High risk strategy
Eeva Korpi-Hyövälti
04.06.2007
Type 2 diabetes – Prevention
strategies


A population strategy – prevention of
obecity
A high risk strategy


persons with high risk of DM are encouraged
to take part in systematic screening, education
and monitoring activities
An early detection and treatment strategy

lifestyle interventions, systematic treatment
Venus von Willendorf 25000 b. Chr
07.08.1908 Austria,miniature statuette
of paleolitic Stone Age
Overweight of the Children at Junior
Grade of Alajärvi Basic School
50
40
%
30
A ala-aste
B ala-aste
C ala-aste
D ala-aste
20
10
0
A ala-asteB ala-asteC ala-aste D alaaste
Kouluterv.hoit. Paula Etula
Diabeteshoitaja Kirsti Mäkinen
Overweight at the Basic School
(7-15 years) in Alajärvi 2005
25 %
20 %
Yhteensä
Total
15 %
10 %
Years 13-15
5%
0%
Yhteensä
Total
Years
Years
13-15
7-12
Kouluterv.hoit. Paula Etula
Diabeteshoitaja Kirsti Mäkinen
Years 7-12
THE WEIGHT AND HEIGHT OF CONSCRIPTS
IN MILITARY SERVICE
HEIGHT
WEIGHT
CONDITION OF CONSCRPTS IN MILITARY SERVICE
MEAN WEIGHT
MUSCLE STRENGHT
COOPER TEST
Type 2 diabetes 2002
South Ostrobothnia
Prevalence of Type 2 diabetes in hospital districts 2002
Population study 2004
(45-74 years)
Random selected
Men 45-74
Women 45-74
Participation rates
62 %
67 %
Central obesity
69 %
Waist(>94/80cm)
DM before the study 7,4 %
76 %
DM after the study 16 %
11 %
Abnormal glucose
regulation
33 %
42 %
4,3 %
Life expectancy






2002 men 74,9 years
2002 women81,5years
2030 men 79,2 years
2030 women84,5years
How to intensify the
care?
Mortality rates in
cardiovascular
complications?
Duodecim 2004;120:2173-9
FIN
Type 2 diabetes – Prevention
strategies


A Population Strategy – prevention of
obecity
A High-Risk Strategy


persons with high risk of DM are encouraged
to take part in systematic screening, education
and monitoring activities
An early detection and treatment strategy

lifestyle interventions, systematic treatment
Improvement of health care
processes in primary and
occupational health care


Screening method of persons with high risk
Organize a lifestyle intervention
co-operation with the municipal field of
physical activities and with other groups
concerned
 co-operation with groups concerning nutritional
education – lack of nutritionists
 co-operation with the local service networks

Project funding in every hospital
district




Hospital district 100 000 €
Ministry of Social Affairs and Health
100 000 €, common costs of the project
20 000 €
180 000 €/ year in every hospital district
That means salary of a nurse for 2-8
months/ year/a health care centre
The staff of the project in South
Ostrobothnia







Nutritionist 12 - 11 months (2003-2007)
Health care nurse 12 - 4 months (2003-2004)
Nurse - secretary 11- 12 months (2003-2007)
Diabetes-nurse 8 – 2 months ( 2003-2007)
Physician 2 months (2003-2007)
Physiotherapist 12 months (2006 – 2007)
Regional coordinator - Finnish Diabetes
Assosiation (RAY-funding)
SENUKO – EDUCATION FAIR 2007
Goals during years 2003 - 2007







Improvement of health care processes in
primary health care
Municipal exercise calendars
Co-operators in the field of nutrition
Step-by-Step lifestyle education
VLCD- education
Regional Health Fair 2005, Farmers Fair2006
Regional education and training
Education and training






Step-by-step weigth control nurses(42 + 20)
VLCD – education, doctor + nurse (40)
2 days education for psychologists including
psychological support of the health care team
Seminars for collecting regional ideas
Doctors lectures in the hospital district
Lectures in Seinäjoki Polytechnic


The care and education in diabetes
Intervention education and data collection
Screening of high risk patients


Women with a history of gestation diabetes
– maternal- and child health centres
Patients who have PAD, CVD, AMI or who
have to undergo a coronary intervention



OGTT is performed in central hospital
Previously diagnosed IGT = Impaired
glucose tolerance or IFG = Impaired fasting
glucose
Findrisk score > 15
High risk patients treatment paths


Nurse intervention 1: FINDRISK, personal risk
score and personal goals
Nurse intervention 2: all the risk factors



OGTT, lipids, hypertension, smoking habits, lack of
physical activity, nutrition habits, status of mental
health
lifestyle intervention in groups or personally, step- bystep education
Doctor / nurse intervention - once in a year

risk factors and personal goals, interventions
FINDRISK
-nurse
-doctor
PRIVATE OCCUPATIONAL
HEALTH CARE
PREVENTION OF DM
TREATMENT PATHS
DIABETES
- in health care centre
Doctor
> 15
D2D-etl
Diabetes
GESTATION DM
-one year after delivery
in child health centres
OGTT + LIPIDS
Nurse in occupational
health care
IFG
IGT
NORM.
AMI, PAD, CVD
OGTT IN CENTRAL
HOSPITAL
INTERVENTION
-personally or in groups
-nurse occ, DM-nurse
PHYS.ACT.
PRESCRIPTION
DM-Nurse
in health
care centre
DOCTORS intervention
in occupational care
INTERVENTION
once in a year
DM-nurse
IFG (6.1-6.9) or IGT (7.8-11.0)
Hovinmäki
2005
8.2.2005
9
Treatment paths




In every municipal health care centres
Treatment paths has been done together with
the occupational health care staff
More advising is still needed
The price: 50 000 €
Salary of the nurse 2 weeks – 2months
 Local expert knowledge is needed

Education of diabetes treatment and
weight control groups 2006
Place
First Hand Education
Informatio of treatment
n
health care 10
1
centre
mun. occ. 2
7
health care
priv. occ. 0
2
health care
Groups
12
10
Tot. 57
weight
control
VLCD
17
4
8
0
3+2
cont.
0
30+
1 ite
4
Results of weight control groups
2004 - 2006







Meetings x 10 -19(10/04 – 8/05 occ. health c)
Size of groups 10 – 27(interrupted 1-7)
Age 47 years ( 26 – 67years)
BMI in the beginning 37 (28 – 60)
Weight change – 4,6 kg (1,3 – 7,8 kg)
Waist circumference – 7 cm(2,5 – 11,9 cm)
BP change - 5,7/- 4,4 mmHg
Doctors orders in group counselling
Physical activity prescription


Liihota-project and Kuortane Sport Institute
Physical activity prescription-project
264 doctors educated
 500 nurses educated


Soininhoikka – The Slim of Soini – project

physical activity prescription in groups
Municipal exercise calendars




in 2 municipalities in
2003
in every municipalities
on the internet
D2D-, Liihota-,
phys.act.prescription-,
Verka-projects
For the professional
use and for inhabitants

www.TEP.fi, updated
2x/year
Low level exercise groups in the week 19. WWW.TEP.FI
Activities
Toiminta
Municipality
Kunta
Organizer
Järjestäjä
Exercise
Rasitustaso level
Time
Kokoontuminen
TULES-kuntosaliryhmä
Seinäjoki
liikuntatoimi
o
Ma 08.05.2006
Niskaryhmä
Alahärmä
Alahärmän
terveyskeskus
o
Ma 08.05.2006
Kuntovoimistelu
varttuneille
Alahärmä
Alahärmän
terveyskeskus
o
Ma 08.05.2006
Lady-Jumppa
Seinäjoki
Seinäjoen Voimistelijat
ry
o
Ti 09.05.2006
Tuolijumppaa naisille
ja miehille
Ylistaro
liikuntatoimi
o
Ti 09.05.2006
KKI- kunta, ikäihmiset
Ylistaro
KKI
o
Ti 09.05.2006
Liikkuva luokka
Seinäjoki
liikuntatoimi
o
Ti 09.05.2006
Eläkeliitto
Ylistaro
Eläkeliitto
o
Ti 09.05.2006
Mielenterveyskuntoutu
jien liikuntaryhmä
Seinäjoki
liikuntatoimi
o
Ti 09.05.2006
Terveysaseman
ulkoliikuntaryhmä
Soini
Terveysasema
o
Ti 09.05.2006
o (matalan kynnyksen ryhmät)
x (helppo, vasta-alkajille sopiva, ei
vaikeusasteita)
xx (kuntotasoltaan vaativampi)
xxx (rasittavuudeltaan vaativin)
-- (kaikille sopiva)
together
0 low level groups and
x easy groups
TEP-municipal exercise calendars

Filled in 26 municipalities, used in 50%-70%


The number of different organizers: 160


more practising is needed
municipal physical training activities, health care
centres, private associations, pension federations,
gymnasts etc
Low level exercise groups + easy groups: hundreds


chair gym, neck group, lady gym, mental physical
activity group, the lowest level: exercise or not, etc
in seven municipalities no low level groups
Nutritional education








Co-operators in the field of nutrition
”Positive lifestyle intervention” 632 participitants
Kauhajoki Polytechnic – nutrition
Pilot schools: Lintuviita, Aapiskuja, Pikku-Alvari ”Healthy
kids” ja ”Healthy snacks after school”
Domestic science teachers
 Senior Grade of the Basic School ”Kitchen Novice”education material
Large scale catering, Meeting catering ”Coffee and
catering” and ”Heavenly delicious and healthy”
ITE-selfhelp-peer groups
Local Associations, Hearth Association
Recipes for Healthy snacks
after school
Healthy Kids - Education Material
for Junior Grade of the Basic School
and Day Care
Kitchen Novice - Education Material for
Domestic Science Teaching
Kaffit
&
Trahteerit
Coffee
&
Catering
RECIPES FOR
MEETINGS
KOKOUSTARJOILURESEPTIT
Etelä-Pohjanmaan sairaanhoitopiiri
Dehkon 2D-hanke ja Ravintokeskus
FIN-D2D, Hospital District of
South Ostrobothnia
Heavenly delicious and healthy
for large-scale catering
Health Fair in South
Ostrobothnia 09.04.2005

A great success: 7000 guests
fair guests from young to old
 looking for true knowledge of health





A careful planning
The municipal regions in key position
No-nonsense – everything controlled by our
nutritionist
The support of pharmaceutical industry
SOUTH 0STROBOTHNIA HOSPITAL DISTRICT
THE HUNTING OF MISSING WAIST 8/2006
Co-operation partnerships


Kuortane Sport Institute
Several Projects, e.g. Syke-project



” Fit for Life” for adults
Heart Association of South Ostrobothnia:
”Health is a Super Thing” – for Senior
Grade at the Basic School
Diabetes - and Heart Associations, ITE-peer
groups, Ruukki-Steal Company
SOINI
The SLIM of SOINI - PROJECT
LAKE SLIM-HOIKKA
FAT-PONDS
FAT-PONDS
The Slim of Soini
Miss Finland 2007
THE REGISTER OF DIABETES
in Lehtimäki, Soini and Ähtäri
DM-luokitus 30.3.2007
LEHTIM
ÄKI
SO
INI
ÄHT
ÄRI
YHT
KAI
KKI
Pieni riski sairastua tyypin 2 diabetekseen (<7)
92
108
375
575
690
Jkv kohonnut riski sairastua tyypin 2 diabetekseen (711)
79
203
354
636
710
Koht. kohonnut riski sairastua tyypin 2 diabetekseen
(12-14)
42
107
150
299
335
20
63
93
176
197
1
4
10
15
17
52
62
127
241
245
Heikentynyt glukoosinsieto (IGT, 2h Gluc 7,8-11,0)
22
57
107
186
189
Ruokavaliohoitoinen tyypin 2 diabetes (E11)
29
109
112
250
258
48
76
180
304
312
33
46
100
179
179
Tyypin 1 diabetes (E10)
4
15
3
22
24
Muu diabetestyyppi (E12-14)
1
1
1
2884
3157
Suuri riski sairastua tyypin 2 diabetekseen (15-20)
67
Hyvin suuri riski sairastua tyypin 2 diabetekseen (>20)
Kohonnut paastoglukoosi (IFG, fP-Gluc 6,1-6,9)
Tablettihoitoinen tyypin 2 diabetes (E11)
Insuliinihoitoinen tyypin 2 diabetes (E11)
Kaikki yhteensä
119
246
423
850
1611
Soini: Inhabitants 2579, screened inhabitants for DM 850,
DM-patients 246 = 10 %
IFG + IGT patients 119 + high risk patients 67 = 186
The second round in municipalities
– the first one 2003


A letter to all municipal managers, who invite
the municipal management, elected officials and
local associations to a meeting
The matters considered at the meeting
Overweight as a risk factor of loosing health(EK-H)
 Promotion of health in our municipality (mun. man)
 Promotion of health in health care and social affairs
 D2D in our municipality
 Discussion

Challenges in the future



Prevention of obesity of children and young
people
Unemployed people – low level of education
A connection between depression and diabetes,
30 – 40 %

Ostrobothnia – project: mental health and
intoxicants