In April of this year, I was honored to speak at the Finnish Nurses in Diabetes educational symposium held in Naantali, a beautiful resort town on the west coast of Finland. This country has long recognized diabetes as a health problem for its citizens. In both research and management, Finland has aggressively pursued its national goals for reducing the effects of this public health problem. My Finnish host, Maria Aarne, General Secretary of the Development Programme for the Prevention and Care of Diabetes (DEHKO), generously offered to give me a tour of one of the country's outstanding diabetes programs.
By a lake outside a small city, a collection of buildings is nestled into the piney landscape. The windows of the buildings have large glass panes inviting the peace and quiet of nature into the indoor spaces. The beauty of the setting is integral to the work that is done inside—the work of putting lives back into balance. People come to this place of learning and support to focus on the lifestyle changes necessary to live successfully with diabetes. This place is the Diabetes Center in Tampere, Finland.
The prevention and care of people with diabetes is taken very seriously in Finland. According to the Diabetes Barometer 2005, a document published by the Finnish Diabetes Association, diabetes affects 10% of the country's adult population.1 Although the preponderance have type 2 diabetes, ~ 15%, or 40,000 people, have type 1 diabetes. The incidence of type 1 diabetes is the highest in the world.2 This is particularly alarming because the 2003 international comparison of the incidence of diabetes in children indicated that the rate in Finland is 40/100,000, giving this country the dubious distinction of being the leader in this statistic as well.
Among those with type 2 diabetes, the highest prevalence is among those of working age, reaching a peak in those ages 55-59 years. However, the statistics for those ages 60-74 years are nearly as high.3 Estimates from various government studies indicate that the rate of diabetes is rapidly growing. The number of all cases of diabetes increased in 2001-2002 by 5.5%.4 About 500,000 Finns have impaired glucose tolerance, and according to the Diabetes Prevention Program, if left unchecked, 5-10% of those will go on to develop diabetes each year.3
During my visit, I was honored to meet with Jorma Huttunen, the managing director of the Finnish Diabetes Association. He described the association's strong role in the government's planning and implementation of public health programs focused on diabetes. Created in 1955, the association has transitioned from an interest organization to a public health and patient organization. It conducts policy advocacy and provides education in diabetes management for both patients and health care professionals through its publications and participation in the development of new approaches to diabetes care.
Although it is a nongovernmental organization, the association has a great impact on the creation and delivery of programs for diabetes in the country. When the government of Finland started to finance the rehabilitation of people with diabetes during the 1970s, the Finnish Diabetes Association recognized this opportunity to become a key player in both an advocacy and advisory capacity. During the creation of the first diabetes program in 1978, the association planned and then built the Diabetes Center. Since 1980, the Finnish Diabetes Association has maintained primacy as a leader in the prevention and treatment of diabetes. The goal of improving the quality of life for those with diabetes lies at the heart of each program.
The Finnish Diabetes Association coordinates DEHKO, Finland's national diabetes program. This program includes clear goals to be achieved by 2010 and 25 concrete recommendations for action.5 One of the national subprojects of this program supports the self-care of people with diabetes.
People with diabetes participate in a comprehensive, experiential program at the Diabetes Center that is geared toward helping them meet their individually selected behavioral goals. The stated objectives of the center are to support, guide, and empower people and their families to manage their life with diabetes and to educate health care professionals to provide high-quality care and counseling. On any given week, there may be 18-26 people involved in a 6- to 9-day educational process.
Each week, different groups of people with diabetes embark on this life-changing journey: parents with children, adolescents, working people, and the elderly. Members of each age-group spend their time learning new information, reinforcing skills, discussing goals and needed life changes, and problem solving with the health care professional staff and each other. A diabetes nurse educator facilitates a small 6- to 8-person team through the various sectors of the program, arranging their meetings with a medical physician, physical education planner, and nutritionist, as well as coordinating psychosocial guidance and podiatry. She is the mainstay who guides the group throughout the week, becomes familiar with their personalities and needs, and is available for individual counseling as requested.
In the group discussions, members are encouraged to tell their diabetes story—how and when they were diagnosed, what they have done to manage their diabetes, and what they hope to accomplish by being at the center. The patients have been under the care of their local physicians and diabetes nurse educators, but have also been referred or asked for admission to the Diabetes Center. Those desirous of admission to the center have on average a 1-year wait. (Exceptions are made in the rare instances of a family or adolescent who needs immediate help.) Coming to the center gives patients the opportunity to focus on their health care needs away from the pressures and burdens of everyday life. As one nurse educator, Sari Härmä-Rodriguez, put it, “Here they have only to think of themselves, to reflect and think deeply about their own health and begin to make the changes.”
The term used is “rehabilitation”—creating new healthy habits that will lead to better self-care. The setting of the Diabetes Center is conducive to this quiet contemplation but also encourages physical activity and healthy eating. In warm weather, the center guests are encouraged to swim in the lake, hike through the woods, and use the outdoor sauna. During the cooler weather, patients use an indoor sauna, do Nordic walking, and use an exercise facility with various pieces of weight-training equipment. After dinner, patients frequently take part in informal team sports in a gym with a basketball court and volleyball net. “Things are lively after dinner, with most of the patients gathering in the gym for games, even the older ones,” said Anneli Jylhä, a diabetes educator. Another favorite gathering spot is a beautiful pine-paneled room adjacent to the warm indoor pool and sauna. With a panoramic view of the lake, it is a perfect place for an afternoon discussion.
Nutrition education takes place in a number of practical venues. Large cooking classes held in a spacious, fully equipped kitchen allow patients to work side by side with a dietitian in preparing a nutritious meal in which carbohydrate, fat, and sodium content are all taken into consideration. At each meal served in the dining room, the concepts of calories and carbohydrate content are reinforced through sample plates that are laid out at the head of the buffet, indicating the carbohydrate value of each portion and the number of food selections that make up the appropriate-calorie diet. In this way, patients are able to select foods from the steam trays, recreating the correct portions and practicing carbohydrate counting. Many traditional foods from the various regions of Finland comprise the menus, making this learning experience easily transitioned to the home setting.
Natural light from transom windows floods a small amphitheater. Patients and health care professionals gather here for more formal meetings. In this large, open space, nature is represented in the sculptural fiber wall hangings of undulating shades of blue wool, reminiscent of ocean waves. For the Finnish people, living in harmony with nature improves health and is highly valued. It seems appropriate that this theme is so apparent throughout the Diabetes Center.
Parents and children, adolescents, and elders spend 6 days at the Diabetes Center, whereas working people remain for 9 days and usually return 6 months later to evaluate their lifestyle changes, reinforcing or adjusting the behavioral changes as needed. The sleeping quarters are similar to conventional dorm rooms but have been modified in some cases for special needs, such as wheelchair use or visual handicaps. For 2-3 weeks per year, patients with particular diabetes complications, such as blindness or renal disease or those with hearing impairments or mental disease, participate in sessions modified to suit their needs.
When surveyed, the patient participants at the center feel that the peer support and relief of the psychosocial burden of diabetes top the list of the most beneficial aspects of the program. They also believe that the time spent at the center helps them to find motivation and become more empowered to make the changes necessary to live a healthy life.
According to education manager Outi Himanen, the Diabetes Center also provides support and consultation for other centers and community programs within the municipalities. The diabetes team operates a free advisory phone service 3 days a week and also provides information on diabetes to newspapers and other publications. In working with the health care professionals who come for continuing education to increase their practical diabetes knowledge and skills, the center staff encourages them to confront and recognize their feelings and attitudes toward diabetes and toward those who have the disease. During 2008, 522 health care professionals attended courses geared toward dietitians, occupational health teams, weight management educators, physical activity therapists, and those involved in mental health counseling.
The Finnish Diabetes Association and DEHKO program general secretary Maria Aarne have their offices within the Diabetes Center complex. A publications department producing diabetes materials to be distributed throughout Finland, as well as many of the reports chronicling the progress of the DEHKO, is housed at the center.
Mr. Huttunen, managing director of the Finnish Diabetes Association, explained that the government supports the DEHKO and other diabetes programs with revenues generated by Finland's Slot Machine Association (RAY), the Finnish Diabetes Association, and diabetes-related companies, dispensed to the association to be administered and distributed. The financing for the FIN-D2D Project (2000-2007), which targeted the obese, at-risk population and included screening and lifestyle counseling, early diagnosis, and treatment, came from a variety of sources: RAY, the five district hospitals engaged in the project, the Ministry of Social Affairs and Health, the National Public Health Institute, and the Finnish Diabetes Association.5
The Finnish government does not control the Finnish Diabetes Association, but it does fund some of the work of the association. Another 20% of the budget comes from the sale of educational materials, subscription fees for publications and journals, and advertisements. Only a small percentage of funding comes from membership dues. The yearly expenditures top € 5 million, or ~ $8.8 million.
Thus far, the interim evaluation reports of DEHKO show that the objectives are being met, some ahead of schedule. Preventive action has gained a firm foothold in the primary care sector, and diabetes education is increasing.6 Organizational structures for functional care chains and ongoing evaluation and monitoring systems are works in progress.
Finland is a model for nations facing the growing need for diabetes prevention and care. From its early recognition of the seriousness of the problem to its dedication in formulating a comprehensive program to address each health sector, the Finnish Diabetes Association has shown creativity and innovation. The Diabetes Center is the culmination of Finland's philosophy and science in diabetes care and stands as a shining example of what is possible when a nation acts for the health of its people.
