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Translating the SLIM diabetes preventionintervention into SLIMMER: implications for theDutch primary health care Geerke Duijzera,*, Sophia C Jansenb, Annemien Haveman-Niesa,b,Rykel van Bruggenc, Josien ter Beekb, Gerrit J Hiddinkdand Edith J M Feskensa aDivision of Human Nutrition, Wageningen University; Academic Collaborative Centre AGORA, Wageningen, bGGD Gelre-IJssel (Community Health Service), Academic Collaborative Centre AGORA, Apeldoorn, cHuisartsenzorg Regio Apeldoorn,Apeldoorn, dDepartment of Social Sciences, Sub Department of Communication Sciences, Communication Strategies, Wagenin-gen University, Wageningen and eDivision of Human Nutrition, Wageningen University, Wageningen, The Netherlands.
*Correspondence to Geerke Duijzer, Wageningen University, Division of Human Nutrition, PO Box 8129, 6700 EV, Wageningen, The Netherlands; E-mail: [email protected] 28 April 2011; Revised 29 September 2011; Accepted 1 October 2011.
All over the world, prevalence and incidence rates of type 2 diabetes mellitus are rising rapidly.
Several trials have demonstrated that prevention by lifestyle intervention is (cost-) effective. This calls for translation of these trials to primary health care. This article gives an overview of thetranslation of the SLIM diabetes prevention intervention to a Dutch real-life setting and discussesthe role of primary health care in implementing lifestyle intervention programmes. Currently,a 1-year pilot study, consisting of a dietary and physical activity part, performed by three GPs,three practice nurses, three dieticians and four physiotherapists is being conducted. The processof translating the SLIM lifestyle intervention to regular primary health care is measured bymeans of the process indicators: reach, acceptability, implementation integrity, applicabilityand key factors for success and failure of the intervention. Data will be derived from programmerecords, observations, focus groups and interviews. Based on these results, our programme will be adjusted to fit the role conception of the professionals and the organization structure in whichthey work.
Keywords. Implementation, lifestyle intervention, prevention, primary health care, type 2 dia-betes mellitus.
groups with pre-diabSeveral international trialshave demonstrated a 29–67% reduction in the inci- All over the world, prevalence and incidence rates of dence of T2DM for adults with IGT who participated type 2 diabetes mellitus (T2DM) are rising rapidly.
in lifestyle interventions targeting dietary behaviour This trend is also seen in the Netherlands. It is ex- and activity pattern.–The potential for cost savings pected that the number of people with diagnosed dia- due to such interventions is also considerable. Rou- betes will double to 1.3 million in 2025, accounting for men et al.concluded in their review that, in general, 8% of the total population.This rising problem con- the implementation of lifestyle intervention as a ther- tributes to a large disease and economic burden. In apy to prevent and postpone T2DM and its complica- 2005, the costs for diabetes care amounted to a total tions looks promising, and cost-effectiveness seems of 813.8 million Euros, accounting for 1.2% of the to- tal health care costs in the Netherlands.In addition, The Dutch SLIM study (Study on Lifestyle inter- 30% of the Dutch population aged >60 years suffers vention and Impaired glucose tolerance Maastricht) from pre-diabetes [impaired glucose tolerance (IGT) was designed to investigate whether a combined diet and/or impaired fasting glucose] and approximately and physical activity intervention programme could one-third to two-thirds of them are expected to improve glucose tolerance in subjects with a high risk for developing T2DM. In total, 147 subjects with IGT Theoretically, over 50% of the expected increase in were randomly allocated to either the intervention or the number of diabetes patients can be avoided by control group. The intervention programme, based on prevention, especially when focussing on high-risk the Diabetes Prevention Study (DPS), was developed Family Practice—The International Journal for Research in Primary Care in 1999, using a combination of theories, such as self-management, followed by a post-core adherence/ Stages of Change modeland the Theory of Planned maintenance phase. The DPP showed a 58% risk re- and tools such as motivational interview- duction at 2.8 years mean follow-uFurthermore, and goal setting. The intervention group received the lifestyle intervention showed to be cost-effective personal dietary advice by a skilled dietician, trained from both a health system and a societal perspec- in motivational interviewing and goal setting, based on the Dutch guidelines for a healthy diet, during Although diabetes prevention studies are available, a 1-hour counselling session every 3 months. Addition- they are not easily applicable in public health practice.
ally, subjects were advised to increase their level of This is due to the fact that experimental trials are de- physical activity to at least 30 minutes a day for at signed to answer scientific questions on the relation least 5 days a week. A body weight loss of 5–7% was between lifestyle and diabetes. They are designed to the objective. Moreover, subjects were encouraged to secure a high internal validity, not to achieve a high participate in a combined aerobic- and resistance exer- external validity. They are therefore carried out under cise programme at an intensity of at least 70% of strictly controlled conditions that do not resemble ev- their maximal peak oxygen consumption (VO2max).
eryday real-life. Thus, implementing these interven- Control subjects were only briefly informed about the tions in daily practice may require changes in, e.g.
beneficial effects of a healthy diet and physical activ- subject screening and selection; intervention frequency ity, whereas no individual advice was provide and duration; intervention strategy and materials and The SLIM study was effective in improving dietary skills of professionals who deliver the intervention.
composition, increasing VO2max and reducing diabe- These changes do have implications for the interven- tes risk by 47% over a mean period of 4.1 years at In this article, we give an overview of the translation Internationally, more examples of diabetes preven- of the SLIM diabetes prevention intervention to tion interventions are available. The Finnish DPS was a Dutch real-life setting, with special attention for the the first large, well-controlled long-term lifestyle inter- roles of GPs and other professionals in implementing vention to prevent diabetes. A total of 522 middle- lifestyle intervention programmes in primary health aged, overweight subjects with IGT [based on two oral care. We will discuss what is known from literature glucose tolerance tests (OGTTs)] were randomly allo- about translation of trials to primary health care, and cated to either a control or intervention group. The the role conception of professionals working in pri- control group received only general advice about mary health care; how the SLIM lifestyle intervention healthy lifestyle at baseline. The intervention group will be translated into the SLIMMER intervention had seven individual sessions with a study nutritionist in order to be applicable in a Dutch primary health during the first year and a session every 3 months care setting and what the role of primary health care thereafter aimed at reducing weight by consuming professionals is in implementing lifestyle interventions.
a healthy diet. Intervention subjects were also guidedindividually to increase their physical activity. Aftera mean follow-up time of 3.2 years, the risk of diabetes Translating trials into primary health care was reduced by 58% in the intervention group. Afteran extended follow-up time of in total 7 years, the rel- Recently, all over the world, diabetes prevention trials ative risk reduction was still 43%.Furthermore, the are being implemented into daily practice. One exam- lifestyle intervention was estimated to be cost saving ple is the translation of the Finnish DPS to several for the health care payer and highly cost-effective for Finnish and Australian primary health care, commu- nity and workplace settings. The Finnish ‘National The US Diabetes Prevention Program (DPP) com- Program for the Prevention of Type 2 Diabetes’ pared the efficacy of an intensive lifestyle intervention (FIN-D2D), based on the DPS, has been implemented (intervention group) with standard lifestyle recommen- in health care centres and occupational health care dations (control group). A total of 3234 high-risk sub- outpatient clinics.Altogether 2798 individuals at jects with IGT and slightly elevated fasting plasma high risk for diabetes were identified in the general glucose (FPG) were recruited. Lifestyle intervention in population by nurses with the Finnish diabetes risk this study was primarily undertaken by case managers score (FINDRISC; scoring >15 points). High-risk called lifestyle coaches. The main goal of the DPP was individuals underwent an oral glucose tolerance test; to achieve and maintain a 7% weight reduction by con- the nurse or GP referred eligible individuals to a life- suming a healthy, low-calorie low-fat diet and to engage style intervention that focussed on weight manage- in physical activities of moderate intensity >150 mi- ment and physical activity. Several intervention nutes/week. The lifestyle intervention commenced with alternatives were provided, like group intervention, a 16-session core curriculum with basic information individual intervention and self-initiated actions. The about nutrition, physical activity and behavioural lifestyle interventions were delivered mostly by public Diabetes prevention in Dutch primary health care health nurses in collaboration with local multi-profes- updated to reflect current standards.The findings sional teams. After 1 year of follow-up, the study show improvements in dietary and physical behaviour showed beneficial changes in cardiovascular disease that are comparable to those achieved in the DPP.
risk factors and glucose tolerance in both sexes.
In short, international studies translated clinical dia- Furthermore, the Finnish ‘Good Ageing in Lahti Re- betes prevention trials to a specific context, taking the gion’ (GOAL) study, also based on the DPS, was im- health care system of the country concerned into ac- count, as recommended by the IMAGE evidence-based primary health care centre, patients with already- guidelines on type 2 diabetes preventioHowever, identified risk factors were referred to the study although international and Dutch effective studies exist, nurse. Risk status was screened with the FINDRISC translation to Dutch practice is still lacking.
score; patients with a score >12 points were recruitedto the trial.The intervention consisted of sixsessions of task-oriented socio-behavioural group counselling by public health nurses over a period of8 months. The study showed that a significant risk In the Netherlands, a project has been started to reduction at 12 months in weight, body mass index implement the SLIM intervention in a real-life setting.
and serum total cholesterol was maintained at 36 This project is called SLIMMER (SLIM iMplementa- months.A comparable lifestyle intervention, based tion Experience Region gelre-ijssel) and consists of on the Finnish GOAL study, was conducted in three steps: (i) translation of the SLIM intervention to Australian primary health care setting: the Greater practice, together with professionals from prevention Green Triangle (GGT) Diabetes Prevention Project.
and primary health care, (ii) implementation of the Patients were opportunistically screened by study modified intervention in a 1-year pilot study by three nurses at local general practices with the FINDRISC general practices, guided by process evaluation and score (scoring >12 points). The intervention was (iii) extension of the SLIMMER intervention in pri- delivered by trained study nurses, dieticians and mary health care, guided by effect evaluation and physiotherapists and found reductions in risk factors approaching those observed in clinical The In this article, we focus on the second step. The first DPS was also implemented in a Finnish airline com- step will be described in detail in a separate article pany. Finnair employees were invited for an annual currently under construction. In short, a modified Del- health examination, including physical examinations, phi technique was used with the aim of reaching a con- laboratory tests, questionnaires and counselling by sensus between SLIM researchers and local health an occupational health nurse or physician.The care professionals on the adaptations needed to make FINDRISC score, fasting blood glucose and/or glu- the SLIM intervention applicable in a Dutch real-life cose tolerance test were used to classify participants setting. In three rounds, key elements of the SLIM in- as having a low, increased or high risk of T2DM.
tervention were identified, rated for applicability and Those with an increased or high risk were referred to a diabetes nurse or a nutritionist for individualcounselling. Results of the effectiveness are not yet Pilot implementation, guided by process evaluation In the second step, we will test the adapted SLIM- Also the US DPP lifestyle intervention has been MER intervention for its actual applicability in translated to a variety of settings, including YMCAs a Dutch primary health care setting. For this, a 1-year (Young Men’s Christian Associations), churches, pri- pilot study is currently being conducted in three mary care practice settings and health care settings.
general practices. A process evaluation is included, in Prevention screening assessments included collection order to assess reach, acceptability, implementation of medical and family history, fasting lipid and glucose integrity, applicability and key factors for success and levels, blood pressure, height, weight and waist cir- failure of the intervention. Elaborated information cumference. The goals and key learning objectives of and data will be given in a forthcoming article on the the DPP curriculum have been maintained, but modi- results of the pilot study. Therefore, here subjects and fications to the DPP lifestyle intervention on imple- mentation were made, including offering groupdelivery rather than individual delivery, reducing the number of core-curriculum sessions from 16 to 12, Participants for the pilot were recruited by three GPs in concentrating on healthy-food choices rather than the the municipality of Apeldoorn from their pa- food pyramid specifically, emphasizing initially on fat tient registration database in August and September intake and calories instead of fat intake only and in- 2010. Apeldoorn has been selected as pilot municipality troducing pedometer use during core sessions instead because it can be considered as an average, middle- of during maintenance phase. The manual was also sized Dutch city (population 156 000), representative Family Practice—The International Journal for Research in Primary Care Details of the SLIMMER lifestyle intervention programme Lifestyle intervention programme—1 year Six times/year individual nutrition advice by dieticianBased on Dutch dietary guidelinesOne group session on label readingGoal: 5–10% weight reduction Weekly group sessions by physiotherapistCombined aerobic- and resistance exercise programmeIndividual advice on physical activity in daily lifeGoal: increase physical activity to at least 30 minutes/day on at least5 days/week per visit; in total 4 hours/year per participant) based on the Dutch guidelines for a healthy diet 2006.Indi-vidual consults instead of group-based consults areused because this is in accordance with the Dutch reg-ular primary health care. The Dutch guidelines for Map of the Netherlands with pilot municipality a healthy diet refer to a carbohydrate intake of >50%of energy consumed (E%), a total fat intake of 30–35 for Dutch real-life setting in general. The three selected E%, a saturated fat intake of <10 E%, a fibre intake GPs were assumed to be representative for their profes- of >30 g/day and a protein intake of 1.2 g/kg body sional group in Apeldoorn and are considered as local weight per day. Topics that are being discussed during pioneers in the field of diabetes prevention. Each GP visits are the Dutch guidelines for a healthy diet, artifi- selected a sample of patients aged 40–65 years with im- cial sweeteners and special occasions, e.g. a party. If paired fasting glucose (fingerprick fasting capillary desired, spouses can join the visits. In addition, the di- blood glucose >5.6 and <6.0 mmol/l or fasting venous etician organizes a group session aimed at sharing ex- plasma glucose >6.1 and <6.9 mmol/l). Exclusion crite- periences, motivating each other and discussing the ria were: not being able to speak the Dutch language; topic of label reading. Subjects are being encouraged cognitive dysfunction or any co-morbidity that made to quit smoking, and if necessary, drink less alcohol.
participation in a lifestyle intervention impossible.
A body weight loss of 5–10% is the objective. Further- The GPs sent all eligible patients a letter and flyer more, the dietician encourages subjects to increase to inform them about the SLIMMER programme and their physical activity level to at least 30 minutes to invite them for an information meeting. Two weeks a day for at least 5 days a week. The dietician uses mo- after sending the invitation letter, practice nurses tivational interviewing to assist individuals aiming to called the patients to invite them again for the infor- achieve a positive attitude towards changes in diet mation meeting and to motivate them to participate if and physical activity. Goals for behavioural change necessary. A short non-response survey was conducted are being set every visit, evaluated in the next visit in case patients were not willing to participate. Finally, an information meeting was organized by the practice The physical activity part consists of a combined nurse in collaboration with the GP, a dietician and aerobic- and resistance exercise programme at the a physiotherapist. During this meeting, patients were physiotherapist’s practice, in which subjects participate given all details of the programme. They were also at an intensity of at least 60–90% of their maximal introduced to the professionals involved in the pro- peak oxygen consumption (VO2max). The training gramme. After the information meeting, patients gave sessions with a duration of 1 hour are group-based and supervised by a physiotherapist. Subjects havefree access to these training sessions and are stimu- lated to participate for at least 1 hour/week. In addi- The adapted SLIMMER intervention resembles the tion, the physiotherapist gives individual advice on SLIM intervention (described in the introduction). In how to increase daily physical activity (walking, short, the programme consists of a dietary and physi- cycling, swimming or running), based on the PACE cal activity part (Six times per year, a skilled questionnaire (adapted version based on van Sluijs dietician gives personal dietary advice (30–60 minutes Diabetes prevention in Dutch primary health care Furthermore, semistructured interviews will be held Process evaluation will be performed to investigate with some of the professionals and participants to how the intervention was implemented, what activi- obtain more in-depth information on acceptability, im- ties occurred under what conditions, by whom and plementation integrity, applicability and key factors with what level of effort. Process measures, among for success and failure. An item list will be developed others based on the indicators as defined by Nut- to guide the interviews, covering topics like expecta- tions, experiences and suggestions for modifications.
One of the researchers will guide the interviews.
 Reach: did the programme reach all of the target Measures of health effects are also included in the pilot study to evaluate whether the measurements will  Acceptability: is the programme acceptable to the be acceptable to the patients in the effectiveness study target population and the health professionals (Step 3 in the translational process). The following measurements are included: body weight, waist and  Implementation integrity: was the programme im- hip circumference, FPG values, blood pressure, medi- cal history, aerobic fitness (SteepRamp test), motiva-  Applicability: does the programme fit into the tion for physical activity (PACE questionnaire) and health care structure, the social and cultural envi- dietary behaviour. Other effect measures, like glucose ronment, the organizational system of local health and cholesterol, are not included because measuring and welfare organizations and professional work- these indicators is not the aim of the pilot study.
Data of the process evaluation will be used in order  Key factors for success and failure.
to optimize the programme for the Dutch real-life set-ting. Finally, the intervention will be expanded, guided To investigate programme reach, programme records with an effect evaluation and cost-effectiveness analy- are used to assess the number of implemented activities ses, including all the above-mentioned health indica- and the number of attending participants. Dropouts tors (this is Step 3 of the translational process).
and unreached eligible subjects are examined to assesswhether this group differs from those participating andto identify reasons for non-participation.
To assess acceptability, implementation integrity and applicability, multiple methods will be used: ob- Primary health care professionals have an important role in implementing lifestyle intervention programmes.
groups. Key factors for success and failure will be de- Hiddink et recognized that GPs are trusted sources rived from all methods used in the process evaluation.
of nutrition information by adults because they had Based on literature and observation methods used in a high referral score, high perceived expertise and they other interventions, a structured observation method reached nearly all segments of the population. This view has been developed. The following activities of the pilot is shared by the Heelsum Collaboration on Nutrition in intervention will be observed: the information meeting Primary Care, as described by van Weel: ‘opportunity for patients and the visits to the practice nurse, dieti- through regular contacts with patients (continuity of cian and physiotherapist. The following aspects of these care), central position in the health care system and activities will be studied: accessibility and appropriate- trust with ‘‘their’’ patients’.Over the last years, a ten- ness of the location; the use of materials; course of the dency can be seen for the GP as nutrition counsellor to- meeting or visit (which parts were discussed, when and wards gatekeeper of the health care system, working how well?); involvement, communication and skills of together with other professionals from primary health the professionals; enthusiasm, motivation and apprecia- care and public health–Generally, GPs have an in- tion of participants and the mood and feelings of the terest in nutrition and perceive themselves as being able to give dietary advice in the treatment and prevention In addition, focus group sessions will be used to as- of coronary heart disease.However, GPs experience sess acceptability of the intervention to professionals as barriers for giving nutrition guidance to their patients, well as participants and implementation integrity of the most importantly not being trained in nutrition, lack of intervention. Focus group sessions will be held with time to address nutrition issues and GPs perception that participating professionals (GPs and practice nurses, di- patients lack motivation to change lifestyle and/or die- eticians and physiotherapists) and participating patients tary patterns.,These main barriers were also found separately. An item list will be developed to guide by Kushnerand HelmanTherefore, a promising these sessions. Questions relate to experiences with sev- possibility is to transfer the dietary and/or physical activ- eral parts of the intervention, the use of materials, com- ity advice to other disciplines in primary health care in munication, barriers and facilitators. An experienced order to alleviate the responsibilities of the GP as is focus group leader will guide the focus group sessions.
done in SLIMMER. In addition, we see a movement Family Practice—The International Journal for Research in Primary Care towards synergy between primary health care and public The tendency towards an alliance between primary health over the last years.This has been expanded in health care and public health especially fits to the Dutch the sixth Heelsum International Workshop themed health care system. Currently, the Dutch primary health ‘Practice-based evidence for weight management: alli- care sector and prevention sector are two different worlds ance between primary care and public health’ since they are based on separate laws and financial sys- Within combined lifestyle interventions, it is impor- tems. However, one of the main topics of the Dutch Pub- tant that one professional has the lead and the over- lic Health Act is to join forces of primary health care and view over the programme. This is indicated as case public health, so that prevention is incorporated in the management. The case manager should work together health care syAlso Greendescribed the urgent with all the professionals involved in the alliance need for an alliance between primary health care and between primary health care and public health. Which public health. Avendonk et described how the Dutch professional should have the role of case manager in College of General Practitioners evaluated the situation combined lifestyle interventions is a matter of discus- and published the guidelines for obesity. Therefore, we sion. In a Dutch lifestyle intervention, the Beweeg- consider the accomplishment of an alliance between pri- Kuur programme, the lifestyle advisor is the pivot of mary health care and public health, such as established the intervention. Often the lifestyle advisor is a prac- in the SLIMMER intervention, as a promising develop- tice nurse, who is designing an individual exercise pro- ment and a necessary step in diabetes prevention.
gramme and providing coaching and supervision.Also in the UK Counterweight programme, it is thepractice nurse who plays a key role in the delivery of the lifestyle intervention, with initial guidance, train- Several trials, such as SLIM, DPS and DPP, have dem- ing and facilitation by weight management advisors onstrated that prevention of diabetes by lifestyle inter- (all state-registered dieticians, who are proactive, crea- vention is (cost-) effective. However, translation of tive and specially trained in health promotion and diabetes prevention trials to Dutch real-life setting is obesity management).In the US DPP, the interven- lacking. Therefore, the SLIMMER project was devel- tion is undertaken by lifestyle coaches. The majority oped in order to translate the SLIM intervention into of these lifestyle coaches are registered dieticians, reg- Dutch daily practice, together with professionals from istered nurses and diabetes educators but also social prevention and primary health care. Currently, the workers, exercise specialists, pharmacists, physicians, adapted SLIMMER intervention is being implemented psychologists and emergency services techniciIn in a pilot study and guided with a process evaluation in the SLIMMER intervention, it is the GP who acts as order to assess reach, acceptability, implementation in- a spider in the web, given his/her role as gatekeeper tegrity, applicability and key factors for success and of the health care system, and works together with failure. Based on these results, the programme will be allied forces. GPs select eligible subjects and refer optimized to fit the role conception of the professionals them to dieticians because they are one of the most and the organization structure in which they work. Es- important nutritional information sources for GPs.
pecially in the Dutch health care system, we consider In addition, GPs refer the subjects to physiotherapists collaboration between professionals from primary for physical activity advice and support. GPs have the health care and public health needed now more than final responsibility for the quality of the delivered ever to combat the rising problem of diabetes.
care, but practice nurses are the case managers in theSLIMMER intervention. They motivate subjects toparticipate in the intervention programme and they are in contact with the dieticians and physiotherapists.
Which professional is in the best position of being Funding: The Netherlands Organization for Health a case manager depends on several factors like type of lifestyle intervention activities, time, money, inter- 20400.7003); Dutch Diabetes Research Foundation Regarding the collaboration between primary health Ethical approval: Medical Ethical Committee of Wa- care professionals and public health, both the commu- nity health service and local authorities are important partners within the last profession. The communityhealth service may act as coordinator of the lifestyle in-tervention programme and has the health promotion expertise that is needed. The local authorities can bring several partners, from different disciplines and profes- IDF Diabetes Atlas. International Diabetes Federation. 4th edn.
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