarily want to invite the the leaders on board as the participants, expecting they will succeed to reverse the pre-diabetes to normal. Further, they are also those who can propose changes on board, to facilitate the reverse the pre-diabetes to normal for the whole crew.

Participants activation

It is the challenge for physicians to give type 2 diabetes patients the tools for active participation in the management of the disease. Since patient activation model was developed by Hibbard and colleagues 2005 [55] . At start we include self-completed questionnaires of health (SF12), pattern of physical activity (IPAQ) and besides food, drink and snacks pattern. These assessments are repeated after the 16 weeks and the pattern are discussed with the seafarers in the weekly contacts. There basic questions are included from the start and at the end: Is it your our goal is to get rid of your pre-diabetes?; How many kg/Lbs do you want to loose in 16 weeks? Is your goal to have 150 min. phys active/week? Permission to use the anynomous data for research is obtained. In the weekly contacts we ask the our seafarers if they has succeeded to obtain the goals, step by step and to give acknowledgements to their gained goals. The results of the surveys, the weekly glucometer self-test, weight and the laboratories tests, A1c, cholesterol and the lipides gives an overwiev of the goals have been reached. Based on the evidence in coaching our mission as coaches is to inspire, not to give direct advice or orders to our clients. The survey results and the patients' self-measures, serve in two ways: as milestones to mark the stepwise improvements to support the patient activity in the weekly contacts, for a dialogue on the personal goals obtained and how to get there and as documentation for the research. Every week the coaches will send out by WhatsApp the task for the next week asking for the result s for the previous week. In agreement the clients and the coach will have online Zoom meetings to discuss hwo to get the goals support.

Laboratory tests

The start lab analysis includes A1c, total cholesterol, LDL, HDL and TG as part of the routine medical exams-to be reported in the Excel data scheme. The same lab tests should be repeated after 16 weeks training to evaluate the effects. There will be no extra costs for the maritime clinics as they are normally allowed to take extra laboratory tests when this is relevant for the seafarer's future health. For the study is also relevant to have lab. tests after 1 one and two years. The latter is part of the routine biannual medical examination.


Goal setting during a weight loss

The primary goal is to normalise weight, blood sugar and blood pressure by setting gradually more physical sub-goals that can be a good way to motivation[56] The seafarers write down their goals step by step in the Excel scheme and compare week by week the obtained results.

Requirements to be a coach for Maritime Diabetes Prevention Coaching

The requirements to be a coach: as a minimum to have a good knowledge on how to prevent diabetes type 2 to help the seafarers to prevent diabetes, hypertension and overweight. The coaches need to have knowledge on the seafarers work, health and life conditions on board. Certification to be an approved coach and support from the relevant maritime organisations to be developed to create credibility to the quality of the service. Training programs on how to be a good coach in general is offered from specialists in the area[57]

As a starting point, it is only the maritime doctors and practice doctors who, via their legal authorization, have the legal responsibility and not the coaches. Soefartsgerne and other authorized healthcare professionals can perform the same type of coaching as patient care under the same rights and duties as all healthcare professionals. Doctors and other health personnel can waive their authorization and carry out diabetes type 2 coaching without stepping over the maritime doctors' professional domain and without being responsible for patients. In order to cover the expected need for diabetes type 2 coaching, master coaching courses must probably be established in the long term for seamen, cooks, staff from the shipping companies and other relevant groups of people. Among the requirements will be that they themselves have completed a good diabetes type 2 coaching course.

Among the 16 weeks, there are multiple choice tasks that must be passed to get the certificate. We will be calling for short multiple choice tasks among WhatsApp groups.

The coaching methods

A mixture of personal telephone-based health coaching and digital data driven coaching method will be used. The digital data driven health coaching method is reported to give similar benefits to in-person or telephone-based health coaching. [58] We argue that, by using this method we have the potential to treat large numbers of individuals in diverse geographic locations, digital coaching offers a promising solution to the rapid increase in diabetes prevalence.

The Educational materials

Globally there is an abundance of materials to educate the population on prevention of overweight, diabetes and hypertension. There are lots of educational materials for seafarers, unfortunately these materials haven't been tested for their usefulness e.g. the ISWAN produced materials, which is also the intention to do and over time replace some of the materials by other and better materials [59].

The program contents and results before and after.

  1. BASIC DATA
Gen (M/F)
Age
Work (Fishing, Merchant, Other (F/M/O)
Tobacco y/n
Country
Height
May your data may be used for research ?
Weight in kg. at start
Goal weight in kg.
Weight in kg. at 16 weeks
2. QUESTIONNAIREs AT START AND END
IPAQ-test
SF-12 test
FFQ Food frequency questionnaire
Multiple choice Stress test [60]
3. 16 WEEKs FOLLOW-UP
To be completed/reported every week (Fridays or Saturdays):
Diastol Blood Pressure
Systolic Blood pressure
Fasting fingerpr Blood Sugar mg/dl (Fridays or Saturdays)
Weight kg
4. REACHING THE GOALS WEEK BY WEEK
Did you reached your goals last week? Yes=1, Nearly=2; No=3,
Goal 1 Did you do 150 minutes/ week physical activity or more?
Goal 2 Eating less high calory meals
Goal 3 Did you take sufficient fruit and vegetables
Goal 4 Taking less snacks and coca-cola
Goal 5 Use good time for learning by texts and videos
Goal 6 Get less stress
5. MARITIME HEALTH EXAMINATIONS start and end
A1C %
Taking diabet medicine? Y/N
Taking blood press medicine? Y/N
Weight kg
Hypertension HTN
BMI
Total Cholesterol
LDH (low-density lipoprotein -not good )
HDL (high-density lipoprotein -good one)
TG Triglycerides
Body circumference cm

Analysis of the data is the base for the evaluation of the size of effect in the 4 different parameters to be used in the learning whether there is a significant effect and how to improve the program to make the most effective interventions programs.

CONTENTS OF THE 16 WEEKS COACHING

To be done by the maritime medical clinic at start.
  • The medical clinic does the usual lab analysis including weight, height, HbA1c, total cholesterol, LDL, HDL, and TG
  • The Clinic selects a possible participant that complies with the inclusing criteria.
  • The clinic Informs the seafarer that the clinical diagnosis is pre-diabetes, that can go back to normal by joining a Coaching program.
  • The seafarer gets the invitation to participate with the objectives and the plan for the coaching in 16 weeks
  • The clinic informs the Coach with contact information the and hands out lab. test results to be added to the Excel file
The first meeting online or physical with the seafarer and the coach
  1. Information on the objectives and the content of the program
  2. His/her possible access to wifi and mobile phone during the next 4 months
  3. Information on how to complete the Excel Scheme (a specific day of the week, e.g. every Saturday)[61].
  4. Agreeement on the start and end day of the program
  5. Agree to buy and bring on board: a Glucometer,[62] and a Blood pressure monitor [63]
  6. Exchange of contact information on mail, mobile WhatsApp and time zones
  7. The seafarer complete the IPAQ test and Coach register the result
  8. The seafarer complete15-Item Food Frequency Questionnaire Measuring Dietary Quality, by the Diet History Method
IPAQ Start self-test The coach take care the seafarer complete the IPAQ test and register the result
To be done by the Seafarer at start, week 1.
Measurements Learn to use Glucometer & Blood pressure monitor.
Laboratory tests The start including A1c, total cholesterol, LDL, HDL, TG from the medical exams to Excel scheme[61].
Personal measures Waist Circumference, cm - How to measure: [64]
Excel scheme, Learn to use the Excel scheme and report the actual status of physical activity, healthy eating and goals
Knowledge T2D test Multiple test of knowledge on T2D and prediabetes (Fitzgerald et al.)
IPAQ START test The seafarer completes the IPAQ test and Coach register the result
FFQ START test The seafarer complete15-Item Food Frequency Questionnaire and the Coach register the result
SF-12 test For wellbeing and healty the Coach register the result
Stress test Do the stress test at the start, in th emiddle and at the end.
To be done by the Seafarer and the Coach every week
To be done by the Seafarer: Complete the Excel file with the results at the end of each week. Measure Blood pressure self-test on two selected days a week

Make the Glucosemeter fasting self test on a fixed day in the week, eg Saturdays. Add all the results to the Excel sheet on Saturdays Read and be orientated on the reading materials marked with A for the weeks meeting.

To be done by the Coach: Get the name and mobile for the seafarer who wants to join

Invite the seafarer for a short orientation Zoom meeting Stay orientated on the seafarers results and the goals in Excel file Send WhatsApps on all Mondays to the participant and praise the goals and the results obtained

Select important readings with an adequate size to be (skimmed) read by the seafarer - marked with an "A"Readings marked with "B" are optional

To be done by the Seafarer at start, after 16 weeks and after 1 year
Laboratory tests Get the lab analysis done including HbA1c, and Total cholesterol, LDL, HDL, TG (report in the Excel)
Personal measures Weight kg and Hip Circumference, cm
Knowledge test Multiple choice test
IPAQ END test The seafarer completes the IPAQ test
FFQ END test The seafarer complete15-Item Food Frequency Questionnaire
SF-12 test For wellbeing and healty the Coach register the result.
STRESS-self test https://www.healthcentral.com/quiz/stress-test
The specific tasks to be done by the seafarer week by week - for evaluation we ask for multiple choice tasks WhatsApp groups.
Goals for type of eating and for training and for weight
Week 1 Prevention of Pre-diabetes A Youtube: Pre-diabetes can be reversed 4 min;[65]ASÍ REVIERTES LA PREDIABETES[66]A Pre-diabetes is a serious health condition: What you need to know (Safety4Sea)[67] A How to prevent type 2 diabetes [68] B What is pre-diabetes type 2 & how to stay healthy(CDC)[69]
Week 2 Prevention by keeping

Physical fit

[70]A How to stay fit? [71] Good exercises for prediabetes

B How to do a proper workout on board[72] Do resistance bands really work?[73] Rubber resistance bands for muscle strength training[73] [74] in the Excel scheme, write down your actual weekly scheme for physical activity and which goals you have.

Week 3 Prevention by

Healthy eating

A Youtube: Healthy eating 4 min [75]A How can I reduce my risk of type 2 diabetes and Hypertension?[76] A: By Healthy Eating and stay healthy fit[77]

B BCH Lecture: How to Stop Pre-diabetes from Becoming Diabetes[78] B No-sugar meal plan for prediabetes [79] Should you have diabetes diet even if you dont have diabetes[80] in the Excel scheme, write down your actual weekly scheme for your eating style and which goals you have for your food pattern and physical training

Week 4 Prevention of High Blood pressure. A What is blood high blood pressure?(Hypertension) [81]A Drug-free approach to lowering high blood pressure[82] A Controling hypertension at sea, Gard[83]
Week 4 Blood glucose A Normal Values of blood glucose[84]A Diabetes Home Testing[85]

A How to use the Glucometer? [86] [87]

Diabetes & work A Supporting seafarers with pre-diabetes on board [88]
Week 5 Welbeing on board A Welbeing courses for seafarers [89] A How to manage seafarers’ mental health challenges[90].
Week 6 Overweight. A What is overweight, the health risks and how to prevent[91]
Week 7 Obesity A What is obesity, the health risks and how to prevent? [92]
Tablets for T2D A Tablets (Metformin) is not the first choice of prevention[93][94]
Week 8 Sleep and rest A How to cope with sleep and nightwork [95]
Week 9 Healthy food A Healthy Eating Diabetes, online Harvard University [96][97] B Cooking course for young seafarers [98]
Seafood and Diabetes T 2 A What is the best seafood for Diabetes Type 2 (T2D)?[99]
Meats A Meats for T2D [100]
Week 10 Snack A Type 2 Diabetes-Friendly Snacks for When You’re Short on Time [101]
Week 11 Drink type A What to drink as prediabetic [102]
Week 12 Alcohol A Alcohol and diabetes 2[103]. A Calories in different types of alcohol [104] A What should my daily intake of calories be? [105]
Week 13 Fibers in the food A Best high fiber snacks for diabetes[106]
Week 14 Dental care A Dental care for seafarers ISWAN [107]
Week 15 Social welbeeing A ISWAN Seafarers welfare, fitness to prevent Diabetes type 2 [108]
Week16 Evaluation and accreditation The seafarer present the goals and the results by using the Excel sheet to the Coach. Were the goals obtained?

Multiple choice test on their knowledge on T2D is repeated The Coach sign a Certificate for the Seafarer for having completed the16 weeks' course with coaching

Data Collection Procedures, Instruments Used, and Methods for Data Quality Control

  1. The medical clinic does the usual lab analysis including weight, height, HbA1c, total cholesterol, LDL, HDL, and TG
  2. The Clinic selects a possible participant that complies with the inclusing criteria.
  3. The clinic Informs the seafarer that the clinical diagnosis is pre-diabetes, that can go back to normal by joining a Coaching program.
  4. The seafarer gets the invitation to participate with the objectives and the plan for the coaching in 16 weeks
  5. The clinic informs the Coach with contact information the and hands out lab. test results to be added to the Excel file

In 2024-25 xx patients in each of the participating maritime medical clinics, completing the elegibility criteria are asked to participate (in the next phase) and randomised into the trial. Over one month or two so, each clinic, selects xx matched pairs for age, gender, and ship type (fishing/merchant ship) and randomize them for the intervention and the control group. In this way the baseline characteristics of the participants are equally distributed across the intervention and control group and the information is given to the research group.

Procedures to Ensure Ethical Considerations in Research with Human Subjects

Confidentiality in the handling of personal data is in accordance with the rules of the national data protection agencies and the General Data Protection Regulation (GDPR) and is prepared with. No personally sensitive information is included in the data set given to the researchers, so approval from the Ethics Committee is not necessary in the European Countries. All the Excel data sheets ask for informed consent as the first question. Types of experiments not to be notified by the Ethics Committees: Questionnaire and interview surveys; Registry research surveys; Quality assurance projects; Non-interventional drug trials[109]. If the cluster and the individual practices in the cluster can access data that is aggregated for the individual extension number in a way that does not make it possible to identify individual patients, it is "statistical information" as far as the patients and personal data are concerned. in relation to the doctor identified via his outpatient number [110] [111]. The specific rules for countries outside the EU, will be followed.

Plan for Analysis of Results

Methods and Models of Data Analysis according to Types of Variables

Data are coded into categorical data and presented in tables. Descriptive statistics are used to identify basic characteristics of the data, including the percentage distribution of responses related to demographic background and job duties. "Outliers" are sorted out on the basis of the frequency tables (with values that are obviously larger or smaller than the average).

Programs to be Used for Data Analysis

Data are analyzed using SPSS version 28.0 and the Excel spreadsheets

Timetable

Establish national steering committees 2024-2028
Finalise the protocol and pilot test of education
More 16 weeks projects in different countries.
Data analysis, preparing articles & publications.
Collection data from the clinics and the coaches 2024-2026
Formalities about GDPR clarified
Analysis of data and tables preparations
Draft Article ready
Submission
Response to Review and revisions
Conference presentations
Evaluation of the project 2027

Budget 2024-2026 16 weeks coaching in each country

INCOME FROM COACHING N USD/16 weeks Total
Seafarers' payment 25 340 8,500
TOTAL INCOME 8,500
COSTS USD/seafarer
Payment to Seafarers clinic 25 15 375
Payment to the Coaches 25 304 7600
Research work 0
Bank +Administration 25 15 375
TOTAL COSTS 8,350
SURPLUS 150
Coach Hours per week/person USD/hour USD/week Total
0.5 38 19 304
Reading results, send mail comments/advice + 0.5 hour zoom meeting/month

Links to Budget: Spanish[112] English[113]

Annex 1

Excel file for registration of data for the Coaches and for the Seafarers

Each seafarer gets "their own" Excel file deposited in the Coach's personal Google Drive, editable with the rights as Editors for the Seafarer to report the data week by week (automatic data saving) that is available for the Coach for comments in mails and collected for analysis for all 16 weeks at the end. Link to the Spanish version: [114]

DISCUSSION[edit | edit source]

Our 16 week pre-diabetes coaching program is designed to inspire and support seafarers how to prevent the further development from pre-diabetes to manifest type 2 diabetes. This program targets individuals with an A1c between 5.7% and 6.4% who are currently not taking medication for diabetes.The new "International Maritime Diabetes and Hypertension Coaching Program" (IMDCP) offers individual patient-centered support, delivered with personal contact to the Coaches.

Health coaching focuses on increasing patients' skills and confidence to manage their own condition and set achievable goals - engaging patients to make informed decisions. Our one year pre-diabetes coaching program is designed to teach members how to prevent the development of type 2 diabetes from pre-diabetes. This program targets seafarers with an A1c between 5.7% and 6.4% who are currently not taking medication for diabetes. The program is done in close collaboration between the Maritime Medical Doctors, the Seafarers and the Coaches. By personal meetings and online support the objective is to activate internal strengths and external resources to make sustainable and healthy lifestyle behavior changes. Health coaches use a personal-centered approach wherein the seafarers decide their goals, engage in active learning processes, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a health coach. Health coaches work to educate and motivate the seafarers on making changes in their lives by placing an emphasis on Nutrition and Exercise in weekly, progressive goals. Along with weekly calls from their dedicated coach and access to online tracking tools, participants receive weekly emails to support them in their lifestyle change. (See the scheme for the 16 weeks training below). Most of the seafarers enrolled have just passed their obligatory health examination and are ready or already at sea.

Future controlled trial by including a control group

No control group are included in this first trial on how the coaching works in everyday life. If it works good a new trial will be done with a control group. Both the intervention group and the control group are asked to contact the same clinic or another clinic after 4 months and again after one year to register A1C, weight and the other variables.

Guidelines on the training of ships’ cooks

The ships' cooks should be prepared to support the crew members with overwight and pre-diabetes. However, the ILO guidelines on training ships' cooks from 2014 don't mention how the ship's cooks could help pre-diabetes seafarers with diet that could also help the non-diabetics. Now with more focus on pre-diabetes, chapters on dietary advice should be added in the next version of the Guidelines. Could be done by referring to some of the materials included here. The ship's cooks would also benefit from training like the seafarers to be prepared to offer "dietary food suppply"[115][116].

VIDEO PRESENTATION[edit | edit source]

Millions in the populations have pre-diabetes and most of them don’t even know it. An individual is pre-diabetic when their blood sugar levels are higher than normal, but aren’t high enough to be diagnosed with type 2 diabetes. Pre-diabetes increases the risk of developing type 2 diabetes, heart disease, and stroke. In Spain, 22% of the fishermen and seafarers with overweight and 41% of those with obesity have pre-diabetes or diabetes. The fishermen have x2 times the risk for diabetes compared to the seafarers. Thankfully, you can reverse the damage of pre-diabetes and we can help you. We have a supporting program with Zoom meetings every 3 weeks and weekly mail contacts starting with your health examination in the maritime medical clinics. Our 16 week pre-diabetes coaching program is designed to inspire and support seafarers how to prevent the further development from pre-diabetes to manifest type 2 diabetes. This program targets individuals with an A1c between 39-47 mmol/L (5,7%-6,4%) and who are currently not taking medication for diabetes. For a start only a few seafarers are carried through the 16 weeks program by the coach.

Later a video will be prepared to be used for announcement

INVITATIONS:[edit | edit source]

TO SEAFARERS[edit | edit source]

Dear seafarers,

With great respect for your important and hard work you do as a seafarer to bring all types of goods around in the world, you will need to stay healthy. Now, you have been diagnosed with pre-diabetes(T2D) you should know that this is not a serious disease, that can be prevented to be a more serious disease by changes of your food and physical exercise pattern. Pre-diabetes increases the risk of developing type 2 diabetes, heart disease, and stroke. Our 16 week pre-diabetes coaching program is designed to support you to change your daily food habbits and physical activities and get rid of diabetes and overweight. If you accept the invitation given by your maritime medical doctor, you will get in contact with a support person, a "coach" with further information.

MARITIME DOCTORS[edit | edit source]

Dear Maritime Doctors,

As you know an increasing part of seafarers have overweight and pre-diabetes that can be changed to normal by early diagnose and early changing the type and pattern of the food and drink and physical activity. This is very difficult for the seafarers to do alone. Our program supports them in learning about pre-diabetes and how they can normalise pre-diabetes, hypertension and overweight by changing their pattern of physical activity and food and drink patterns. As a maritime medical doctor you will not use much extra time and probably no extra costs for laboratory you are allowed to take, but your collaboration is very important. If you want to participate in the project, you are kindly asked to identify just one seafarer for a start from your actual medical examinations with newly diagnosed pre-diabetes and ask him/her to participate. The interested seafarer is put in contact to our coaches, that will help them to normalise the pre-diabetes and probably also loose some kg weight over a 16 weeks course.

Thank you for your attention

Contact person: ______________________, WhatsApp______________

The International Maritime Diabetes-2 Coaching Group (MDCG)

Project Title Project Summary Statement of Problem (scientific justification) Justification and Use of Results (final objectives, applicability) Theoretical Framework (argumentation, possible answers, hypothesis) Research Objectives (general and specific) Methodology Type of Study and General Design Operational Definitions (operationalization) Universe of Study, Sample Selection and Size, Unit of Analysis and Observation: Selection and Exclusion Criteria Proposed intervention (if applicable) Data-Collection Procedures, Instruments Used, and Methods for Data Quality Control Procedures to Ensure Ethical Considerations in Research Involving Human Subjects Plan for Analysis of Results Methods and Models of Data Analysis according to Types of Variables Programs to be Used for Data Analysis Bibliographic References Timetable Budget Annexes (data-collection instruments, elaboration on methods and procedures to be used, and more)

DRAFT ARTICLE[edit | edit source]

PAHO GUIDELINES PROTOCOL[edit | edit source]

Bibliographic References.

  1. ↑ 1.0 1.1 Pre-diabetes Coaching Program "Empower your employees to improve their health through lifestyle changes https://www.healthcheck360.com/prediabetes-program
  2. ↑ 2.0 2.1 The Effectiveness of Patient Activation Intervention on Type 2 Diabetes Mellitus Glycemic Control and Self-Management Behaviors: A Systematic Review of RCTs Almutairi, Nasser et al.Primary Care Diabetes 14, no. 1 (February 2020): 12–20. https://doi.org/10.1016/j.pcd.2019.08.009.
  3. ↑ 3.0 3.1 The Diabetes Health Coaching Randomized Controlled Trial: Rationale, Design and Baseline Characteristics of Adults Living With Type 2 Diabetes. Sherifali, Diana et al. Canadian Journal of Diabetes 43, no. 7 (October 1, 2019): 477–82. https://doi.org/10.1016/j.jcjd.2018.10.004
  4. ↑ 4.0 4.1 Jefferson, Vanessa, Sarah S. Jaser, Evie Lindemann, Pamela Galasso, Alison Beale, Marita G. Holl, and Margaret Grey. “Coping Skills Training in a Telephone Health Coaching Program for Youth at Risk for Type 2 Diabetes.” Journal of Pediatric Health Care: Official Publication of National Association of Pediatric Nurse Associates & Practitioners 25, no. 3 (2011): 153–61. https://doi.org/10.1016/j.pedhc.2009.12.003.
  5. ↑ Hallberg, Sarah J., Amy L. McKenzie, Paul T. Williams, Nasir H. Bhanpuri, Anne L. Peters, Wayne W. Campbell, Tamara L. Hazbun, et al. “Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study.” Diabetes Therapy 9, no. 2 (April 2018): 583–612. https://doi.org/10.1007/s13300-018-0373-9
  6. ↑ Nittari G, Tomassoni D, Di Canio M, Traini E, Pirillo I, Minciacchi A, et al. Overweight among seafarers working on board merchant ships. BMC Public Health. 2019 Jan 9;19(1):45
  7. ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Coronary risks among seafarers aboard German-flagged ships. Int Arch Occup Environ Health. 2008 May;81(6):735–41
  8. ↑ Tu M, Jepsen JR. Hypertension among Danish seafarers. Int Marit Health. 2016;67(4):196–204
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  10. ↑ Kaerlev L, Dahl S, Nielsen PS, Olsen J, Hannerz H, Jensen A, et al. Hospital contacts for chronic diseases among danish seafarers and fishermen: a population-based cohort study. Scand J Public Health. 2007;35(5):481–9.
  11. ↑ Baygi F, Djalalinia S, Qorbani M, Dejman M, Nielsen JB. Lifestyle interventions in the maritime settings: a systematic review. Environ Health Prev Med. 2020;25:10
  12. ↑ New Guidance on Blood Pressure Management in Low-Risk Adults with Stage 1 Hypertension [Internet]. American College of Cardiology. [cited 2022 Feb 7]. Available from: https://www.acc.org/latest-in-cardiology/articles/2021/06/21/13/05/http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2farticles%2f2021%2f06%2f21%2f13%2f05%2fnew-guidance-on-bp-management-in-low-risk-adults-with-stage-1-htn
  13. ↑ Alderman MH. Non-pharmacological treatment of hypertension. The Lancet. 1994 Jul 30;344(8918):307–11
  14. ↑ Baygi F, Mohammadi-Nasrabadi F, Zyriax B-C, Jensen OC, Bygvraa DA, Oldenburg M, et al. Global overview of dietary outcomes and dietary intake assessment methods in maritime settings: a systematic review. BMC Public Health. 2021 Aug 21;21(1):1579
  15. ↑ Baygi F, Mohammadi-Nasrabadi F, Zyriax B-C, Heitmann BL. Healthy nutrition for seafarers during and after COVID-19 pandemic. Int Marit Health. 2022;73(1):56–7
  16. ↑ Taylor R, Al-Mrabeh A, Sattar N. Understanding the mechanisms of reversal of type 2 diabetes. Lancet Diabetes Endocrinol 2019 Sep 1;7(9):726–36
  17. ↑ Nittari G, Tomassoni D, Di Canio M, Traini E, Pirillo I, Minciacchi A, et al. Overweight among seafarers working on board merchant ships. BMC Public Health. 2019 Jan 9;19(1):45
  18. ↑ Oldenburg M, Jensen H-J, Latza U, Baur X. Coronary risks among seafarers aboard German-flagged ships. Int Arch Occup Environ Health. 2008 May;81(6):735–41
  19. ↑ Tu M, Jepsen JR. Hypertension among Danish seafarers. Int Marit Health. 2016;67(4):196–204
  20. ↑ Herttua K, Ahrenfeldt LJ, Paljarvi T. Risk of major chronic diseases in transport, rescue and security industries: a longitudinal register-based study. Occup Environ Med. 2022 Mar;79(3):162–8.
  21. ↑ Kaerlev L, Dahl S, Nielsen PS, Olsen J, Hannerz H, Jensen A, et al. Hospital contacts for chronic diseases among danish seafarers and fishermen: a population-based cohort study. Scand J Public Health. 2007;35(5):481–9.
  22. ↑ New Guidance on Blood Pressure Management in Low-Risk Adults with Stage 1 Hypertension [Internet]. American College of Cardiology. [cited 2022 Feb 7]. Available from: https://www.acc.org/latest-in-cardiology/articles/2021/06/21/13/05/http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2farticles%2f2021%2f06%2f21%2f13%2f05%2fnew-guidance-on-bp-management-in-low-risk-adults-with-stage-1-htn
  23. ↑ Alderman MH. Non-pharmacological treatment of hypertension. The Lancet. 1994 Jul 30;344(8918):307–11
  24. ↑ Baygi F, Mohammadi-Nasrabadi F, Zyriax B-C, Jensen OC, Bygvraa DA, Oldenburg M, et al. Global overview of dietary outcomes and dietary intake assessment methods in maritime settings: a systematic review. BMC Public Health. 2021 Aug 21;21(1):1579
  25. ↑ Baygi F, Mohammadi-Nasrabadi F, Zyriax B-C, Heitmann BL. Healthy nutrition for seafarers during and after COVID-19 pandemic. Int Marit Health. 2022;73(1):56–7
  26. ↑ Taylor R, Al-Mrabeh A, Sattar N. Understanding the mechanisms of reversal of type 2 diabetes. Lancet Diabetes Endocrinol 2019 Sep 1;7(9):726–36
  27. ↑ Baygi, Fereshteh, Shirin Djalalinia, Mostafa Qorbani, Masoumeh Dejman, and Jesper Bo Nielsen. “Lifestyle Interventions in the Maritime Settings: A Systematic Review.” Environmental Health and Preventive Medicine 25 (2020): 10. https://doi.org/10.1186/s12199-020-00848-7.
  28. ↑ Jepsen, Jørgen Riis, and Hanna B Rasmussen. The metabolic syndrome among Danish seafarers: a follow-up study. Int Marit Health. 2016;67(3):129-36. doi: 10.5603/IMH.2016.0025 PMID: 27681211
  29. ↑ Almutairi , Nasser, Hassan Hosseinzadeh, and Vinod Gopaldasani. “The Effectiveness of Patient Activation Intervention on Type 2 Diabetes Mellitus Glycemic Control and Self-Management Behaviors: A Systematic Review of RCTs.” Primary Care Diabetes 14, no. 1 (February 2020): 12–20. https://doi.org/10.1016/j.pcd.2019.08.009
  30. ↑ Jensen, Olaf, George Charalambous, Agnes Flores, Fereshteh Baygi, Mluisa Canals, and Debbie Andrioti. “Strategies for Prevention of Non-Communicable Diseases in Seafarers and Fishermen: Lessons Learned.” International Journal of Community & Family Medicine 3, no. 2 (September 10, 2018). https://doi.org/10.15344/2456-3498/2018/142
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  33. ↑ CDC (2023-04-18). "Learn more about the nation's first prediabetes awareness campaign". Centers for Disease Control and Prevention. Retrieved 2023-12-30.
  34. ↑ Menéndez Torre, Edelmiro Luis, Jessica Ares Blanco, Santiago Conde Barreiro, Gemma Rojo Martínez, and Elías Delgado Alvarez. “Prevalence of Diabetes Mellitus in Spain in 2016 According to the Primary Care Clinical Database (BDCAP).” Endocrinología, Diabetes y Nutrición (English Ed.) 68, no. 2 (February 1, 2021): 109–15 https://doi.org/10.1016/j.endien.2019.12.009
  35. ↑ Quintana, Hedley Knewjen, Ilais Moreno Velásquez, Roger Montenegro Mendoza, Cecilio Niño Hall, Jorge Motta, and Reina Roa. “Diabetes Mellitus, Its Prevalence, Awareness, and Control in Panama: Data from ENSPA 2019, a National Cross-Sectional Study.” Medicine 102, no. 32 (August 11, 2023): e34600 https://doi.org/10.1097/MD
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  95. ↑ https://shw.dk/nyheder/2023/9/6/nyt-at-sea-magasin-stort-tema-om-svn-og-natarbejde
  96. ↑ https://pll.harvard.edu/course/healthy-eating-type-2-diabetes
  97. ↑ https://www.lark.com/resources/what-to-eat-for-prediabetes
  98. ↑ https://shw.dk/madlavningskursus?locale=en
  99. ↑ https://www.everydayhealth.com/type-2-diabetes/diet/the-best-seafood-for-diabetes/
  100. ↑ https://www.medicalnewstoday.com/articles/meats-for-diabetes
  101. ↑ https://www.healthline.com/health/type-2-diabetes/grab-and-go-snacks#nuts
  102. ↑ https://www.healthline.com/health/diabetes/drinks-for-diabetics
  103. ↑ https://diabetes.org/health-wellness/alcohol-and-diabetes
  104. ↑ https://medlineplus.gov/ency/patientinstructions/000886.htm
  105. ↑ https://www.nhs.uk/common-health-questions/food-and-diet/what-should-my-daily-intake-of-calories-be/#:~:text=An%20ideal%20daily%20intake%20of,women%20and%202%2C500%20for%20men.
  106. ↑ https://www.eatingwell.com/article/8048547/best-high-fiber-snacks-for-diabetes/
  107. ↑ https://www.seafarerswelfare.org/seafarer-health-information-programme/dental/dental-care-a-guide-for-seafarers
  108. ↑ https://www.seafarerswelfare.org/seafarer-health-information-programme/fit-on-board
  109. ↑ https://komite.regionsyddanmark.dk/i-tvivl-om-anmeldelse
  110. ↑ https://www.kiap.dk/resources/files/klynge/administration/vejledning/juridiske_rammer_for_data_til_klyngerne.pdf
  111. ↑ https://www.kiap.dk/kiap/klynge/klyngekoordinator/hjaelp /jura.php
  112. ↑ https://docs.google.com/spreadsheets/d/11ftLEki5v7wtHEpPmE69DtymXiMgha2q/edit?usp=sharing&ouid=108580480582522419049&rtpof=true&sd=true
  113. ↑ https://docs.google.com/spreadsheets/d/1Vr9GFdEmMp-9ECTjKoARSrgLDSKokjCm/edit?usp=sharing&ouid=108580480582522419049&rtpof=true&sd=true
  114. ↑ https://docs.google.com/spreadsheets/d/1KjUwyRW5eTFpi0eQkapSKb3ke3turWDw/edit?usp=sharing&ouid=108580480582522419049&rtpof=true&sd=true
  115. ↑ https://safety4sea.com/cm-world-diabetes-day-what-seafarers-need-to-know/
  116. ↑ https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_218575.pdf
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