good ageing in lahti region (ikihyvä project) – from ... · 17/11/2010 absetz ncd 2009 2 goal...

17/11/2010 1

Good Ageing in Lahti Region (Ikihyvä project)– From research into everyday practice

Pilvikki Absetz, Adjunct Professor, Senior researcher, [email protected]

17/11/2010 Absetz NCD 2009 2

GOAL Program– Collaborative community health promotion program– Partners:

• Päijät-Häme Social and Health District and its 15member municipalities

• National Institute for Health and Welfare (formerNational Public Health Institute)

• University of Helsinki:– Palmenia Centre for Continuing Education in

Lahti– Department of Social Policy

• Lahti University of Applied Sciences

Fogelholm M, Valve R, Absetz P, Heinonen H, Uutela A, Patja K, Karisto A, Konttinen R, Mäkelä T, Nissinen A,Jallinoja P, Nummela O, Talja M. Rural-urban differences in health and health behaviour: a baseline descriptionof a community health-promotion programme for the elderly. Scand J Public Health. 2006; 34(6): 632-40.

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GOAL Program area, Päijät-HämePopulation ~ 200,000

Main urban center Lahti

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GOAL Program timeline

2002 2005 2008 2011

C-1 C-2 C-3 C-4

I-1 I-2

Communitydiagnosis

Communitydiagnosis

Communitydiagnosis

Intervention Intervention Intervention

C = longitudinal cohort study; I = independent, cross-sectional sample

2012

17/11/2010 Absetz NCD 2009 5

The GOAL intervention model

The GOALresearch group

Municipaladministration

Implementation by professionals in each specific setting

Regionalapplicationof Current

Careguidelines

Type IIdiabetes

prevention

Promotionof

functionalcapability

Program design, training and evaluation

Regionalmodel

for NCDprevention

System-wide uptake of successful programs

Good Self-Rated Health (SRH) by SocialCapital, GOAL Cohort Study 2002

• Social capital measure basedon participation and trust:

– low social capital (lowparticipation/low trust)

– traditionalism (low/high),– “the miniaturisation of

community” (high/low)– high social capital (high/high).

• The highest rate of good SRHwas found among the highsocial capital group

• After adjusting for backgroundfactors (age, gender, maritalstatus, education and subjectiveincome), statistical significanceremained only in the urbanarea.

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0 1 2 3OR (95% CI)

High social capital Miniaturisation Traditionalism Low social capital

Urban

Rural population centre

Sparsely populated countryside

1.09 (0.78-1.53)

1.20 (0.72-2.00)

1.55 (1.08-2.22)

0.89 (0.61-1.30)

0.85 (0.47-1.52)

1.38 (0.91-2.11)

0.96 (0.57-1.60)

1.51 (0.73-3.11)

1.60 (0.88-2.91)

From research by Nummela O, Sulander T, Rahkonen O, Karisto A, Uutela A.

Overweight and aging• Preventing overweight among children and working-

age adults is an important goal for health policy• Overweight among older adults a more complex

phenomenon:– Maintenance of weight and even overweight predict

independent living– But: overweight and obesity may lower ability to

manage activities of daily life (ADL)

From Valve R et al. In Haapola et al.: Ikihyvä Päijät-Häme -tutkimus, perusraportti 2008. Päijät-Hämeen sosiaali- jaterveysyhtymän julkaisuja 70, 2009.

The youngest age cohort has gainedweight during 6 yr follow-up

Obese Overweight Normal weight

MenWomen

0 %

5 %

10 %

15 %

20 %

25 %

30 %

1946-50 1936-40 1926-30 1946-50 1936-40 1926-30

Naiset Miehet

BMI < 25

BMI 25-29,9

BMI 30

Type 2 Diabetes is significantly morecommon among the obese

MenWomen


0 %

5 %

10 %

15 %

20 %

25 %

30 %

1946-50 1936-40 1926-30 1946-50 1936-40 1926-30

Naiset Miehet

BMI < 25

BMI 25-29,9

BMI 30

Six-year incidence rates were 11% among healthy obese vs 2% amonghealthy normal weight adults


Incidence of T2D in 2002-2008

MenWomen

Overweight and functional capacity• Walking, climbing up stairs, leaning down without

difficulties in the oldest age cohort• Among the obese:

– 1/10 women and 1/5 men manage climbing the stairs– 1/3 manage walking 500 meters (vs 2/3 of those with

normal weight)– ¼ manage leaning down

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

1946-50 1936-40 1926-30 1946-50 1936-40 1926-30

Naiset Miehet

BMI < 25

BMI 25-29,9

BMI 30

Stair climbing without difficulties, 2008Participants with no difficulties in 2002

1. Women experience difficulties earlier than men– Difference already between two youngest age cohorts

2. Those with obesity experience problems earlier

MenWomen


Some implications of the Cohort Study• Interventions that foster participation and trust are

likely to promote perceived health• Lifestyle counseling for weight management and

weight loss should mainly be targeted at– Working-aged adults and those who have recently

retired AND– Who have been identified with high risk for type 2

diabetes (e.g., risk test or impaired glucosetolerance)

• Obesity-related functional problems should betargeted primarily with physical exercise that helpsto maintain lean mass and improve muscle strength

GOAL Lifestyle Implementation Trial toPrevent Type 2 Diabetes

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Population at-risk for cardiovasculardiseases in Päijät-Häme Hospital DistrictEstimated numbers in 2002

Totalnumber

Age 50-65 yrs 49 126

Overweight 35% 17 194

Obese 15% 7 369

Impaired glucose tolerance 15% 7 369

Smoking 23 % 11 299

Estimations based on population risk factor prevalences, from Peltonen etal SLL 2006 and Helakorpi et al 2005


Needs asessment for DM2 preventionNeed for improved practice in primary health care

Increasing numbers of patients at risk for DM21

Effectiveness of current practice? (individually given nurse advice)2-3

Evidence: DM2 can be prevented by lifestyle change4

Evidence-based program goals:1 No more than 30% of energy from fat2 No more than 10% of energy from saturated fats3 At least 15g / 1000 kcal fiber4 At least 30 min / day moderate physical activity5 At least 5% weight reduction

Behavioral sciences: Increasing self-efficacy and self-regulationeffective strategies5

1 Peltonen et al. Lihavuuden, diabeteksen ja muiden glukoosiaineenvaihdunnan häiriöiden esiintyvyys suomalaisessa aikuisväestössä.Dehkon 2D-hanke (D2D). [Prevalence of obesity, type 2 diabetes, and other disturbancees in glucose metabolism in Finland - The FIN-D2Dsurvey]. Suomen Laakarilehti 61:163-170, 20062 Poskiparta M, Kasila K, Kiuru P. Dietary and physical activity counselling on type 2 diabetes and impaired glucose tolerance by physiciansand nurses in primary healthcare in Finland. Scand J Prim Health Care 2006;4:206–10.3 Kettunen T, Poskiparta M, Kiuru P, Kasila K. Lifestyle counseling in type 2 diabetes prevention: a case study of a nurse's communicationactivity to produce change talk. Commun Med 2006;3:3–14.4 Tuomilehto et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance.New England Journal of Medicine, 344, 1343-1350.5Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol 2009a;28(6):690-701.


GOAL Lifestyle Implementation Trial• To implement findings from RCT’s to primary health

care– Participant behavior change based on health

behavior theories– Aiming to change preventive practices and to provide

tools for promoting behavior change– Outcome and process evaluation:

• Who were the ones to benefit?• What factors accounted for the success?

Absetz, P., Valve, R., Oldenburg, B., et al. Type 2 diabetes prevention in the “real world”: One-year results of the GOAL implementation trial. Diabetes Care 30, 2465-2470, 2007.

Absetz, P., Oldenburg, B., Hankonen, N., et al. Type 2 diabetes prevention in the “real world”:Three-year results of the GOAL implementation trial. Diabetes Care, 32 (8), 1418-20, 2009.


Setting and participantsAll 16 primary health care centres in the 14 municipalities ofPäijät-HämeGroup counselling program, 6 structured 2-hour sessionsPublic health nurses and physiotherapists as facilitators36 groups, M = 11 participants per groupTotal N = 389, men (N = 103, 26.3%); women (N = 286, 73.7%)

Baseline N = 352 (non-diabetics); 12 month F-U N = 319(91%)Age 50-65 yearsAt least moderate risk of type II diabetes:

1/6 will get diabetes in the next 10 yearsType 2 diabetes risk test*, risk score 12

Exclusion criteria:Diagnosed T2D; cancer; recent MI or stroke; or mental disorder orsubstance abuse interfering with group activities

* Lindström, J. & Tuomilehto, J. The diabetes risk score: a practical tool to predict type 2diabetes risk. Diabetes Care. 2003 Mar; 26(3):725-31. (www.diabetes.fi).


0 1 mo 3 mo 8 mo 13 mo 18 mo 3 yrs

A1 A2 A3 A4L1 L2 L3 L4Q1 Q2 Q3 Q4 Q5

C1 C2 C3 C4 C5 C6

Study timeline & data collectionF T

F = Focus group interviewsT = Thematic interviewsQ1-Q5 = QuestionnairesL1-L4 = Lab testsC1-C6 = Counselling sessionsA1-A4 = Anthropometric measurements

GOAL Lifestyle Implementation Trial

Theory-base for health behaviorchange

• Process view on lifestyle change (Health Action Process Approach1):– Motivation, intention, planning, action, esp. Self-efficacy and action planning

• Self-determination of behaviour2:– Empowerment– Internal vs external motivation– Autonomous vs controlled regulation of behavior

• Self-regulation skills3:– Self-monitoring, goal setting, action and coping planning, feedback and

evaluation• Positive emotions4:

– Valuable as such but have also health benefits

1 Schwarzer & Fuchs. (1996). Self-efficacy and health behaviors. Teoksessa: Conner & Norman (toim.): Predicting healthbehaviour: Research and practice with social cognition models (ss. 163-196). Buckingham, UK: Open University Press.2 Williams, Deci & Ryan. (1998). Building health care partnerships by supporting autonomy: promoting maintained behaviorchange. Teoksessa: Suchman ym. (toim.): Partnerships in health care. Transforming relational process (ss. 67-88). NY:University of Rochester Press.3 Gollwitzer. (1999). Implementation intentions: The strategic preparation of automatic goal pursuit. American Psychologist,54, 493-503.4 Fredrickson. (2001) The role of positive emotions in positive psychology. The Broaden-and-built theory of positive emotions.American Psychologist, 56, 218-226.


Attainment of intervention objectives (%)Intervention objectives GOAL*

N=352DPSN=265

Total fat < 30E% 48 47

Saturated fat < 10E% ‡ 34 26

Fibre > 15g/1000 kcal§ 52 25

Moderate intensity PA > 30minutes / day

66 86

Weight reduction > 5% ¶ 12 43

4-5 objectives attained 20 18

* Intention to treat, non-respondents regarded as not reaching the intervention objectives‡ Statistically significant difference between DPS and GOAL ( 2 = 4.614, p < 0.05)§ Statistically significant difference between DPS and GOAL ( 2 = 46.070, p < 0.001)

Statistically significant difference between DPS and GOAL ( 2 = 33.068, p < 0.001)¶ Statistically significant difference between DPS and GOAL ( 2 = 75.613, p < 0.001)

GOAL participantswith 4-5 objectiveswere more likely tohave normalglucose at follow-up

2 = 7.120, p < 0.05)

Absetz, P., Valve, R., Oldenburg, B., Heinonen, H., Nissinen, A., Fogelholm, M., Ilvesmäki, V., Talja, M.,Uutela, A. Type 2 diabetes prevention in the “real world”: One-year results of the GOAL implementationtrial. Diabetes Care 30, 2465-2470, 2007.


Moderate reduction in BMI maintained at3 years (p<.001)

Women N = 189

Men N = 70

Baseline 1 yr 3 yrs

Absetz, Oldenburg, Hankonen et al. Type 2 diabetes prevention in the “real world”: Three-yearresults of the GOAL implementation trial. Diabetes Care, 2009, 32 (8), 1418-20.


Glucose tolerance at year 3• 193 participants had normal glucose tolerance at

baseline– 10.9% had IGT and 1.6% diabetes at year three.

• 65 participants had IGT at baseline– 12% had diabetes and 43% had returned to normal by

year three• Conversion rate from IGT to diabetes – 12% at year

three – is reasonable compared to 9% in theintervention and 20% in the control group of the DPS

Absetz, P., Oldenburg, B., Hankonen, N., et al. Type 2 diabetes prevention in the “real world”:Three-year results of the GOAL implementation trial. Diabetes Care, 2009, 32 (8), 1418-20.

• Baseline optimism vs pessimism do not predictmaintenance of weight loss

• Increase of self-efficacy during the 3 months ofintervention predicts maintenance at 3 years

Predicting maintenance of weight-lossat three year follow-up

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25

Promoting Healthy Ageing AndIndependence Among The Ageing

Population In Päijät-Häme

GOAL Program for Good Ageing

Strength and balance• Poor balance is the main risk factor for falls• In year 2000, the cost of falls related injuries in

Finland € 39 million, 82% due to hip fractures• Annually, > 7000 hip fractures, 90% resulting from

falling• Treatment costs in the first year after fracture, in

average € 17,000• Cost in the first year after permanent

institutionalization due to hip fracture, in average €41,900 (Sihvonen & Salmela 2009)

Health Care CenterNon-Governmental Organizations

GOAL Healthy Aging Program 2008-2012

- Development of a model to evaluate,enhance/maintain, and monitor functional capacityamong the aged population- Fostering partnership between public sector andthird sector organizations in preventive care- Utilising existing infrastructure for implementingnovel practices- Regional and local emphasis

Implementation ofintervention:

• Guided stregthand balancetraining• Creative groupactivities for socialfunctioning, healthyeating and dailyphysical activity

Screening andidentification ofolder adults 70 yrs at risk ofimpairedfunctionalcapacity

Referral to intervention for those identified

Referral to follow-up testing and recording of functional capacity

The GOAL Healthy Aging Program

Design and measurements• Intervention group, a non-randomised control group

(target N=320)– Intervention 12 weeks, 24 sessions with 1 h exercise,

1,5 h group discussion• Baseline (recruitment)• 3 months (immediate post-intervention)• 15 months (one-year post-intervention)

Measures• Recruitment by nurse

– Inclusion:• SPPB 7-9 (physical functioning)

– Exclusion:• MMSE 20 (memory)• GDS >10 (mood)• AUDIT 12 (alcohol)

– Other:• MNA (nutrition)

• Self-administered questionnaire study:– SPS (social support, quantity and quality)– Hyve-measure (social functioning)– RAND 36 (Health-related QoL)– Health behavior

Those excluded are referred torelevant other care processeswithin the health care

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Goal-oriented approach (self-regulation) foractive, healthy aging:• Clarify your own life goals and values• Self-monitor your current situation (in relation to social

networks, eating, physical activity etc relevant areas in yourlife you want to tackle)

• Identify needs (by evaluating current situation in relation to lifegoals and values)

• Set SMART goals to overcome discrepancies betweencurrent situation and life goals

• Make a step by step action plan• Monitor and evaluate outcomes

GOAL Healthy Ageing Program

Pilot phase of the intervention

• Participants: Intervention arm n=33, control n=12

• Mean age 78 years (71-90 vuotta)

• Men n=9, women n=36

Falls during 6 months before intervention

42

58

0

10

20

30

40

50

60

70

No falls Falls

2/3 have had pains during the past month, 2/5 quite a lot/ very much

Current physical condition(small value means better condition)

3

2,9

2,85

2,9

2,75

2,8

2,85

2,9

2,95

3

3,05

Intervention Control

kesk

iarv

o

BaselineFollow-up

Pain during past month in the intervention group

2,8

2,9

3

3,1

3,2

3,3

3,4

3,5

3,6

Baseline Follow-up

Average pain

P<.05

Lifting a shopping bag and ease of walking up the stairs (intervention group)

2,502,40

1,952,10

,00

,50

1,00

1,50

2,00

2,50

3,00

Lifting shopping bag Walking up stairs

BaselineFollow-up

P<.05 P<..01

No changes in control group

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Promoting system-wide uptake andmaintenance of lifestyle intervention• Quality management in health care

– Training– Standard protocol– Self-monitoring and recording of professional practices– Feedback

• Infrastructure that promotes maintenance of the program– Management support– Co-ordinators– Ongoing training programs– Electronic patient database to record and evaluate

outcomes

Absetz & Patja (eds.): Ennaltaehkäisyn kehittäminen Päijät-Hämeessä. Interventiot osana Ikihyvä Päijät-Häme –tutkimus- ja kehittämishanketta. [Developing preventive strategies in the province of Päijät-Häme. Interventionswithin the GOAL Program for Good Aging.] Päijät-Hämeen sosiaali- ja terveysyhtymän julkaisuja [Publications ofthe Päijät-Häme Social and Health Care District] 68/2008.

From research to practice

Randomized,controlled trial:

Efficacy oflifestyle change

Tuomilehto et al.,2001

Population basedrisk factor studies

Behavior changetheories

Organizationalchangetheories

Sustainability:Preventive

Processes andsupporting

infrastructureAbsetz & Patja

(eds.), 2008

Quality control

Implementationresearch:

Feasibility of groupcounselling

Absetz et al.,2007

Implementationresearch:

Current CareGuidelines in

CVD preventionKuronen et al.,

2006

Basic research

Applicability

Functionality

Systemicity

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Identification of a patient at risk forT2DM

Absetz & Patja (eds.): Ennaltaehkäisyn kehittäminen Päijät-Hämeessä. Interventiot osana Ikihyvä Päijät-Häme –tutkimus- ja kehittämishanketta. [Development of preventive practices in Päijät-Häme.Interventions within the GOAL Program for Good Aging]. Päijät-Hämeen sosiaali- ja terveysyhtymänjulkaisuja 68/2008. [Publications of the Päijät-Häme Hospital District].

Patient

Nurse

Physician

Identifiespatient &screensfor risk

Identifiesbeing at risk

Identifiespatient is at risk

Reviewprinciples of

healthylifestyle

Plan forlifestyle

counselling(group/indiv

idual)

Lifestylecounselling

Followshealthylifestyle

Reviewlab tests Diabetes

care

FINDRISC 15

FINDRISC < 15

NON-DIABETIC

SUSPECTEDDIABETES

17/11/2010 Absetz NCD 2009 41

Process for supporting lifestyle changes

Absetz & Patja (eds.): Ennaltaehkäisyn kehittäminen Päijät-Hämeessä. Interventiot osana Ikihyvä Päijät-Häme –tutkimus- ja kehittämishanketta. [Development of preventive practices in Päijät-Häme.Interventions within the GOAL Program for Good Aging]. Päijät-Hämeen sosiaali- ja terveysyhtymänjulkaisuja 68/2008. [Publications of the Päijät-Häme Hospital District].

Patient

Nurse

Physician

Managinggroupwating

list

1. Groupmeeting:

Motivation

Offer sports and recreation services

Diabetescare

NON-DIABETICMAX 1 YR

SUSPECTEDDIABETES

Group

facilitator

Sports

Individualcounselling:Goal settingand planning

Follow-up andsupport of

lifestylechanges

6. Groupmeeting:

Maintenance

2. Groupmeeting:

Motivation

3. Groupmeeting:

Goal settingand

planning

4. Groupmeeting:

Goal settingand

planning

5. Groupmeeting:Progress

evaluation

Follow-upand

evaluation

Offer sports and recreation servicesIntroductionto services

Keep up healthy lifestyle and self-measurements

INVITATION

MAX 1 YR

Evaluation ofoutcomes

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Diffusion to down-under and elsewhere:• Australian DPP: an

implementation trial bythe GGT University inVictoria in 2003-2006

• State-wide roll-out:Life! program byDiabetes Australia -Vic in 2008-2011

• Malaysian DPP tostart in 2010?

• India: DPP in Kerala,funding granted byMRC Australia

Kilkkinen, A., Heistaro, S., Laatikainen T., Janus, E., Chapman, A., Absetz, P., Dunbar, J. Prevention of type 2diabetes in a primary health care setting. Interim results from the Greater Green Triangle (GGT) DiabetesPrevention Project. Diabetes Research and Clinical Practice, 2006, doi: 10.1016/j.diabres.2006.09.027

Laatikainen, T., Dunbar, J.A., Chapman, A., Kilkkinen, A., Vartiainen, E., Heistaro, S., Philpot, B., Absetz, P., Bunker,S., O'Neil, A., Reddy, P., Best, J.D., Janus, E.D. Prevention of Type 2 Diabetes by lifestyle intervention in anAustralian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project. BMC PublicHealth, 7:249.

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Diabetes Prevention in PracticeEditors: Schwarz P, Reddy P, Greaves CJ, Dunbar JA, Schwarz J.TUMAINI Institute, Dresden 2010.

www.image-project.eu/pdf/final_version_of_toolkit-perfect.pdfPractical tools:

17/11/2010 Absetz 2010 44

Thank you!

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