Facilitators and barriers to implementing lifestyle intervention programme to prevent cognitive decline.

BACKGROUND: The Finnish Intervention Study to Prevent Cognitive Impairment and Disability is a randomized controlled trial that has tested the efficacy of a multidomain intervention targeting modifiable risk factors to prevent cognitive impairment/dementia. A combination of healthy diet, physical, social and cognitive activity, and management of cardiovascular risks was shown to be an effective model to promote brain health among older people. The aim of this qualitative study was to explore healthcare professionals' perceptions of facilitators and barriers to implementing this lifestyle programme into health care. METHODS: Four semi-structured focus group interviews were conducted among healthcare professionals working in primary care and in non-governmental organizations (N=27). Participants were asked to discuss their perceptions of facilitators and barriers for implementing the multidomain intervention into clinical practice. Interviews were analyzed using content analysis. RESULTS: Barriers and facilitators described by the healthcare professionals were related to infrastructure and resources, client's personal characteristics and the lifestyle intervention itself. These main categories included several sub-categories related to knowledge, motivation, resources, individualization and collaboration. The interviewees pointed out that more education on dementia prevention is needed, the work should be coordinated efficiently, resources to provide preventive health care should be adequate and multiprofessional collaboration is needed. CONCLUSIONS: Transferring a lifestyle intervention from a trial-setting to real life requires knowledge about the factors that influence effective implementation. Identifying drivers and constraints of successful implementation helps to design and tailor future prevention programmes, increases motivation and adherence and supports system change.

Formation and Validation of the Healthy Diet Index (HDI) for Evaluation of Diet Quality in Healthcare.

Lack of tools to evaluate the quality of diet impedes dietary counselling in healthcare. We constructed a scoring for a validated food intake questionnaire, to measure the adherence to a healthy diet that prevents type 2 diabetes (T2D). The Healthy Diet Index (HDI) consists of seven weighted domains (meal pattern, grains, fruit and vegetables, fats, fish and meat, dairy, snacks and treats). We studied the correlations of the HDI with nutrient intakes calculated from 7-day food records among 52 men and 25 women, and associations of HDI with biomarkers and anthropometrics among 645 men and 2455 women. The HDI correlated inversely with total fat (Pearson's r = -0.37), saturated fat (r = -0.37), monounsaturated fat (r = -0.37), and the glycaemic index of diet (r = -0.32) and positively with carbohydrates (r = 0.23), protein (r = 0.25), fibre (r = 0.66), magnesium (r = 0.26), iron (r = 0.25), and vitamin D (r = 0.27), (p < 0.05 for all). In the linear regression model adjusted for BMI and age, HDI is associated inversely with waist circumference, concentrations of fasting and 2-h glucose and triglycerides in men and women, total and LDL cholesterol in women, and fasting insulin in men (p < 0.05 for all). The HDI proved to be a valid tool to measure adherence to a health-promoting diet and to support individualised dietary counselling.

High need for recovery from work and sleep problems are associated with workers' unhealthy dietary habits.

OBJECTIVE: We aimed to examine the association of recovery from work and sleep with workers' dietary habits. DESIGN: Cross-sectional study. Need for recovery (NFR) from work was assessed with a validated questionnaire. Sleep was assessed with five questions from the Nordic Sleep Questionnaire and sleep quality question. Dietary habits were estimated using a validated sixteen food groups-containing questionnaire. Ordered logistic regression was used to explore the associations of NFR and sleep with dietary habits adjusted for age, education, marital status, work schedule, working full or part time and occupation. SETTING: Follow-up visits of type 2 diabetes prevention study cohort in a Finnish airline company. PARTICIPANTS: The study included 737 men and 605 women. RESULTS: Poor recovery from work was associated with a higher eating frequency (OR = 1·03, 95 % CI 1·00, 1·06), higher intake of fast food (OR = 1·05, 95 % CI 1·02, 1·08) and sweets (OR = 1·05, 95 % CI 1·02, 1·08) as well as lower intake of vegetables (OR = 0·96, 95 % CI 0·93, 0·98) and fruits (OR = 0·96, 95 % CI 0·93, 0·98) among men. In women, poor recovery from work was associated with higher fast food (OR = 1·06, 95 % CI 1·02, 1·09) and desserts consumption (OR = 1·04, 95 % CI 1·00, 1·07). Among men and women, sleep problems were associated with higher eating frequency (men: OR = 1·04, 95 % CI 1·00, 1·07, women: OR = 1·06, 95 % CI 1·02, 1·11), consumption of fast food (men: OR = 1·07, 95 % CI 1·04, 1·11, women: OR = 1·06, 95 % CI 1·02, 1·10) and sweets (men: OR = 1·05, 95 % CI 1·01, 1·08, women: OR = 1·04, 95 % CI 1·00, 1·08). CONCLUSIONS: Poor recovery from work and sleep problems were associated with unfavourable dietary habits especially in men.

The association of work stress and night work with nutrient intake - a prospective cohort study.

Objectives In a prospective study among workers in an airline company, we explored whether change in work stress symptoms or night shifts was associated with nutrient intake. Methods Participants in a workplace type 2 diabetes (T2D) prevention study completed a questionnaire on lifestyle, work stress symptoms, work schedule, and food intake at baseline and after 2.4-years follow-up (211 men and 155 women, 93% with increased risk for T2D). Multiple linear regression models with covariates were used to explore the associations between change in work stress symptoms or night shifts and change in nutrient intake during the follow-up. Results Among men, an increase in stress and a decrease in perceived workability was associated with a higher proportion of energy (E%) from fat [ß 0.6, 95% confidence interval (CI) 0.07-1.11, ß 1.3, 95% CI 0.57-2.05] and saturated fat (ß 0.3, 95% CI 0.02-0.58, ß 0.5, 95% CI 0.14-0.90), respectively. Furthermore, a decrease in workability was associated with lower vitamin C intake (ß-9.2, 95% CI -16.56- -1.84) and an increase in sleepiness with higher E% from saturated fat (ß 0.7, 95% CI 0.00-0.15). Among women, an increase in work-related fatigue was associated with higher alcohol intake (ß 7.5, 95% CI 1.25-13.74) and an increase of night shifts was associated with higher E% from fat (ß 0.24, 95% CI 0.00-0.47) and saturated fat (ß 0.17, 95% CI 0.04-0.29). Conclusions Work stress symptoms were associated with a reduction in diet quality especially among men. The possible impact of work stress symptoms on workers' dietary habits should be acknowledged and the assessment of dietary habits should consequently be incorporated into occupational health examinations.

Neonatal Nutrition Predicts Energy Balance in Young Adults Born Preterm at Very Low Birth Weight.

Epidemiological studies and animal models suggest that early postnatal nutrition and growth can influence adult health. However, few human studies have objective recordings of early nutrient intake. We studied whether nutrient intake and growth during the first 9 weeks after preterm birth with very low birth weight (VLBW, <1500 g) predict total energy intake, resting energy expenditure (REE), physical activity and food preferences in young adulthood. We collected daily nutritional intakes and weights during the initial hospital stay from hospital records for 127 unimpaired VLBW participants. At an average age 22.5 years, they completed a three-day food record and a physical activity questionnaire and underwent measurements of body composition (dual X-ray absorptiometry; n = 115 with adequate data) and REE (n = 92 with adequate data). We used linear regression and path analysis to investigate associations between neonatal nutrient intake and adult outcomes. Higher energy, protein and fat intakes during the first three weeks of life predicted lower relative (=per unit lean body mass) energy intake and relative REE in adulthood, independent of other pre- and neonatal factors. In path analysis, total effects of early nutrition and growth on relative energy intake were mostly explained by direct effects of early life nutrition. A path mediated by early growth reached statistical significance only for protein intake. There were no associations of neonatal intakes with physical activity or food preferences in adulthood. As a conclusion, higher intake of energy and nutrients during first three weeks of life of VLBW infants predicts energy balance after 20 years. This association is partly mediated through postnatal growth.

Food and nutrient intake among workers with different shift systems.

OBJECTIVES: Over 20% of employees in Europe work in shifts. Shift work increases the risk for chronic diseases, but a healthy lifestyle may attenuate the adverse effect of shift work. The aim of this study was to explore food and nutrient intake differences between working time groups. METHODS: The participants were 1478 employees (55% of men) of an airline divided into three working time groups: day work (n=608), shift work without in-flight work (n=541) and in-flight work (n=329). Measures included laboratory tests, physical measurements, a questionnaire, and food and nutrient intake estimations by a validated 16-item food intake questionnaire. RESULTS: Shift working men were less likely to consume vegetables (p<0.001) and fruits (p=0.049) daily than male day and in-flight workers. In women, energy intake from saturated fat was higher among shift workers compared with day workers (12.6 vs 12.2 E%, p=0.023). In older female participants, energy intake from fat and saturated fat was higher in the shift work and in-flight work groups than in the day work group (p<0.001). CONCLUSIONS: In this study, shift work and working environment were associated with dietary habits, and this association was not explained by other characteristics such as workers' educational level. Shift workers' increased risk for chronic diseases should be taken into account and lifestyle counselling including advice in nutrition should be incorporated in routine occupational healthcare of shift workers.

Prevention of diabetes and cardiovascular diseases in occupational health care: feasibility and effectiveness.

AIMS: To evaluate feasibility and effectiveness of lifestyle counseling in occupational setting on decreasing risk for diabetes and cardiovascular disease. METHODS: A health check-up including physical examination, blood tests, questionnaires and health advice was completed on 2312 employees of an airline company. Participants with elevated risk for type 2 diabetes based on FINDRISC score and/or blood glucose measurement (n=657) were offered 1-3 additional lifestyle counseling sessions and 53% of them agreed to participate. After 2.5 years, 1347 employees of 2199 invited participated in a follow-up study. RESULTS: Among women and men with low baseline diabetes risk, cardiovascular risk factors increased slightly during follow-up. Larger proportion of the men who attended interventions lost weight at least 5% compared with the non-attendees (18.4% vs. 8.4%, p=0.031) and their FINDRISC score increased less (0.6 vs. 1.5, p=0.037). Older age associated with participation in follow-up and higher baseline FINDRISC score and presence of clinical and lifestyle risk factors and problems in sleep and mood increased attendance in interventions. CONCLUSIONS: Identification of employees with cardiovascular and diabetes risk, and the low intensity lifestyle intervention were feasible in occupational health-care setting. However, the health benefits were modest and observed only for men with increased risk.

A simple tool for diet evaluation in primary health care: validation of a 16-item food intake questionnaire.

Our aim was to validate a 16-item food intake questionnaire (16-FIQ) and create an easy to use method to estimate patients' nutrient intake in primary health care. Participants (52 men, 25 women) completed a 7-day food record and a 16-FIQ. Food and nutrient intakes were calculated and compared using Spearman correlation. Further, nutrient intakes were compared using kappa-statistics and exact and opposite agreement of intake tertiles. The results indicated that the 16-FIQ reliably categorized individuals according to their nutrient intakes. Methods to estimate nutrient intake based on the answers given in 16-FIQ were created. In linear regression models nutrient intake estimates from the food records were used as the dependent variables and sum variables derived from the 16-FIQ were used as the independent variables. Valid regression models were created for the energy proportion of fat, saturated fat, and sucrose and the amount of fibre (g), vitamin C (mg), iron (mg), and vitamin D (µg) intake. The 16-FIQ is a valid method for estimating nutrient intakes in group level. In addition, the 16-FIQ could be a useful tool to facilitate identification of people in need of dietary counselling and to monitor the effect of counselling in primary health care.

Diet and nutrient intake in young adults born preterm at very low birth weight.

OBJECTIVE: To assess dietary intake in young adults born preterm at very low birth weight (VLBW) (≤ 1500 g). STUDY DESIGN: We studied 151 young adults aged 19-27 years who were born at VLBW and 156 term-born controls, group-matched for age, sex, and birth hospital. Participants completed a 3-day food record, which was checked by a nutritionist. Food and nutrient intakes were calculated with use of a dietary analysis program. Data were analyzed by multiple linear regression, adjusted for age, sex, body mass index, height, living at parental home, daily smoking, and highest parental education. RESULTS: Compared with controls, VLBW subjects had lower mean (SD) daily intake of vegetables, fruits, and berries (183 [150] g vs 241 [168] g, P = .002] and milk products (343 [242] g vs 427 [316] g, P = .003). Energy intake from carbohydrates, protein, and fat was similar, as was salt intake. VLBW participants had lower daily intake of calcium (858 [389] mg vs 1080 [514] mg, P < .0001), vitamin D (3.7 [2.6] µg vs 4.4 [3.6] µg, P = .02), and cholesterol (189 [74] mg vs 227 [105] mg, P = .002], whereas intake of essential fatty acids was higher (4.3 [1.5] mg vs 4.0 [1.5] mg, P = .01). CONCLUSIONS: Lower consumption of vegetables, fruits, berries, and milk products combined with lower calcium and vitamin D intake in VLBW participants offers a target for reducing the risk of osteoporosis and cardiovascular diseases in persons of VLBW.

Occupational health care identifies risk for type 2 diabetes and cardiovascular disease.

AIMS: To assess the risk for type 2 diabetes (T2D) and cardiovascular disease (CVD) among employees of a Finnish airline; to study the association of shift work with T2D and CVD risk; and to test the feasibility of risk screening in occupational health care setting. METHODS: Altogether 4169 employees were invited for a health check-up and 2312 participated in this study. The check-up included physical examinations, questionnaires on working hours, sleep, and lifestyle, diabetes risk score FINDRISC, and blood tests. Lifestyle counselling was offered for those with increased T2D risk. RESULTS: Altogether 15% of participants had a high T2D risk (FINDRISC≥15 and/or elevated, but non-diabetic blood glucose), and a further 15% had a moderate T2D risk (FINDRISC 10-14 and normal blood glucose). Of those 60% agreed to attend lifestyle counselling. Metabolic syndrome was more common, lipid profile more unfavorable and hsCRP higher by increasing FINDRISC score category. Risk factor profiles linked to shift work status were not self-evident. CONCLUSIONS: The renewed health check-up process effectively identified those employees with increased T2D and CVD risk who would benefit from lifestyle intervention. The use of FINDRISC questionnaire was a feasible first-step screening method in occupational health care setting.

Reducing the risk of type 2 diabetes with nutrition and physical activity - efficacy and implementation of lifestyle interventions in Finland.

BACKGROUND: The prevalence of type 2 diabetes has been increasing in Finland, in parallel with a gradual increase in overweight and obesity during the past decades. The expanding prevalence of type 2 diabetes brings along complications, most importantly CVD. Therefore, it is extremely important to implement activities to prevent type 2 diabetes. OBJECTIVE: In the present paper, the clinical evidence for the prevention of type 2 diabetes is presented with the Finnish diabetes prevention study. In addition, the paper discusses the practical implementation of prevention of type 2 diabetes using three different types of prevention programmes as examples: FIN-D2D, including risk-screening and repeated consultation in primary health-care; FINNAIR, a workplace-targeted intervention project involving airline employees; and the good ageing in Lahti region (GOAL) programme, a community-based prevention programme. CONCLUSIONS: FIN-D2D, the FINNAIR project and the GOAL programme have shown that screening for type 2 diabetes risk and implementing large-scale lifestyle intervention in primary health-care are feasible. However, the crucial questions still are whether it is possible to replicate the results concerning effectiveness of lifestyle intervention in primary and occupational health-care systems. Furthermore, it remains to be shown whether it is possible to achieve the same results in different health-care settings, cultures, regions and age groups, especially in adolescents and young adults among whom the increase in the incidence has been the highest. In addition, the importance of co-operation among all sections of society, citizens' awareness of healthy lifestyles and the social inequalities in health must be emphasised because the diabetes epidemic cannot be solved only by concentrating on preventive actions carried out by health-care systems.

Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study.

BACKGROUND: Lifestyle interventions can prevent the deterioration of impaired glucose tolerance to manifest type 2 diabetes, at least as long as the intervention continues. In the extended follow-up of the Finnish Diabetes Prevention Study, we assessed the extent to which the originally-achieved lifestyle changes and risk reduction remain after discontinuation of active counselling. METHODS: Overweight, middle-aged men (n=172) and women (n=350) with impaired glucose tolerance were randomly assigned to intensive lifestyle intervention or control group. After a median of 4 years of active intervention period, participants who were still free of diabetes were further followed up for a median of 3 years, with median total follow-up of 7 years. Diabetes incidence, bodyweight, physical activity, and dietary intakes of fat, saturated fat, and fibre were measured. FINDINGS: During the total follow-up, the incidence of type 2 diabetes was 4.3 and 7.4 per 100 person-years in the intervention and control group, respectively (log-rank test p=0.0001), indicating 43% reduction in relative risk. The risk reduction was related to the success in achieving the intervention goals of weight loss, reduced intake of total and saturated fat and increased intake of dietary fibre, and increased physical activity. Beneficial lifestyle changes achieved by participants in the intervention group were maintained after the discontinuation of the intervention, and the corresponding incidence rates during the post-intervention follow-up were 4.6 and 7.2 (p=0.0401), indicating 36% reduction in relative risk. INTERPRETATION: Lifestyle intervention in people at high risk for type 2 diabetes resulted in sustained lifestyle changes and a reduction in diabetes incidence, which remained after the individual lifestyle counselling was stopped.