III International Scientific Congress of Maritime, Tropical, Hyperbaric and Travel Medicine...

III International Scientific Congress of Maritime, Tropical, Hyperbaric and Travel Medicine

Copenhagen / Oslo, 20-24 May 2015 on-board the DFDS SEAWAYS ferry. Organisers: Polish Society of Maritime, Tropical and Travel Medicine

Institute of Maritime and Tropical Medicine – Medical University of Gdansk National Centres for Maritime, Tropical and Hyperbaric Medicine in Gdynia

International Maritime Health Association

Events’ motto: Healthcare upon the sea and in the travel

The IDEAL Intervention study model of the Non-Communicable Diseases –A challenge

Olaf Jensen, Centre for Maritime Health and Society,

Esbjerg, Denmark

Background

The World Health Organization reports the Non-Communicable Diseases to be by far the leading cause of death in the world, representing over 60% of all deaths. Risk factors such as a person's physical activities and the type and amount of food are known to be the major preventable risk factors.

Natural History of Obesity Leading to Type 2 Diabetes

Genetic susceptibilityEnvironmental factors

NutritionPhysical inactivity

AtherosclerosisHyperglycemiaHypertension

RetinopathyNephropathyNeuropathy

BlindnessRenal failureCHDAmputation

Onset ofdiabetes

Complications

Disability

DeathOngoing hyperglycemiaIGTObesity Insulin resistance

Risk forDisease Metabolic

Syndrome

Tendencias Obesidad Entre Adultos EEUU (BMI ≥ 30)

Intervention research – success?

•Intervention studies to prevent the Non-Communicable Diseases have been increasingly used in many countries. The methods are most often counselling or education to modify the specific risk factors for overweight, cardiovascular diseases, diabetes and hypertension,

Intervention research – success?

The objective here is to present the methodological gold standard for the intervention studies and to discuss how to improve the intervention studies and the prevention of this global epidemy

Goal of intervention research

The primary goal of intervention research is to try out in a sample whether some particular learning could or should be implemented in a larger scale to improve health.

1.Incidence/prevalence(of health and exposures)Cross sectional or cohort

2. 2. Causal analysisCohort or case-referent

3. 3. Intervention - prognosticCohort (before and after randomized)

• Full-scale implementation

Triad of Epidemiology

Objective _ example

To reduce the number of seafarers unable to pass the health examination caused by high BMI from 10% to 5% in 3 years.

Study design, example

• Randomized cohort of seafarers aged 20-40 years from long distance cargo ships

• Development of program • Implementation of program• Epidemiological Impact evaluation • Qualitative evaluation of learning and change objectives• Evaluation of sustainability and full scale implementation

1. Define the cohort to be used for the intervention

2. Randomize the cohort in 2 groups

Randomized

Inter-vention

Persons=104

ReferenceGroupPersons=

98

3. Define time shedule

Randomized

Inter-vention

Persons=104


98


Randomized

T0 T1

Inter-vention

Persons=104


98

1 year


Randomized

T0 T1

T2

Inter-vention

Persons=104


98

1 year 1 year


Randomized

T0 T1

T2 T3

Inter-vention

Persons=104


98

1 year 1 year 1 year

4. Define intervention period

Randomized

T0 T1

T2 T3

Inter-vention

Persons=104


98


5. Define type of intervention

Randomized

T0 T1

T2 T3

Inter-vention

Persons=104


98


6. Measure incidence rates T0-T1 before intervention

Randomized

T0 T1

T2 T3

Inter-vention

Persons=104


98



Randomized

T0 T1

T2 T3

Inter-vention

Persons=104

* * * * * * *

*•* *

**


98



Rates per 1000 persons per year

Randomized

T0 T1

T2 T3 A T0-T1

Inter-vention

Persons=104

* * * * * * *

*•* *

**

121255


98

* * * * *

*•* *

** *




Randomized

T0 T1

T2 T3 A T0-T1

Inter-vention

Persons=104

* * * * * * *

*•* *

**

121255


98

* * * * *

*•* *

** *

121222


7. Perform the intervention T1-T2


Randomized

T0 T1

T2 T3 A T0-T1

Inter-vention

Persons=104

* * * * * * *

*•* *

**

121255


98

* * * * *

*•* *

** *

121222


7. Perform the intervention T1-T2


Randomized

T0 T1

T2 T3 A T0-T1

Inter-vention

Persons=104

* * * * * * *

*•* *

**

121255


98

* * * * *

*•* *

** *

121222


8. Measure incidence rates T1-T2 during intervention


Randomized

T0 T1

T2 T3 A T0-T1

Inter-vention

Persons=104

* * * * * * *

*•* *

**

121255


98

* * * * *

*•* *

** *

121222


8. Measure incidence rates T1-T2 during intervention


Randomized

T0 T1

T2 T3 A T0-T1

B T1-T2

Inter-vention

Persons=104

* * * * * * *

*•* *

**

* ** *

* *

*

121255

6767


98

* * * * *

*•* *

** *

* * * *

*•* *

* *

121222

102102


9. Measure incidence rates T2-T3 after intervention


Randomized

T0 T1

T2 T3 A T0-T1

B T1-T2

C T2-T3

Inter-vention

Persons=104

* * * * * * *

*•* *

**

* ** *

* *

*

* ** *

* *

* *

*

121255

6767 7777


98

* * * * *

*•* *

** *

* * * *

*•* *

* *

* * *

**

** *

*

121222

102102 9292


10. Calculate Relative Risks T1/T3 after/before intervention

Rates per 1000 persons per year RR

Randomized

T0 T1

T2 T3 A T0-T1

B T1-T2

C T2-T3 C/A

Inter-vention

Persons=104

* * * * * * *

*•* *

**

* ** *

* *

*

* ** *

* *

* *

*

121255

6767 7777 0.60.622


98

* * * * *

*•* *

** *

* * * *

*•* *

* *

* * *

**

** *

*

121222

102102 9292 0.70.755


11. Relative Risks of Intervention and reference groups

Rates per 1000 persons per year RR

Randomized

T0 T1

T2 T3 A T0-T1

B T1-T2

C T2-T3 C/A

Inter-vention

Persons=104

* * * * * * *

*•* *

**

* ** *

* *

*

* ** *

* *

* *

*

121255

6767 7777 0.60.622


98

* * * * *

*•* *

** *

* * * *

*•* *

* *

* * *

**

** *

*

121222

102102 9292 0.70.755

1 year 1 year 1 year RR 1.0 0.650.65 0.830.83

Conclusion of the theoretical example

• Let´s say there was no significant effect of the intervention

• Should a large scale program be implemented ?

• Why ?

Worksite Nutrition and Physical Activity Interventions - review

… found that worksite nutrition and physical activity programs achieve modest improvements in employee weight status at the 6–12-month follow-up.

Anderson LM, Quinn TA, Glanz K, Ramirez G, Kahwati LC, Johnson DB, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. Am J Prev Med. 2009 Oct;37(4):340–57.

The ’Healthy Heart Programmes’ Cochrane review

Multiple risk factor interventions in 57 studies had little or no impact on the risk of coronary heart disease mortality or morbidityThe effects of attempting behaviour change in the general population are limited and do not appear to be effective.

Ebrahim S, Taylor F, Ward K, Beswick A, Burke M, Davey Smith G. Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database of Systematic Reviews. Issue 1, 2011, Issue 2, 2013

Lancet Series 1 ”The global obesity pandemic: shaped by global drivers and local environments”

• The increases in obesity in almost all countries seem to be driven mainly by changes in the global food system.

• Unlike other major causes of preventable death and disability, such as tobacco use, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures.

• Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011 Aug 27;378(9793):804–14.

34

1950 - multifactural causal model multifatural prevention

35

1980 -> limited causal model limited or no prevention

36

1980 -> limited – individual causal model limited effect documented

37

2014 -> a comprehensive model

ILO: Integrating health promotion into workplace

•Integrating health promotion into workplace OSH policies•Stress •Violence, •Smoke-free workplaces•Alcohol and drugs, •Nutrition, •Physical activity, •Healthy sleep •HIV/AIDS.

WHO: Definition of health

Good health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. Good health is a fundamental human right - Universal Declaration of Human Rights (1948).

ConclusionsHealth promotion intervention studies are so far likely to have only small impact on mortality and morbidity

Despite these facts: health promotion intervention research is still needed to persue the other part of the WHO goals: physical, mental and social well-being.

This may on the long run, reduce the mortality and morbidity – time will show

To reduce mortality and morbidity, concerted actions with comprehensive structural programs by the national governments, civil communities, educators, employers, unions etc are needed

In the maritime area, interventions should be wider than on board the ships

– the maritime industry may go together with the national and international (ILO-WHO) public and occupational health programs

Issues for discussion

1) How can effective maritime health intervention studies be designed? 2) How can the seafarer´s health examinations be used for systematic health intervention programs? 3) A challenge for the global maritime industry with the IMHA-Research joining the public health programs

Thank you very much

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III International Scientific Congress of Maritime, Tropical, Hyperbaric and Travel Medicine...

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