Pilvikki Absetz

Type 2 Diabetes Prevention in the Real World: Three-year results of the GOAL Lifestyle Implementation Trial

OBJECTIVE We study the effectiveness of the GOAL Lifestyle Implementation Trial at the 36-month follow-up. RESEARCH DESIGN AND METHODS Participants (n = 352, type 2 diabetes risk score FINDRISC = 16.2 ± 3.3, BMI 32.6 ± 5.0 kg/m2) received six lifestyle counseling sessions over 8 months. Measurements were at baseline, 12 months (88.6%), and 36 months (77.0%). RESULTS Statistically significant risk reduction at 12 months was maintained at 36 months in weight (−1.0 ± 5.6 kg), BMI (−0.5 ± 2.1 kg/m2), and serum total cholesterol (−0.4 ± 1.1 mmol/l). CONCLUSIONS Maintenance of risk reduction in this “real world” trial proves the interventions potential for significant public health impact.

Prevention of Type 2 Diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project

BackgroundRandomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.MethodsAn intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.ResultsAt twelve months participants mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.ConclusionThis study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.Trial NumberCurrent Controlled Trials ISRCTN38031372

The dilemma of patient responsibility for lifestyle change: Perceptions among primary care physicians and nurses

Objective. To explore physicians’ and nurses’ views on patient and professional roles in the management of lifestyle-related diseases and their risk factors. Design. A questionnaire study with a focus on adult obesity, dyslipidemia, high blood pressure, type 2 diabetes, and smoking. Setting. Healthcare centres in Päijät-Häme hospital district, Finland. Subjects. Physicians and nurses working in primary healthcare (n =220). Main outcome measures. Perceptions of barriers to treatment of lifestyle-related conditions, perceptions of patients’ responsibilities in self-care, experiences of awkwardness in intervening in obesity and smoking, perceptions of rushed schedules, and perceptions of health professionals’ roles and own competence in lifestyle counselling. Results. A majority agreed that a major barrier to the treatment of lifestyle-related conditions is patients’ unwillingness to change their habits. Patients’ insufficient knowledge was considered as such a barrier less often. Self-care was actively encouraged. Although a majority of both physicians and nurses agreed that providing information, and motivating and supporting patients in lifestyle change are part of their tasks, only slightly more than one half estimated that they have sufficient skills in lifestyle counselling. Among nurses, those with less professional experience more often reported having sufficient skills than those with more experience. Two-thirds of the respondents reported that they had been able to help many patients to change their lifestyles into healthier ones. Conclusions. The primary care professionals experienced a dilemma in patients’ role in the treatment of lifestyle-related diseases: the patient was recognized as central in disease management but also, if reluctant to change, a major potential barrier to treatment.

RURAL URBAN DIFFERENCES IN HEALTH AND HEALTH BEHAVIOUR: A BASELINE DESCRIPTION OF A COMMUNITY HEALTH-PROMOTION PROGRAMME FOR THE ELDERLY

Study objective: To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals. Design: The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments. Setting: Fourteen municipalities in the Lahti region (Päijät-Häme County) in Finland. Participants: A regionally and locally stratified random sample of men and women born in 1946—50, 1936—40, and 1926—30. A total of 4,272 were invited and 2,815 (66%) participated. Main results: Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43). Conclusions: The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in Päijät-Häme County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.

A systematic review of real-world diabetes prevention programs: learnings from the last 15 years

BackgroundThe evidence base for the prevention of type 2 diabetes mellitus (T2DM) has progressed rapidly from efficacy trials to real-world translational studies and practical implementation trials over the last 15xa0years. However, evidence for the effective implementation and translation of diabetes programs and their population impact needs to be established in ways that are different from measuring program effectiveness. We report the findings of a systematic review that focuses on identifying the critical success factors for implementing diabetes prevention programs in real-world settings.MethodsA systematic review of programs aimed at diabetes prevention was undertaken in order to evaluate their outcomes using the penetration, implementation, participation, and effectiveness (PIPE) impact metric. A search for relevant articles was carried out using PubMed (March 2015) and Web of Science, MEDLINE, CENTRAL, and EMBASE. A quality coding system was developed and included studies were rated independently by three researchers.ResultsThirty eight studies were included in the review. Almost all (92xa0%) provided details on participation; however, only 18xa0% reported the coverage of their target population (penetration). Program intensity or implementation—as measured by frequency of contacts during first year and intervention duration—was identified in all of the reported studies, and 84xa0% of the studies also reported implementation fidelity; however, only 18xa0% of studies employed quality assurance measures to assess the extent to which the program was delivered as planned. Sixteen and 26xa0% of studies reported ‘highly’ or ‘moderately’ positive changes (effectiveness) respectively, based on weight loss. Six (16xa0%) studies reported ‘high’ diabetes risk reduction but ‘low’ to ‘moderate’ weight loss only.ConclusionOur findings identify that program intensity plays a major role in weight loss outcomes. However, programs that have high uptake—both in terms of good coverage of invitees and their willingness to accept the invitation—can still have considerable impact in lowering diabetes risk in a population, even with a low intensity intervention that only leads to low or moderate weight loss. From a public health perspective, this is an important finding, especially for resource constrained settings. More use of the PIPE framework components will facilitate increased uptake of T2DM prevention programs around the world.

Type 2 Diabetes Prevention in the Real World Three-year results of the GOAL Lifestyle Implementation Trial

OBJECTIVE We study the effectiveness of the GOAL Lifestyle Implementation Trial at the 36-month follow-up. RESEARCH DESIGN AND METHODS Participants (n = 352, type 2 diabetes risk score FINDRISC = 16.2 ± 3.3, BMI 32.6 ± 5.0 kg/m2) received six lifestyle counseling sessions over 8 months. Measurements were at baseline, 12 months (88.6%), and 36 months (77.0%). RESULTS Statistically significant risk reduction at 12 months was maintained at 36 months in weight (−1.0 ± 5.6 kg), BMI (−0.5 ± 2.1 kg/m2), and serum total cholesterol (−0.4 ± 1.1 mmol/l). CONCLUSIONS Maintenance of risk reduction in this “real world” trial proves the interventions potential for significant public health impact.

Health psychological theory in promoting population health in Päijät-Häme, Finland: first steps toward a type 2 diabetes prevention study

In public health promotion, behavioural science theories and theory-based methods should be translated into practical strategies that fit environmental conditions and are feasible for implementation. In this article, an effort to meet this challenge is presented. As a starting point we describe the conditions for development and success of the previous generation of public health promotion programmes in Finland. However, changes both in the population structure and in the population health bring new demands for programme development. We consider possibilities offered by health psychology and give a practical example of how theories and theory-based methods are applied in a community programme for type 2 diabetes prevention implemented in the Finnish primary health care.

Repertoires of lifestyle change and self-responsibility among participants in an intervention to prevent type 2 diabetes.

This paper analyses participants accounts on their experiences of lifestyle change during and after the intervention to prevent type 2 diabetes. This paper explores whether the individual is seen as capable of autonomously seeking for a healthier lifestyle or as dependent on external controls and support. The study is based on focus group interview data collected among intervention participants one-and-a-half years after the intervention ended. Those who had been successful in the weight reduction and those whose weight had increased after the intervention were interviewed in separate interview groups. Both weight-losers and weight-gainers agreed with the health-related objectives of the intervention. Despite this agreement, we found three distinct repertoires concerning individuals potential to proceed in and maintain lifestyle change. The hopelessness repertoire was used mainly by the weight-gainers to describe experiences where lifestyle change was seen to be very difficult. The struggle repertoire was used frequently especially by the weight-gainers but also by the weight-losers to describe struggling against external temptations and ones weaknesses. The self-governing individual repertoire was used most often by weight-losers to describe experiences where new, healthier lifestyle had to a significant extent become a routine and the individual was seen as in charge of his/her lifestyle. The study revealed that the interviewees hold an ambivalent stance towards self-responsibility. The individual was seen as both a sovereign actor and a dependent object of interventions. Most of our interviewees called for continuous controls and even surveillance but at the same time rejected the idea of authoritarian health education. This ambivalence was most clearly present in the struggle repertoire and could be a fruitful target of clarification in health interventions. For a major part of intervention participants, lifestyle change is characterized as a constant struggle and hence interventions should plan the continuation of a support system.

Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program

BackgroundIndia currently has more than 60 million people with Type 2 Diabetes Mellitus (T2DM) and this is predicted to increase by nearly two-thirds by 2030. While management of those with T2DM is important, preventing or delaying the onset of the disease, especially in those individuals at ‘high risk’ of developing T2DM, is urgently needed, particularly in resource-constrained settings. This paper describes the protocol for a cluster randomised controlled trial of a peer-led lifestyle intervention program to prevent diabetes in Kerala, India.Methods/designA total of 60 polling booths are randomised to the intervention arm or control arm in rural Kerala, India. Data collection is conducted in two steps. Step 1 (Home screening): Participants aged 30–60xa0years are administered a screening questionnaire. Those having no history of T2DM and other chronic illnesses with an Indian Diabetes Risk Score value of ≥60 are invited to attend a mobile clinic (Step 2). At the mobile clinic, participants complete questionnaires, undergo physical measurements, and provide blood samples for biochemical analysis. Participants identified with T2DM at Step 2 are excluded from further study participation. Participants in the control arm are provided with a health education booklet containing information on symptoms, complications, and risk factors of T2DM with the recommended levels for primary prevention. Participants in the intervention arm receive: (1) eleven peer-led small group sessions to motivate, guide and support in planning, initiation and maintenance of lifestyle changes; (2) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors, prevention and management; (3) a participant handbook containing information primarily on peer support and its role in assisting with lifestyle modification; (4) a participant workbook to guide self-monitoring of lifestyle behaviours, goal setting and goal review; (5) the health education booklet that is given to the control arm. Follow-up assessments are conducted at 12 and 24xa0months. The primary outcome is incidence of T2DM. Secondary outcomes include behavioural, psychosocial, clinical, and biochemical measures. An economic evaluation is planned.DiscussionResults from this trial will contribute to improved policy and practice regarding lifestyle intervention programs to prevent diabetes in India and other resource-constrained settings.Trial registrationAustralia and New Zealand Clinical Trials Registry: ACTRN12611000262909.

Health coaching by telephony to support self-care in chronic diseases: clinical outcomes from The TERVA randomized controlled trial

BackgroundThe aim was to evaluate the effect of a 12-month individualized health coaching intervention by telephony on clinical outcomes.MethodsAn open-label cluster-randomized parallel groups trial. Pre- and post-intervention anthropometric and blood pressure measurements by trained nurses, laboratory measures from electronic medical records (EMR). A total of 2594 patients filling inclusion criteria (age 45u2009years or older, with type 2 diabetes, coronary artery disease or congestive heart failure, and unmet treatment goals) were identified from EMRs, and 1535 patients (59%) gave consent and were randomized into intervention or control arm. Final analysis included 1221 (80%) participants with data on primary end-points both at entry and at end. Primary outcomes were systolic and diastolic blood pressure, serum total and LDL cholesterol concentration, waist circumference for all patients, glycated hemoglobin (HbA1c) for diabetics and NYHA class in patients with congestive heart failure. The target effect was defined as a 10-percentage point increase in the proportion of patients reaching the treatment goal in the intervention arm.ResultsThe proportion of patients with diastolic blood pressure initially above the target level decreasing to 85u2009mmHg or lower was 48% in the intervention arm and 37% in the control arm (difference 10.8%, 95% confidence interval 1.5–19.7%). No significant differences emerged between the arms in the other primary end-points. However, the target levels of systolic blood pressure and waist circumference were reached non-significantly more frequently in the intervention arm.ConclusionsIndividualized health coaching by telephony, as implemented in the trial was unable to achieve majority of the disease management clinical measures. To provide substantial benefits, interventions may need to be more intensive, target specific sub-groups, and/or to be fully integrated into local health care.Trial registrationClinicalTrials.gov Identifier: NCT00552903