Presentation meeting 5 Pölönen

The implementation of the nationaltype 2 diabetes prevention programme,FIN-D2D, in the Pirkanmaa HospitalDistrict – Lessons learned5th Meeting of the WG ISHC BSPCTampere, Finland, 16–17.3.2015Auli PölönenCoordination managerPirkanmaa Hospital District, FinlandBackgroundFIN-D2D ProjectFIN-D2D model (high risk strategy)FIN-D2D in practiseExperiences and models developed in PirkanmaaResultsDiscussion2 16.3.2015 Pirkanmaa Hospital District – Auli PölönenBackgroundType 2 diabetes (T2D) and its co-morbidities are rapidlyincreasing health problems in Finland and worldwideRandomized trials have shown that lifestyle modification canpostpone T2D among individuals at high risk for T2D3 16.3.2015 Pirkanmaa Hospital District – Auli PölönenDiabetes prevalence in FinlandNiemi, Winell: Diabetes Suomessa, Stakes 2005YearTotal T1D T2D DMType uncertain4 16.3.2015 Pirkanmaa Hospital District – Auli PölönenrebmuNDiabetes patients in dialysis in Finland 1965 - 2000Patients/year180T2D15012090T1D60300year-65 -70 -75 -80 -85 -90 -95 -00Finnish Registry for Kidney Diseases – Report 20005 16.3.2015 Pirkanmaa Hospital District – Auli PölönenCosts of diabetes care(on average, euros/person/year, Finland)T1D T2D24 x12 xComplications No complicationsKangas 20026 16.3.2015 Pirkanmaa Hospital District – Auli PölönenStudies:Risk factors of T2D and metabolic syndrome Obesity, central obesity and weight gainPhysical inactivity and sedentary lifestyle Diet: high fat and saturated fat intake Diet: low nutrient fiber intake Insulin resistance Family history of diabetes Ethnicity Increasing age Lifestyle modification and prevention? Trials7 16.3.2015 Pirkanmaa Hospital District – Auli PölönenEffects of diet and exercise in preventing NIDDM inpeople with impaired glucose tolerance.The Da Qing IGT and Diabetes Study, ChinaPan et al. 1997. Diabetes Care 20:537-544The cumulative incidence of diabetesRisk reductionat 6 yearsDiet 31 %Exercise 46 %Diet + exercise 42 %Control n=133Diet n=130Exercise n=141Diet + exc. n=1268 16.3.2015 Pirkanmaa Hospital District – Auli PölönenThe Finnish Diabetes Prevention Study (DPS)Tuomilehto et al. 2001. N Engl J Med 344:1343-1350522 overweight, middle-aged men and women with IGTRandomly allocated to:intensive lifestyle intervention or control groupIntervention goals:• Weight reduction > 5%• Moderate fat < 30 E%• Low saturated fat < 10 E%• High fibre >15g /1000 kcal• Physical activity > 30 min / day7 individual dietary counselling sessions (by dietitians)during the first year, every 3 months thereafter9 16.3.2015 Pirkanmaa Hospital District – Auli PölönenDPS: Diabetes incidence was 58% loweramong the intervention group compared withthe control group after mean follow-up of 3.2 yearsHRWeight reduction > 5%Moderate fat < 30 E%Low saturated fat < 10 E%High fibre >15g/1000kcalPhysical activity > 30 min/dayN Engl J Med 2001; 344:1343-135010 16.3.2015 Pirkanmaa Hospital District – Auli PölönensetebaidfoecnedicnievitalumuCDPS: The more goals achieved, the lower the risk!10HR86Weight reduction > 5%4Moderate fat < 30 E%Low saturated fat < 10 E%2High fibre >15g/1000kcal0Physical activity > 30 min /day0 1 2 3 4 5Number of goals achievedGoals at year 3; incidence during 7 years follow-up11 16.3.2015 Pirkanmaa Hospital District – Auli Pölönennosrep001repecnedicnIsraeyDiabetes Prevention Program (DPP)N Engl J 2002, 346:393-403N = 3234 , IGT and elevated fP-glucControl/Placebo groupIntervention groups:MetforminLife styleWeight reduction (>7%)Lower fat ja energy intakeEnhanching physical activity(>150min/vko)Metformin intervention group riskfor diabetes decreased 31%Lifestyle intervention group:Risk for diabetes decreased 58%12 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen13 16.3.2015 Pirkanmaa Hospital District – Auli PölönenDPS (2001), DPP etc. evidence of the prevention of T2DImplementation Project of T2D Prevention ProgrammeFIN-D2D Project 2003 - 2007 and the Follow-up Project 2008 - 2010FIN-D2D: PartnersFour => Five hospital districtsFinnish Diabetes AssociationNational Institute for Health and WelfareTarget population 1.5 million people400 health care centres200 occupational health centres> 2000 health care professionals14 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Funding 2003 - 2007Hospital districts 100 000 euros/year/districtFunding from the State 100 000 euros/year/districtFinnish Diabetes Association 450 000 euros/year(The Slot Machine Association of Finland)National Public Health Institute 100 000 euros/yearTotal: 8.4 million euros during the years 2003-2007Target population 1.5 million 1.1 euro/person/yearThe project had to apply for the funding every year (the State,the Slot Machine Association and municipalities separately)15 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Project GoalsTo reduce the incidence and prevalence of T2Dand cardiovascular risk factorsTo identify individuals with T2DTo generate new models for the prevention of T2DTo evaluate the effectiveness, feasibility and thecost-effectiveness of the projectTo increase awarenessof T2D and its risk factors among the population16 16.3.2015 Pirkanmaa Hospital District – Auli PölönenThree strategies:Population Strategy:Prevention of obesity and T2D at population levelHigh-Risk Strategy:Screening of people with elevated risk (adults) andmanagement of risk factors by lifestyle counsellingEarly Diagnosis and Management Strategy:Appropriate treatment and prevention of complicationsamong newly diagnosed people with T2D17 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFINDRISC:Age, BMI, Waist,Physical activity, Nutrition,Hypertension, Family historyForm available:• On-line www.diabetes.fi• In pharmacies• At selected public events• In newspapers• Given by a health careprovider at a normal visit• As a part of routine healthcare check-ups• At self-service check-uppointsDiabetes Care 2003;26:725-31.18 16.3.2015 Pirkanmaa Hospital District – Auli PölönenAt high risk19 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D InterventionsPrimary health care or other service providers:Weight- Mental Alcohol usemanagement Exercise Healthy support management Peergroups groups cooking groups groups groups groupsIdentificationGroupas a high-riskinterventionpersonIndividual1. visit 2. visit (3. visit)intervention(nurse) (nurse) (GP) Annual follow-upsSelf-Height, Weight, BMI, Waist,initiatedBlood pressure,lifestyleOGTT, LipidschangesQuestionnaire on medical history,Smoking, Physical activity, Food habitsOtherRegularGlobal risk assessment interventionhealthformsReadiness to change habits care visits20 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Project: Intervention goalsin life-style modificationRisk factor: Overweight (BMI > 25 kg/m2)Goal: 5 % reductionRisk factor: Low physical activityGoal: > 30 min/dayRisk factor: High saturated fat intakeGoal: < 10 E%Risk factor: High fat intakeGoal: < 30 E%Risk factor: Low fiber intakeGoal: > 15 g/1000 kcal21 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Project interventionBased on:• Research evidence• Current Care Guidelines: Obesity, Hypertension, Dyslipidemias• Finnish Nutrition and Physical Activity Recommendations• FIN-D2D goalsLife-style modification as a long-term process, step by step:Stages of the changes - modelNew approach and methods for counselling - empowermentCustomer-oriented and target-oriented approachMultiprofessionality shared responsibities, experticeProtocols for screening and interventionValidated material for counsellingDocumentationEvaluation on individual and organisational levelsCollaboration networks:public and private primary health care, specialised caremunicipal actors, local organisations, associations etc.22 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D - basic questionnaire forhigh risk individualsHow Are You?Health statusSmokingPhysical activityDietWeight managementSleepAs a tool forintervention andcounselling follow ups23 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen24 16.3.2015 Pirkanmaa Hospital District – Auli PölönenEveryday physical activityis beneficial as wellSmall changesyield big resultsExamples of daily one-hour motionopportunities:walkingfrom home to bus 5 minfrom bus to work 7 minto and from lunch restaurant 6 minfrom work to bus 7 minfrom bus to store 8 minfrom store to home 6 minusing stairs during the day 8 minclearing snow away 13 mintotal 60 min25 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFinnish Nutrition Recommendations26 16.3.2015 Pirkanmaa Hospital District – Auli PölönenEat well – You are well Proper foodBetter mood27 16.3.2015 Pirkanmaa Hospital District – Auli PölönenMaking the Food Choices VisibleEtelä-Pohjanmaan sairaanhoitopiiriJuotko vaiDEHKON 2D -hankesyötkö?400 kcalKummanOmenoita 3,6 kiloanapostelethuomaamatta?Iso karkkipussi(350 g)1600 kcal 600 kcalSaman verran energiaa (1230 kcal)28 16.3.2015 Pirkanmaa Hospital District – Auli PölönenThe Amount of Fat During Half a Year29 16.3.2015 Pirkanmaa Hospital District – Auli PölönenMedia CampaingsFIN-D2DLook at Your Belly Button A Small Decision a Day30 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D in Pirkanmaa Hospital District31 16.3.2015 Pirkanmaa Hospital District – Auli PölönenRRREEEGGGIIIOOONNNAAALLL LLLEEEVVVEEELLL FFFIIINNN---DDD222DDD PPPRRROOOJJJEEECCCTTT PPPIIIRRRKKKAAANNNMMMAAAAAA LLLOOOCCCAAALLL LLLEEEVVVEEELLLNNNEEETTTWWWOOORRRKKK AAANNNDDD CCCOOOLLLLLLAAABBBOOORRRAAATTTIIIOOONNNHHHeeeaaalllttthhh CCCaaarrreee CCCeeennntttrrreeesssMMMuuunnniiiccciiipppaaallllll GGGooovvveeerrrnnneeemmmeeennntttsssOOOccccccuuupppaaatttiiiooonnnaaalll HHHeeeaaalllttthhh CCCaaarrreee UUUnnniiitttsssHHHeeeaaalllttthhh CCCaaarrreee CCCeeennntttrrreeesssTTTaaammmpppeeerrreee UUUnnniiivvveeerrrsssiiitttyyy HHHooossspppiiitttaaalll aaannndddRRReeegggiiiooonnnaaalll HHHooossspppiiitttaaalllsss DDDD2222DDDD PPPPiiiirrrrkkkkaaaannnnmmmmaaaaaaaa AAAccctttooorrrsss iiinnn ttthhheee OOOttthhheeerrr MMMuuunnniiiccciiipppaaalllOOOrrrgggaaannnsssSSSStttteeeeeeeerrrriiiinnnngggg 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aaannnddd PPPhhhaaarrrmmmaaaccciiieeesssSSSpppooorrrtttsss aaannnddd PPPhhhyyysssiiicccaaalll AAAccctttiiivvviiitttyyy CCCllluuubbbsssTTThhheee NNNaaatttiiiooonnnaaalll RRReeessseeeaaarrrccchhh aaannndddDDDeeevvveeelllooopppmmmeeennnttt CCCeeennntttrrreee fffooorrr WWWeeellllllfffaaarrreeeaaannnddd HHHeeeaaalllttthhh MMMeeedddiiiaaa AAAddduuulllttt EEEddduuucccaaatttiiiooonnn CCCeeennntttrrreeesss Large variety of actors and professionalsin screening and life style modification32 16.3.2015 Pirkanmaa Hospital District – Auli PölönenVisits to every health care centerand occupational health care unitto chart resourcourses and needsfor the prevention of T2D, workingmethods, tools, materials, andneeds for education and traininglocal D2D multidisciplinaryteams, local D2D projects33 16.3.2015 Pirkanmaa Hospital District – Auli PölönenNetworksCollaborationMultidisciplinary workWorkshopsEduction and trainingDeveloping care chains, portocolsProjects plans and prosesses34 16.3.2015 Pirkanmaa Hospital District – Auli PölönenMultidisciplinary work,roles, and responsibilities in health care protocolsThe regional (Valkeakoski) protocol for the prevention and care of T2D in Pirkanmaa, 2008The protocol for the Pirkanmaa hospital district 201135 16.3.2015 Pirkanmaa Hospital District – Auli PölönenDocumentation developed: food habits, physical activityData collection for FIN-D2D evaluation36 16.3.2015 Pirkanmaa Hospital District – Auli PölönenAnnual reports of localKEHITTÄMISSEMINAARITprojectsWorkshopsSharing experienciesPlanning further37 16.3.2015 Pirkanmaa Hospital District – Auli PölönenNew models for theoccupational health care38 16.3.2015 Pirkanmaa Hospital District – Auli PölönenCatering servicesGood opportunities forhealth promotion andcommunication39 16.3.2015 Pirkanmaa Hospital District – Auli PölönenPharmacies incollaboration40 16.3.2015 Pirkanmaa Hospital District – Auli PölönenSastamala board meeting: Seminars for men in Sastamala”Something for men?once a year - real successCompetitions, diet information,physical activities, celebrities...”Male personnel of the municipalityin charge of planning the seminar.> 300 participants/event41 16.3.2015 Pirkanmaa Hospital District – Auli PölönenCampaigns for decision-makers and personelSastamala: ”One cent out of your waist for the health” campaingVirrat: Checking the waistcircumference of the staffannuallyYlöjärvi: ”Light summercampaign” for the staffTays: Campaigns for the staff,well-being weeks, healthpromotion events42 16.3.2015 Pirkanmaa Hospital District – Auli PölönenParticipatingfairs togetherwithcollaborators43 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen AP PSHP 09Hand in hand with the third sector44 16.3.2015 Pirkanmaa Hospital District – Auli PölönenActivating physically inactive men -An adventurous approach (SuomiMies seikkailee)FINNISH HEARTASSOCIATIONPIRKANMAAFINNISH SPORTSFEDERATION, HÄMED2D PIRKANMAAKKI-AWARD 2006 KKI product since 200745 16.3.2015 Pirkanmaa Hospital District – Auli PölönenConcern of the childrens’obesity problemMultidisciplinary work since 2004 Special project to improvechildrens’ nutrition education atday care 2011 - 2013 District care chain and servicenetwork 201346 16.3.2015 Pirkanmaa Hospital District – Auli PölönenInternationalReporting Days2006 and 2007WCPD 200847 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D De Plan Project and Image Project(EU) and toolkits48 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2DResults and Lessons Learned49 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Survey 2004 (in three hospital districts):High prevalence of abnormal glucose tolerance in themiddle-aged Finnish population (age group 45-74 yrs.)Men (n = 1396) Women (n = 1500)Diagnosed type 2diabetes 7.1% 3.9%Screen-detected } 16.4% } 11.2%type 2 diabetes 9.3% 7.3%Impaired glucosetolerance 15.5% 17.0%Impaired fastingglucose 10.0% 5.2%__________Total*: 42.0% 33.4%* Age-adjustedSaaristo T et al. BMC Public Health 2008.8:42350 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen200 000 - 250 000 screened for risk of T2Dduring FIN-D2DModerate riskcohort n = 9898Diagnostics,interventions andfollow-up inprimary healthcare as usualHigh risk cohort for evaluationn = 10176Evaluation, follow-up51 16.3.2015 Pirkanmaa Hospital District – Auli PölönenPerformed Oral Glucose Tolerance Testsin the Pirkanmaa Hospital District 2002-200790008000700060005000OGTT40003000 311 %2000100002002 2003 2004 2005 2006 200752 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D high risk cohort participantsNumber of participants 10 149 (33.4 % men)MeanAge 53.6 (10.9) yearsBMI, kg/m2 31.3 (4.7)BMI > 30 kg/m2 59.6 %Waist circumference 102.9 (13.1) cmFINDRISC score 17.2 (3.2)Saaristo T et al. Primary Care Diabetes 201053 16.3.2015 Pirkanmaa Hospital District – Auli PölönenIntervention visits in the high risk cohort of FIN-D2D%Number of visits Men (n = 3421) Women (n = 6845)At least one 45 47≥ 4 24 28Visit to physician 33 27Saaristo T et al. Primary Care Diabetes 201054 16.3.2015 Pirkanmaa Hospital District – Auli PölönenOGTT classification at the baseline andduring the one year follow-upin the FIN-D2D high risk men and womenMen (n = 926) Women (n = 1972)OGTT Baseline Follow-up Baseline Follow-upNormal 39 % 45 % 54 % 60 %IFG 30 % 23 % 18 % 16 %IGT 31 % 22 % 28 % 19 %DM 10 % 5 %Saaristo T et al. Primary Care Diabetes 201055 16.3.2015 Pirkanmaa Hospital District – Auli PölönenChange in risk factors in the FIN-D2D high-riskindividuals during the 1st year of intervention,all hospital districtsMen (n = 1492) Women (n = 3196)Baseline, Absolute Baseline, Absolutemean change mean changeWeight kg 96.5 -1.02 84.1 -0.88Waist cm 107.8 -1.06 99.8 -0.98BP syst mmHg 142.2 -0.75 138.9 -1.67BP diast mmHg 88.1 -1.30 85.5 -1.33Cholesterol mmol/l 5.1 -0.26 5.2 -0.12Saaristo T et al. Primary Care Diabetes 201056 16.3.2015 Pirkanmaa Hospital District – Auli PölönenDiabetes risk in one year follow-upaccording to weight change in FIN-D2DAdjusted to the age of 50+10 %8Ref76-29 %543 -69 %210 Weight changeL>o5s%t > l a5 s%k u 2L,5o-s4t, 9% StaE bi le G>a2i,n5e%d2la.5s-k4u.9 % mwueuitgohstt a n>o 2u.5s u%Diabetes Care 2010; 33: 2146-215157 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen)%(setebaidfoecnedicnIResults – practices and models (1)FINDRISC has proved out to be a practical toolfor screening and mini-intervention and a usefultool for the third sector.D2D questionnaire has proved out to be apractical tool when identifying, registering andevaluating customers’ habits. Shorter versionsdeveloped by Northern Savo and Pirkanmaa.New material for the preventive work developedby the FIN-D2D was necessary.The Model for the Stages of Change providesa practical model for understanding thecharacter of changes in habits.58 16.3.2015 Pirkanmaa Hospital District – Auli PölönenThe demand for nutrition therapy services has increased. Before the D2D Project only two health carecentres had an AN. Some AN services were purchased, but not focused on prevention. In 2007 fourmunicipalities consider establishing AN vacancies. In occupational health care there were no AN servicesThe deamvaaniladb foler. nNuotrwit io sne vtheeraral puyn istse rhvaicvees e hxapsr einscsreeda tsheedir. Bneeefodr efo trh Ae ND 2seDr vPicroejse.c t only two health carecentres had an AN. Some AN services were purchased, but not focused on prevention. In 2007 fourmunicipalities consider establishing AN vacancies. In occupational health care there were no AN servicesavailable. Now several units have expressed their need for AN services.FIN-D2D has shown the magnitude of the diabeticResults (2)epidemic in Finland.In 2004 the health care centres had no establishedpractices for high-risk intervention.During the project a multiprofessional local steeringgroup co-ordinated the work in most health centres.The D2D model has been adopted in most healthcare centres and some occupational health units forscreening and interventions.The FIN-D2D model has been included into the localand regional T2D prevention care protocols.The FIN-D2D model has been adopted also for theprevention of other noncommunicable diseases.Other prevention projects in Finland, De Plan, andImage Project in Europe have adopted the FIN-D2Dmodel as well.59 16.3.2015 Pirkanmaa Hospital District – Auli PölönenResults (3)The need for nutrition and physical activity educationbecame obvious. During the project health careprofessionals knowledge and skills of life style counsellingimproved.Public nurses got a central role in the prevention of T2D.Multiprofessional guidance and support was needed.Over 300 new models were documented.Occupational health care got a new role in the prevention ofT2D.District and local networks of heath care, third, and privatesector were established.At the population level the awareness of T2D and its riskfactors has increased.60 16.3.2015 Pirkanmaa Hospital District – Auli PölönenResults – National LevelThe Amount of diabetes patients based on reimbursementfor diabetes medication (103) in Finland 1986 – 2013The Social Incurance Institution of FinlandKela: Diabeetikoiden määrä (erityiskorvausoikeus 103) 1986–2013Suomen Diabetesliitto 201561 16.3.2015 Pirkanmaa Hospital District – Auli PölönenNew T2D Patiens in Finland 1997 - 2007Diabetesbarometri 201062 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D Survey 2004 and 2007Half of all T2D in the age group 45-74 are unidentifiedObesity trend in Finland seems to leveling off63 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFinnish Registry for Kidney Diseases – Report 201364 16.3.2015 Pirkanmaa Hospital District – Auli PölönenPublic awareness regarding T2D and itsprevention has been raised•Health communication and media visibility all overthe country: TV, radio, journals, newspapers•”Look at yourself” campaign•”A small decision every day” campaign•FIN-D2D exhibitions•A wide selection of training material for people at risk•Material for health care providers•Various local innovations for raising awarenessDiabetes mentioned in the media in Finland during 1980-20061980-1993 1300-15001994-1999 1800-23002000-2006 3700-6000Finnish Diabetes Association 200865 16.3.2015 Pirkanmaa Hospital District – Auli PölönenAwareness of the prevention ofdiabetes in the 2007 population surveyQuestion: Which action results in the prevention of type 2 diabetes?1008060%4020MenWomen0Normal weight 5-10% weight Reduced waist Increase fiberreduction intakeRisk factor66 16.3.2015 Pirkanmaa Hospital District – Auli PölönenFIN-D2D: Factors to overcome•Limited resources for prevention in primary health care.•Strong focus on treatment, not prevention and health promotion, inprimary health care.•Lack of knowledge and skills of the health care personnel concerninglife style modification.•Lack of long term approach to life style modification.•Lack of documentation and systematic follow-up of life style factors•Lack of tradition and practices of group counselling.•Lack of cross-sectional way of working in municipalities.•Strict job descriptions limited cross-sectional work.•FIN-D2D models and practices were seen as project work, notpermanent practice in many health care centers.•Physicians less committed to prevention work than other personnel.•Men less active than women in participating in T2D prevention activities.•Sedentary life style and unhealthy food habits as a counterforce to.prevention67 16.3.2015 Pirkanmaa Hospital District – Auli PölönenConclusionsLarge-scale screening and effective life style intervention for preventingT2D are possible in primary health care setting.There are plenty of interfering factors to overcome.Change of paradigm is necessary both in health care organisations andin other sectors of public services.Well-defined protocols for prevention and treatment, and systematicallyorganised professional services are needed.Local network and collaboration, and continuous multidisciplinary lifestyle education and training are prerequisites for success.Attention must be paid to the population strategy. The work mustinvolve the entire community.Politicians and other decision-makers are in a key role to realize theimpact potential of health promotion and prevention of non-communicable diseases.68 16.3.2015 Pirkanmaa Hospital District – Auli PölönenAcknowledgements•Pirkanmaa hospital district, health care centers, occupational health careHeikki Oksa, Rauno Ihalainen, Ritva Himanka, Olli A Mäkinen, Anneli Salminen, PirjoAromaa, Scott Yoder•South Ostrobothnia hospital district, health care centers, occupational healthcareEeva Korpi-Hyövälti, Jaakko Pihlajamäki, Arja Hyytiä, Hilpi Linjama, Riitta-Liisa Rekiaro,Elina Leikkainen, Hannu Puolijoki•Northern ostrobothnia hospital district, health care centers, occupationalhealth careSirkka Keinänen-Kiukaanniemi, Hannu Leskinen, Karita Pesonen, Jari Jokelainen, LeeaJärvi, Antero Kesäniemi, Liisa Hiltunen•Central Finland hospital district, health care centers, occupational health careJuha Saltevo, Mauno Vanhala, Timo Kunttu, Kaija Korpela, Jukka Puolakka, lIlkkaKunnamo, Marita Poskiparta, Nina Peränen, Tapani Kiminkinen, Urho Kujala•Northern Savo hospital district, health care centers, occupational health careLeo Niskanen, Matti Uusitupa, Matti Pulkkinen, Mervi Lehmusaho, Leena Moilanen,Annikki Sutinen, Markku Laakso•National Public Health InstituteMarkku Peltonen, Jaakko Tuomilehto, Jaana Lindström, Pekka Puska, Johan Eriksson,Vladislav Moltchanov•Finnish Diabetes AssociationLeena Etu-Seppälä, Jorma Huttunen, Satu Kiuru, Pirjo Ilanne-Parikka, Eliina Aro, EnnaBierganns, Jarmo Riihelä, Maria Aarne, Sari Koski, Tarja Sampo, Outi Himanen, KirsiHeinonen, Liisa Heinonen, Mervi Lyytinen, Juha Mattila•Other actorsJouko Saramies, Aino Myllyluoma, Harri Sintonen Tapani Melkas, Jarno Viikki. Reijo69 16.3K .20ä 15r kkäinen, Noel Barengo, P Pira kas nmi aA a Hr oo spn itae l Dn is, t riV ct i –r Ag uli i n Pöi löa n eM n attila, Robert HollingsworthMore informationwww.diabetes.fi/en/finnish_diabetes_association/dehkowww.thl.fi (in English, på svenska, D2D)70 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen71 16.3.2015 Pirkanmaa Hospital District – Auli Pölönen