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LET’S BEAT DIABETES

LOOKING BACK, MOVING FORWARD A Review of Progress since 2005 and Recommendations for the Future November 2009 Chad Paraone Tracey Barron Brandon Orr-Walker Siniva Sinclair

“Cancer, diabetes, heart diseases are no longer the diseases of the wealthy.

Today, they hamper the people and the economies of the poorest populations, even more than infectious dise ases.

This represents a public health emergency in slow m otion” (Ban Ki-moon, UN Secretary-General, 2009)

“We have to be more active in prevention … It will not be easy …

but it is a battle that we will all have to fight.

The choice is simple. Either we spend all our time mopping the floor,

or we get up and turn off the tap.” (Professor Jean Claude Mbanya, President, International Diabetes Federation, 2009)

“Kua tawhiti ke to haerenga mai, kia kore e haere t onu; he tino nui rawa ou mahi, kia kore e mahi nui tonu. ”

“We have come too far not to go further. We have done too much not to do more”

(Sir James Henare, Ngati Hine, 1989)

CONTENTS

EXECUTIVE SUMMARY ........................................................................................... 1

1. WHAT WE SET OUT TO DO.............................................................................. 7 1.1 A Letter from 2020..............................................................................................................................7 1.2 The Original Challenge .......................................................................................................................9 1.3 Response..............................................................................................................................................9 1.4 Brief Plan Outline..............................................................................................................................10

2. MAKING IT HAPPEN ................................... .................................................... 12 2.1 Key achievements and commentary ..................................................................................................12

3. PROGRESS MARKERS................................... ................................................ 19 3.1 LBD Key Performance Indicator Framework ...................................................................................19 3.2 Key results by KPI and commentary .................................................................................................20 3.3 LBD Intermediate term indicators – nutrition and physical activity..................................................29 3.4 Summary – Progress Markers............................................................................................................31

4. LOOKING BACK - STRENGTHS AND CHALLENGES ............ ...................... 33 4.1 Strengths............................................................................................................................................33 4.2 Challenges .........................................................................................................................................34

5. CURRENT ENVIRONMENT ............................................................................. 35 5.1 Obesity, diabetes and cardiovascular disease – size and cost ............................................................35 5.2 Other key environmental factors .......................................................................................................43

6. MOVING FORWARD: THE NEXT FIVE YEARS............... .............................. 47 6.1 Recommendation to continue ............................................................................................................47 6.2 Supporting rationale ..........................................................................................................................47 6.3 Key aspects of the 2010-2015 Plan ...................................................................................................50 6.4 The next six months...........................................................................................................................55

7. APPENDICES................................................................................................... 59 APPENDIX 1: LBD network and connections...............................................................................................60 APPENDIX 2: Marae running initiatives in Counties Manukau ....................................................................61 APPENDIX 3: List of LBD evaluation reports from the School of Population Health..................................62 APPENDIX 4: Summary of Achievements by action area.............................................................................65 APPENDIX 5: LBD Implementation Score ...................................................................................................86 APPENDIX 6: Strengths and Challenges To Date .........................................................................................88

8. REFERENCES.................................................................................................. 94

LBD: Looking Back, Moving Forward Page 1

EXECUTIVE SUMMARY In 2004, Counties Manukau was experiencing a growing epidemic of type 2 diabetes. At the time it was estimated more than 12,000 people had been diagnosed as having diabetes, with nearly twice this number having undiagnosed diabetes. The numbers were projected to double in 20 years, inflicting major costs on the health sector and wider community. In response, a wide group of community partners, lead by Counties Manukau District Health Board (CMDHB) developed and launched Let’s Beat Diabetes, a five year district-wide strategy aimed at long-term, sustainable change to: � prevent or delay the onset of diabetes, � slow down disease progression, and � improve quality of life for people with diabetes. Encompassing ten action areas, the Let’s Beat Diabetes (LBD) strategy proposed a wide-ranging set of concurrent initiatives across many fronts with multiple partners representing many different sectors and interests. It was guided by the basic concept that a ‘whole society, whole life course and whole whanau/family’ approach was needed, and that sustained effort was needed over a 15-20 year period to achieve material change. In February 2005, the CMDHB Board approved a base funding envelope of $10 million to support implementation of the five year plan. MAKING IT HAPPEN Action got underway in July 2005. Given the scale and complexity of the strategy, programme organisation was vital to the success of LBD. Despite the many challenges, there has been good progress in this area over the last four and a half years, including:

� Development of a good foundation and networks for c ollective action with community partnerships, relationships and ‘common interest’ connections;

� Large scale mobilisation of community partners and coordinated activity , with over 500 organisations having implemented or supported aligned initiatives in the district;

� Attracting more than $10 million in additional fund ing to assist with these efforts (over and above the CMDHB five year funding commitment);

� Increased conversation and dialogue in the communit y around obesity and diabetes, nutrition and physical activity;

� Hard-earned experience and accumulated understandin g of network management and cross-sector collaboration on a large scale, complex project of this nature; and

� Rich new knowledge and insight from evaluation learnings and major LBD population surveys in Counties Manukau.

RESULTS LBD objectives for the first five years were focussed on Knowledge, Attitudes and Participation levels. Change in population level nutrition and activity behaviour patterns was not expected at this stage.


In terms of participation, LBD was successful in attracting substantial investment and resources, and using this to galvanise large scale action in Counties Manukau, from government agencies to grassroots community groups. In terms of improving awareness, knowledge and atti tudes, a comparison of results from two large population surveys spaced 2.5 years apart indicates LBD made good gains in some areas, offset by disappointing result s in others. Timing differences in the two surveys (the first in summer, second in winter), plus the impact of the recession biting in 2009 (thus higher unemployment and tighter household budgets) may have impacted the results. Positive results picked up by the 2009 survey inclu de pockets of improvement around the benefits of healthy eating, impact of overweigh t on health, concerns about getting diabetes, and a more supportive environmental suppo rt. Specific increases include: � Connections made between a healthy diet and prevention of diabetes (big increase) � Pacific people associating drinking water with healthy weight � South Asians associating not cooking in fat with healthy weight � Interest among Pacific people in eating more healthily � Concern among Maori about health problems from being overweight � Concern overall that someone in the family has/may get diabetes � Reported support for eating healthy and being more active from:

o from doctors and medical centre staff o whanau and close friends

� Reported support at work for being active Examples of areas where the results were disappoint ing, in terms of no movement or deterioration at a population level, include: No movement in: � Associating the control or reduction of fat intake with achieving a healthy weight � Associating being active or maintaining a health weight with preventing diabetes � Interest in being more active � Pacific people who reported support from churches for eating healthily or being active

Decrease in: � People associating the control or reduction of portion/serving size with a healthy weight � Maori who reported support from marae for eating healthily or being active The finding that most of the obese population do no t perceive themselves as being obese is concerning, as they are less likely to res pond to messages associating obesity with health problems and diabetes. This makes the LBD task more difficult. Behaviour changes included a reduction in reported fizzy drink consumption, an increase in Pacific people consuming 5+ fruit and v egetable servings per day, and more South Asians removing fat from meat when cooki ng. These were offset by fewer people being regularly physically active plus an increase sedentary behaviour. Participation in diabetes management programmes is either increasing or on target. Screening for complications and prescribing medication as per guidelines has increased, while glycaemic control indicator is on target. Blood pressure and cholesterol indicators are poor though. In particular, the proportion of CCM patients with high levels of LDL (bad) cholesterol has not improved from December 2007 baseline data. These results confirm that, while gains have been m ade, the problem has not gone away. Nor can it be expected to, not without furth er action and interventions.


CURRENT SITUATION The obesity and diabetes epidemics continue unabated, with Counties Manukau obesity rates for children and adults are significantly higher than the national average. Pacific and Maori adult obesity rates are around 80% and 52% respectively. There are now around 110,000 obese adults in Counties Manukau, many of whom will end up with diabetes. Diagnosed diabetes prevalence for adults in Counties Manukau is also significantly higher than the national average. In 2008, CMDHB estimated there are around 35,000 people with diabetes here (26,000 who have been diagnosed and a further 9,000 who are undiagnosed).

On current trends, future projections estimate:

� The number of obese people in Counties Manukau will increase by 80% over the next 20 years, to exceed 195,000 by 2027.

� The number of people with diabetes will increase by 100% in 20 years, doubling the current numbers to 72,000 by 2027.

� Only one third of that 72,000 currently have diabet es. 64% of the projected 72,000 diabetes cases in 2027 will come from people who ar e currently obese and others not currently obese (but heading that way). These are preventable cases.

� 41% (267,000) of the population in 2027 will either be obese or have diabetes.

This level of projected diabetes growth in Counties Manukau will cause major challenges for CMDHB and other health sector partners in terms of the funding, prioritisation, organisation and delivery of services for people with diabetes. Improvements in diabetes service quality and productivity will be vital, making smarter use of primary and secondary health professionals and systems to deliver quality care within constrained resources. Diabetes service improvements will not turn the tide though. They are simply about getting better, more efficient while coping with ever-increasing numbers. Given that 64% of the total 2027 diabetes numbers a re preventable, effective interventions and prevention programmes will be nee ded to slow or reduce this obesity and diabetes tsunami, easing pressure on a stretched health system. COST IMPLICATIONS The costs of the current and projected burden of diabetes are significant, including the burden on individuals, families, employers, communities, social services, local government, government agencies, and of course, the health sector. In terms of direct health sector costs, CMDHB analysis shows that:

� Known diabetes cases cost CMDHB an estimated $83 million in pharmaceutical, laboratory and hospitalisation costs in 2008.

� If the average cost per diabetes patient was the sa me in 2027, it would cost CMDHB $141 million in that year (in 2008 dollar ter ms), up $60 million from 2008.

� The cumulative additional cost (over and above the $83 million) over the 20 year period would be around $490 million.

This does not include the cost of GP visits, outpatient clinics, and other diabetes initiatives.


POTENTIAL FOR SAVINGS On the basis that two thirds (64%) of the estimated number of people with diabetes in 2027 are preventable, there is significant potential for savings. To quantify the size of this potential, and the scale of change needed to have a material impact on the projected growth, scenarios run by CMDHB estimated that:

• Stopping teenage obesity from 2007 and keeping them non-obese for the next 20 years would only reduce the 72,000 by 5% (3,300).

• Holding the obesity rate the same for the next 20 y ears would reduce it by 14% (10,300).

• Reducing the obese population by 1% every 3 years w ould reduce the 72,000 by 20% (14,200), of which 6,200 would be from those wi th diagnosed diabetes.

• Reducing Maori and Pacific obesity to European leve ls would reduce it by 22% (15,600).

• Delivering 200 bariatric surgery procedures per year for people with diabetes will reduce known diabetes numbers by 6% (2,700).

Concentrating all efforts on stopping any further teenager from becoming obese from today will not reduce diabetes statistics significantly by 2027. The change will not be seen until they enter their 40s and 50s, when diabetes usually manifests itself (at that point however, the results would be very significant). Holding or reducing adult obesity, on the other hand, would show up earlier – certainly by 2027. It is a question of time scale. Relating these potential reductions to direct health costs, CMDHB analyses indicate that:

� One less person with diagnosed diabetes saves CMDHB an estimated $2,381 per year in pharmaceutical, laboratory and hospitalisat ion costs.

� Interventions that reduce the obese population by 1 % every 3 years would reduce diagnosed diabetes numbers in 2027 by 6,200. This w ould equate to savings of $14.8 million in 2027.

� Cumulative savings between now and 2027 would be $1 11 million in those cost areas alone.

� Potential savings are substantially higher once oth er areas are taken into account , such as savings from fewer GP visits, outpatient clinics, Get Checked, CCM costs; fewer new buildings, equipment or staff to cater for increased volumes; and a reduction in numbers of people suffering cardiovascular disease and obesity-related cancers.

MOVING FORWARD On the basis of � LBD achievements and progress to date, � the established platform of community partnerships, action and momentum, � future projections of the ongoing obesity and diabetes epidemics, and � the significant potential to reduce the size and impact of the diabetes epidemic, - this report recommends that CMDHB commits to a fu rther five year plan and funding path for the Let’s Beat Diabetes programme, from 2010 to 2015.


Future Programme Shape It is recommended that the next five year plan, 2010 to 2015, retain core components of the current model, such as the long term vision and inclusive model, the ‘whole society, whole life course, whole whanau/family’ approach, a focus on reducing inequalities, and the commitment to a learning approach. To strengthen the integrity of the programme, it is proposed that CMDHB (and partners) commit to a five year base funding envelope, a five year evaluation programme and retention of the ten action areas. There are four key changes recommended for the 2010-2015 plan:

1. Add cardiovascular disease (CVD) and smoking to the programme. While current activity already picks up CVD, this will make it more explicit. Smoking compounds the risks of both diabetes and CVD. A change in Programme name will be needed.

2. Give increased emphasis to primary care and seconda ry care, including service improvement and integration across both health systems. This will better balance upstream and downstream activities, and picks up on impending health sector changes.

3. Devolve more accountability to LBD partners for project leadership and management, matched with appropriate contracts, reporting and representation on partnership groups.

4. Pursue fewer and larger projects . Some innovation is still needed, but emphasis and resource should be concentrated on driving a smaller number of larger initiatives.

NEXT STEPS If the main recommendation of the report is accepted, action in the next six months will focus on five key steps to build and launch the next five year Programme. This includes: 1. Developing the detailed Five Year Plan for 2010-201 5.

2. Confirming the size of CMDHB’s five year funding co mmitment

3. Linking with the three approved primary care change proposals that touch Counties Manukau, including the Greater Auckland Integrated Health Network, the National Maori PHO coalition, and the Health Alliance PHO (Pacific)

4. Engaging with the Auckland Transition Agency and th ree local councils on the local government landscape after October 2010

5. Developing the Programme’s Operational Plan for 201 0/11.

The detailed Five Year Plan, 2010/11 Operational Pl an and proposed CMDHB five year funding commitment will be brought back to CPHAC fo r consideration by June 2011.

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1. What we set out to do

1.1 A Letter from 2020 The following letter is lifted directly from the Let’s Beat Diabetes five year plan signed off by the Board of the Counties Manukau District Health Board in February 2005. It is written from the year 2020, and, looking back, describes the Counties Manukau journey to tackle obesity and diabetes. It aptly sets the scene for the current review of the Let’s Beat Diabetes programme. A Letter From 2020 It is the year 2020. Type 2 Diabetes is still a major health problem in Counties Manukau - the number of people diagnosed with diabetes is greater than it was in 2010 - but positive trends are emerging that show diabetes rates and numbers will decrease over the next decade. We are beating diabetes! The turning point in the battle against diabetes came in 2010, when the growth in population obesity stabilised, and from 2012 when average weights began to decrease. Many experts have commented on the rapid reduction in the number of obese children since 2015, with a new wave of well nourished, fit children now flowing through the primary schools. How did we get to this point, when back in the early years of the century it seemed nothing could stop the growth in diabetes? The simple answer is that it has been the collective efforts of many strategies applied over decades and a commitment from all parts of society to a shared vision and goal – much like the smoking epidemic of 50 years earlier. While the big gains in health have been made in the past five year (2015 – 2020), the real changes came in the 2005 - 2010 period. Those years are remembered as the ‘hard yards’, when there was a lot of effort for little change in outcome. But they put in place many of the strategies that continue to guide us today, and most importantly, galvanised commitment and action across society. It was during those years that the renaissance in Maori and Pacific health began, with community leadership, through marae and Pacific churches, taking up the challenge of improving the health of their people, especially the young ones. The change in community attitude and behaviour towards nutrition and physical activity seemed to reach a tipping point in 2009 - adult and child obesity levels in Maori and Pacific populations began to decrease significantly faster than those of the general population. The general change in community attitude had its roots in community leadership but was further supported by a comprehensive social marketing programme that began in 2005 and is now part of our cultural landscape. In fact, the partnerships between health sector, local government, and the food and physical activity industries, which characterises the national social marketing programme of today, was forged in Counties Manukau 15 years ago. The fast food industry is now competing on product ‘health/goodness’. And while the trends towards eating out and consuming pre-prepared food have continued, the population diet has significantly improved. Children cringe when they are shown some of the meals their parents used to eat. For more than a decade, schools have taken explicit accountability for the physical health of children while they’re at school. This has meant ensuring students get at least 30 minutes of physical activity every day. All schools in Counties Manukau actively support good nutrition. The number of children walking or cycling to school has doubled since 2010, thanks to efforts by schools, working with


communities, local government, and activity organisations. Many educationalists have noted that the improved health of students has also contributed to improved academic performance in Counties Manukau. The Flat Bush development, which was identified as the pilot for the ‘healthy by design’ planning initiative, is now seen across New Zealand as a watershed in urban design, with its focus on healthy, active and socially cohesive communities. The lessons from Flat Bush have already been applied to urban developments and redevelopments across the country. Child health has been a substantial success story, attributed to improved services and changes in attitudes towards health in the first years of life. Well Child Services are now broad in scope and include a focus on good nutrition and chronic disease prevention, through pregnancy and from birth. There is a significant investment in parental education and sophisticated techniques for identifying vulnerable families and children. Multi-sectoral support is available for vulnerable families, with information systems helping co-ordinated service delivery across agencies. The Well Teen pilot for a structured health assessment of 13 year olds has now become a national programme. Primary care has evolved (despite continual government restructuring … some things don’t change) to have a far greater focus on disease prevention. Primary Health Organisations (PHOs) have become sophisticated organisations, with a strong community and civic presence. GP surgeries have in general been consolidated into fewer larger centres, with the development of nurse-led healthy living and disease management teams The primary-care based in-clinic and outreach teams have become expert at processes of family and group-based behaviour modification, which, coupled with early diagnosis, has led to a measurable slowing in disease progression and a reduction in expensive hospital-based care. Supporting the re-orientation of primary care is the continuous development of a world-leading IT system that provides best practice advice to GP teams and to the health consumer. Health promotion is often described as the glue in the system. A set of strong organisations effectively link the community development, social marketing and primary care strategies at an operational level, and provide a source of community-based innovations to service design. One of the most remarkable and enduring changes during the 2005 - 2010 period was the development of the health alliances –self-organising groupings of community, health and social service providers - which developed long term place-based strategies to identify and support the most vulnerable families. One of the key features of Counties Manukau’s efforts to beat diabetes has been an extremely stable governance and leadership structure. Representatives from many organisations and communities still form the core governance structure to beat diabetes, and the group has become something of a Counties Manukau institution. This stability has been at the heart of the persistent year-on-year progress. Another key feature that has been emphasised in academic reviews is the ‘success model’ of learning and service development that has been adopted across many health providers. Some have likened it to ‘action research on a massive scale’ or a continuous quality improvement strategy. But the result has been the rapid uptake of innovations in practice across providers. The ability to learn from each other is one of the defining features of the ‘Counties Manukau way’. The final success factor was the decision by the District Health Board to invest ‘upstream’ and commit effort and money to support strategies that reduced risk and identified vulnerable people at an early stage in their disease. It is these strategies that are providing payback now in terms of health sector costs and community vitality.


1.2 The Original Challenge In 2004, analysis showed Counties Manukau was experiencing a growing epidemic of Type 2 Diabetes (“diabetes”). At the time, it was estimated that more than 12,000 people in Counties Manukau were diagnosed with diabetes. It was estimated that almost double this number remained undiagnosed. With the severe growth trend in obesity (a major risk factor for type two diabetes), modelling projections estimated that the number of people with diabetes would more than double over the next 20 years, given population growth, the significant proportion of Maori, Pacific and Asian people in the Counties Manukau population, a relatively youthful and generally low socio-economic make up of our populationi. If unchecked, this growth would pose serious challenges to the health sector’s capacity to cope. Diabetes is a major driver of health sector costs, contributing to a range of serious complications such as increased cardiovascular disease, kidney disease, stroke, lower limb ulcers and amputations, and retinal (vision) damage leading to blindness. The impacts would be felt in many areas, such as the required number of hospital beds related to diabetes admissions (projected to nearly double by the year 2020) and the need for new satellite clinics with dialysis stations to keep up with demand as the number of kidney failure patients increased. As well as large increases in hospital costs, the impacts extend further, surfacing in areas such as impaired workplace productivity, loss of work, social support costs, reduced life expectancy, and the impact of chronic disease on family and community life including reduced community participation and wellbeing.

1.3 Response There was widespread agreement that a major change to the health sector and our broader society was required to stop the diabetes epidemic. Counties Manukau District Health Board (CMDHB) launched a planning process to develop a plan for the Counties Manukau district as a whole (not just the health sector) and to build community momentum in support of the plan. Key Planning Concepts Six key concepts underpinned the planning process:

1. Guiding principles of the World Health Organisation’s Global Strategy on Diet, Physical Activity and Health (2004)

2. Evidence of need and effective action (including the desire to develop evidence of effective action where this was lacking, through a commitment to thorough evaluation)

3. Sector capacity and community motivation (identifying where need, evidence and good ideas match local community and organisations capacity and readiness to act)

4. Long term approach (emphasis was placed on identifying areas where actions over five years will deliver positive benefit and align with a 15 year vision, given the complexity of the obesity issue and the requirement for broad changes to environment, societal norms and health sector capabilities before substantive changes and outcomes are achieved)

5. Alignment with national and CMDHB overarching strategies

6. Building on lessons from past strategies/services and existing strengths


Planning Process and Report Extensive consultation and development work with community partners took place throughout 2004, including more than 40 workshops and meetings with community and partners, building to a Counties Manukau Diabetes Summit in October 2004. This culminated in delivery of the plan (Let’s Beat Diabetes: A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau) to the CMDHB Board in February 2005, where it was formally endorsed for implementationii.

1.4 Brief Plan Outline The Aim To stimulate and support joint community action targeting long-term changes to � prevent and/or delay the onset of diabetes, � slow disease progression, and � increase the quality of life for people with diabetes. Strategic Approach To employ a range of strategies, guided by the basic concept that a ‘whole society, whole life course, whole family/whanau’ approach is required to beat diabetesiii, and that focused effort will need to be sustained over decades.

� Whole society – success is dependent on the motivation and support of the communities, institutions and businesses that make up Counties Manukau. This called for community partnerships and action in Counties Manukau.

� Whole life course – support health and prevent and manage diabetes at all stages of disease progression.

� Whole family/whanau – acknowledging that whanau/households have direct influence on environmental risks, choices and decisions of individuals, so working with them wherever possible is central to creating sustainable change.

Inequalities focus Maori and Pacific peoples have greater risk of diabetes and are disproportionately affected compared with other New Zealanders, so focus on these groups was a priority. South Asians fit this category as well. Action Areas (workstreams) Complex and wide-ranging, the framework for action was set out under ten key action areas, each of which involved key community partners who held a stake in that particular field. The ten action areas were:

• Supporting Community Leadership and Action • Promoting Behaviour Change Through Social Marketing • Changing Urban Design to Support Healthy, Active Lifestyles • Supporting a Healthy Environment Through a Food Industry Accord • Strengthening Health Promotion Co-ordination and Activity • Enhancing Well Child Services to Reduce Childhood Obesity • Developing a Schools Accord to Ensure Children are ‘Fit, Healthy and Ready to Learn’ • Supporting Primary Care-based Prevention and Early Intervention • Enabling Vulnerable Families to Make Healthy Choices • Improving Service Integration and Care for Advanced Disease


The action areas comprised a range of intervention strategies, from prevention through to treatment and management. They covered health sector responsibilities and those of other groups and organisations in the wider Counties Manukau society:

� Society – these action areas reflect the social and environmental determinants of health, which are the responsibility of society (e.g. culture, knowledge, the urban environment, food supply, socio-economic circumstances)

� Health sector – these capture the direct relationship between individuals and the health and services environment that the health sector has more control over (health promotion, well child, school health, early intervention, disease management).

Thus, an overall strategy to reduce risk factors for diabetes and slow disease progression, while building capacity in the health sector and a sustainable whole society approach. Governance and management The plan was supported by a governance structure that aimed to represent the broad societal support required for successful implementation. It was reached after considerable discussion and debate on the most effective format for community partnership governance, balancing the need for an effective and focused leadership group to drive the project forward against the need for broad community membership and guidance for the project. The three levels proposed in the governance structure were:

� Community Governance Group (broad stakeholder forum that meets 2-4 times per year, enabling overall guidance from community partners),

� Partnership Steering Group (key action area leaders meeting monthly to provide operational leadership and coordination for plan implementation), and

� Action Area leadership hubs (explicit leadership groups for each of the action areas, involving key stakeholders who operate in that particular field).

CMDHB committed to providing admin support to the governance and steering groups, as well as a project management team to provide core management support for the whole programme and to the 10 action areas (to varying degrees, depending on need and programme characteristics). Funding At their February 2005 meeting, the CMDHB Board formally endorsed the Let’s Beat Diabetes (LBD) plan, with a funding envelope of $10million over the five years (1 July 2005 to 30 June 2010) to support its implementation. The five year budget commitment was agreed in order to provide an explicit and sustained funding environment, which was deemed critical to engaging community and agency partners into joint resourcing of projects. It was acknowledged the plan would require significant investment from multiple funders to gain traction and momentum. The $2million per year from 2005/06 provided a base of funding that was able to generate meaningful action across the action areas. It was also agreed that 10% of the budget was to be applied to evaluation on the basis that it contained a strong learning and continuous improvement component. Launch date and implementation With the endorsement of the five year plan, detailed developmental work and preparations continued in the first half of 2005, with plan implementation kicking off on 01 July 2005.


2. Making it Happen From July 2005, the focus shifted to implementation of the LBD plan. It was not a ‘big bang’ start. Implementation was a gradual process, reflecting differences in infrastructure, knowledge and capacity across the various action areas. Much of this early period involved further planning and development work to get delivery mechanisms right. To drive implementation of this large scale and complex programme, to ‘make it happen’, action was needed on several fronts, including: - developing partnerships, collaboration and collective effort, - galvanising community ownership and action, - building capacity, - leveraging resources, - fostering knowledge and learning, - building profile and influence, - maintaining coordination, and - keeping a focus on inequalities. This section summarises progress and achievements made by LBD in these areas, based on the annual operational plans and project reporting against themiv.

2.1 Key achievements and commentary Partnerships and collaboration LBD was hailed as a flagship programme for building broad community partnerships and coalition around a common goal in Counties Manukau. Achieving wider collaboration was deemed fundamental to building and creating long-term change across the whole district. For CMDHB, it was also seen as an opportunity to re-define its role in the Counties Manukau community, extending relationships and linkages for mutual benefit. LBD has been successful in facilitating and supporting a considerable range of collective action and broadened relationships over the past four years. A conservative count exceeds 500 in terms of the number of partners, agencies, commercial organisations, NGOs and community groups who have engaged in joint or aligned activity across Counties Manukau over this period. These range from ‘grassroots’ community groups to government agencies, from pre-school centres to large employers, from social service support groups and health providers to large multinational food companies (see selection in Appendix 1). This reflects good headway in galvanising a ‘whole of society’ effort. Community Involvement and Action International evidence shows that community involvement and participation is a key factor in achieving success, so LBD was charged with reaching community at all levels – right down to grassroots organisations. To date, LBD partners have been successful on this front, in either generating or facilitating a substantial level of community action focused on nutrition, physical activity, obesity and diabetes initiatives. Examples of community engagement and action include work and initiatives in Counties Manukau with 84 Pacific churches; 21 marae (listed in appendix 2); all 3 local councils; 100+ schools; 130+ early childhood education centres; 48 companies and employers (workplace focus); 60+ faith-based, community, or sports and recreation groups; food vendors and stall


holders; large food industry players; school tuckshop operators; primary health organisations (PHOs); primary care practices; non government organisations (NGOs); government agencies; not to mention social service providers, and many others. There were typically between 50 and 70 initiatives on the annual LBD Operational Plan. In some cases, action was shaped by national or local government programmes and priorities. In many situations, the initiatives were based on the priorities or interests of local groups, communities or organisations (such as the marae, church, school/pre-school and local sports clubs initiatives). It was a sizeable work programme. Underlying much of this action has been the leadership demonstrated by civic leaders, church ministers, marae spokespeople, school principals, doctors and nurses, community group ‘organisers’ and leaders, community health workers, employers and parents/youth who got involved and made things happen. They took ownership of the issue and put their support behind it. While LBD has been a key catalyst for supporting and growing large scale community action, community leadership is needed for sustainable change. Building Capacity Marshalling action across the ten broad LBD action areas, on the scale indicated, was always going to create challenges in terms of the capacity to move and deliver effectively. As part of ‘making it happen’, the need to grow and up-skill a broader workforce in the basics of nutrition, physical activity, obesity and diabetes was evident. As LBD got underway, three limiting factors emerged in terms of programme implementation: workforce, resources, and organisational capacity. Progress has been made with workforce development, albeit slow. Most would agree more is needed. Training, education and support for the diverse groups involved (e.g. church volunteers, marae coordinators, school teachers, community health workers, nurses, GPs, other health professionals dealing with obese or diabetic patients) is a work in progress. Results for efforts to date include a range of tailored scholarships, formal training programmes, train-the-trainer courses, professional development workshops and continuing medical education (CME) sessions now available and being utilised by the various workforce clusters in Counties Manukau. Alongside workforce, considerable effort has also gone towards ensuring appropriate resources are available to help reach target populations and groups. There is a greater range of more relevant items available now for Counties Manukau audiences. From formal review and culling of more than 500 diabetes education materials, to compilation of GP resource folders, Maori, Pacific and Asian language materials, cookbooks, DVDs, teaching resources and packages, guidelines, service navigation guides, meal ‘plate’ pamphlets, social marketing posters and giveaways, and so forth. Organisational capacity was the other ‘rate limiting factor’ that impacted LBD. Organisations were generally fully committed to existing work programmes, and often had limited ability to promptly focus resource (human or otherwise) on LBD-related initiatives – even where there is clear alignment of goals or objectives. Working to annual budget cycles or around staff shortages/vacancies slowed progress of a number of initiatives.


Leveraging Resources Given the scale of Counties Manukau’s obesity and diabetes problem, LBD needed to attract funding and resourcing beyond the initial CMDHB and partner investment. LBD has been successful on this front, leveraging the collective, the weight of a comprehensive programme and national programmes to bring additional investment of approximately $10 million to bear on the issue in Counties Manukau since July 2005. Examples include:

� $5.3 million from rollout of the national Health Eating, Healthy Action (HEHA) programme to DHBs

� $1.6 million from Sport & Recreation New Zealand (SPARC), the three councils, two PHOs and the regional sports trust for Counties Manukau Active programme

� $1.25 million from Ministry of Health (Auckland) for a range of initiatives

� $1.17 million from successful bids to the initial HEHA Innovation Fund and the later HEHA Evaluation Fund

� $500k+ from food industry and gardening partners (funding + resources)

� $150k from Health Sponsorship Council for social marketing In part, this success was due to timing. The launch and rollout of the national HEHA strategy provided a strong funding boost to the LBD programme, although there was a cost to this in terms of additional overhead, alignment and continuity issues that diverted management attention from steering a broad and complex programme.

An example of leverage: Gardening for Health and Sustainability initiative � Initiated by LBD, this multi-agency project aims to foster a surge in community-based food

gardens as a means of encouraging families and households back into gardening. This supports physical activity and healthy eating – primarily fruit and vegetable intake).

� Ministry of Health (MoH), CMDHB, Mangere Community Health Trust, Robert McIsaac Charitable Trust, General Mills, Bunnings Ltd, Red Cross NZ, Workforce Auckland, ASB Community Trust, and many others have committed funding/resources to support gardens.

� As a result, achievements to date include 64 new or planned community gardens, across parks, schools, early childhood centres, marae, churches and other community centres in Counties Manukau. Reaching thousands of people.

� Manukau City Council has made significant investment in setting up and running community food (teaching) gardens in parks and other council-controlled land, and Franklin District Council has joined in as well.

� Manukau Institute of Technology has developed an NZQA-accredited horticulture course, tailored for delivery in community settings alongside the community garden project, introducing qualifications to the mix.

� Te Puni Kokiri has recognised these efforts, with funding expected from the recently announced Maara Kai (food garden) programme to be delivered for gardens in up to 8 more marae in Counties Manukau.

� Given the project scope, achievements to date, and the many collaborating partners, ASB Community Trust are giving very positive signals regarding a planned large funding grant application in February 2010. This will assist the project considerably.

� Waitemata and Auckland DHBs are committing funding to support the initiative growing beyond Counties Manukau, reaching across the wider Auckland region.


The figures given are largely cash contributions. T he true value of the additional investment in the LBD programme is much higher than this. Although difficult to quantify, there needs to be strong recognition of the substantial contributions to LBD by way of commitment, time, energy, enthusiasm, expertise, resources, and other ‘support in kind’ from the very large number of committed partners, supporters and community members. Ultimately, it is these people who have enabled the progress and achievements of LBD. Other partners are also creating investment in areas supportive of LBD’s goals and objectives. A prime example is Manukau City Council’s iconic Find Your Field of Dreams programme. Launched in 2008, it has attracted significant additional investment of public and private resource to stimulating and assisting youth into healthy, active lifestyles through sport and physical recreation. Fostering Knowledge and Learning One of the key challenges was to track progress being made across the breadth of the programme, and to do this in a way that builds and shares knowledge for the benefit of the wider programme, LBD stakeholders in LBD and Counties Manukau communities. LBD made some good progress in this area. A large contribution was made by Auckland University’s School of Population Health (SoPH), leading local public health academics who were engaged by CMDHB to develop a core evaluation and learning framework for LBD and deliver evaluation services over the five year period. SoPH did some groundbreaking work in coming up with a model and framework for evaluating the complex LBD programme – something never attempted before on this scale in New Zealand. They worked closely with LBD on the ensuing evaluation activity, often challenged by the dual expectations of being an independent evaluator as well as an important programme partner contributing to programme learning, growth and development. The range of evaluation reports and advice delivered over the four years (see the list of reports in appendix 3) captured important insights that influenced the programme and the design/shape of later activity. Their engagement was unfortunately ended a year earlier than planned, due to budget cuts. Many groups and organisations delivering initiatives successfully embedded evaluation in their activities, adding to the growing evidence and knowledge base within Counties Manukau. For example, the 2008 and 2009 independent monitoring surveys of the LBD social marketing campaign – the early one confirming the strength of the campaign design and the latter highlighting successful campaign reach and impact. The impact of the Fresh For Less fruit and vegetable initiative with Pak ‘N Save supermarkets in Counties Manukau, and the great results from the Sprite Zero project with Coca Cola and 21 McDonald’s restaurants in Counties Manukau are two other examples, from the Food Industry action area. On the flip side, LBD did struggle with the sheer volume of information emerging from evaluation activity, in terms of breaking it down into layman’s terms and trying to disseminate key findings out to all interested parties – from the groups involved in delivering the initiatives, to LBD partners, community leaders and interested observers.


There is room for improvement in ensuring the design of initiatives facilitates good evaluation. Some initiatives were run without a sound mechanism for measuring success or aligning with key LBD objectives and performance indicators. This often reflected a bias for action and limited evaluation knowledge/skills. The evaluation contract also had a requirement for a set of focus studies each year, but these ‘single year’ studies were often reduced to progress (not outcome) evaluations due to initiative design, delivery and timing issues, so the outcomes of those initiatives still needed to be assessed. Nevertheless, overall evaluation activity made an important contribution to learning, building an evidence base, and improvement or wider application of project findings. Beyond evaluation, LBD partners have also been successfully growing a bank of data and information to both monitor progress and inform future directions/action for Counties Manukau. Examples of additions to Counties Manukau’s obesity and diabetes ‘knowledge bank’:

• CMDHB analyses around ‘known diabetes’ numbers, plus obesity and diabetes modelling and future projections.

• Two major LBD surveys of 2,400 Counties Manukau residents, researching attitudes, knowledge and behaviour around food, exercise, obesity, diabetes and GP interaction. The first (2006/07) establishing the baseline and the second (2009) to track progress and guide future decisions.

• A comprehensive LBD Living with Diabetes survey of 1,200 Counties Manukau residents with diabetes, covering knowledge, attitudes, service provision and impact on quality of life.

• Literature reviews of the evidence in the field, such as: the connection between nutrition, physical activity and academic achievement (schools), competency frameworks for delivery of health education/promotion by community health workers, and self management education models.

Building Profile and Reputation LBD has certainly elevated Counties Manukau’s profile and reputation, regionally and nationally, in terms of demonstrating comprehensive and concerted action against the obesity and diabetes epidemics. With that profile came influence. The MoH design and implementation of the HEHA strategy across DHBs drew on the infrastructure and learnings from LBD, which had come into existence before HEHA and was more advanced than any other district in the country. The subsequent establishment of a $10million district-wide five year strategy and action plan in Nelson Marlborough was modelled closely on the LBD programme. When an open day was held in 2007 on LBD and CMDHB’s chronic care management programme, over 100 people from DHBs and other organisations travelled from around the country to learn about what we were doing and how it might assist their planning.


International visitors to CMDHB have frequently received briefings on the LBD programme and expressed strong interest in what is happening here. LBD partners have been invited to present on the LBD model, on LBD initiatives, key findings and insights at conferences and seminars across the country and internationally. Maintaining Coordination Importantly, linkages and activity with core partners have been maintained around LBD over the past four years. To have key players at the table for this long is a measure of success for LBD, one which speaks volumes for partner commitment and belief in the collaborative programme, and reflects efforts in maintaining relationships, managing networks and communication/information-sharing. General experience with large long-term projects of this nature is that enthusiasm and support naturally subsides over time. LBD certainly experienced this, within CMDHB and across partner organisations. This partly reflected the challenge of trying to maintain a steady stream of short-term ‘wins’ to keep stakeholders feeling rewarded, while driving ‘deeper’ initiatives and projects that may have greater impact but for which results will not be visible for quite some time (workforce development, urban design, obesity prevention). The initial governance and steering group structures also underwent change as LBD progressed and governance/management needs evolved. The creation of a new governance and strategic advisory group with senior civic and influential leaders is part of LBD evolving and re-engaging the top levels again. Getting the right mix of decision-making, information-sharing and strategic discussion at the Partnership Steering Group (now the Community Partnership Group) was tricky and remains a work in progress. Communication and information-sharing requirements increased over time, with the programme size, number of stakeholders and range of initiatives testing LBD’s ability to get the right pieces of information to the right groups in a timely and digestible manner. This was one of the costs of large-scale collaboration, and also remains a challenge. Despite the challenges and changes, the core group of stakeholders has maintained the leadership and coordination role around LBD implementation, supported by a fortnightly meeting of all the action area project leaders that acts as an important mechanism for checking and aligning multiple workstreams. Focus on Inequalities LBD has successfully kept the focus on the core Maori and Pacific target audiences. Specific action areas worked directly with community leaders and influential cultural institutions/groups (such as churches, marae, kohanga reo, language nests), while all other workstreams focused on these key target audiences. This was standard targeting criteria that applied, for example, in design and delivery of the social marketing campaign, in the allocation of community action fund grants, in school and early childhood nutrition fund grants, in health promotion initiatives, in food industry initiatives, and in urban design health impact assessments. LBD more recently spearheaded a priority focus on South Asian communities, who also suffer disproportionately from diabetes. Compilation of a South Asian health profile,


establishment of a leadership group, engagement with community leaders, development of a South Asian strategy, funding and/or support of targeted initiatives by partners has set the foundation for longer-term development with these communities. Other vulnerable families and low socio-economic groups have also been targeted, as planned. Examples include Ministry of Social Development (MSD) and their contracted community organisations, programmes such as Family Start and Strengthening Families, work with the Salvation Army and Auckland City Mission, initiatives with food companies and councils.


3. Progress Markers The previous section outlined the efforts and action undertaken to drive implementation of the LBD, including the organisation, coordination and delivery of programme initiatives. This section provides an overview of the high level LBD key performance indicator (KPI) framework, then a snapshot of results and commentary of performance against the individual measures.

3.1 LBD Key Performance Indicator Framework The LBD programme logic and KPI framework was developed with the expectation that changes will occur over time and in fact some changes will take a generation to flow through (15-20 years). Progress will be gradual over time. The table below summarises the type of change that could be expected over different time periods, and applies a set of high-level indicators that could be used to mark progress. It is a cumulative model, where each period will build on (and is dependent on) success in the earlier periods. Indicator type Timeframe

for change At Risk population People with Diabetes

Qualitative assessment of programme

1 year Achieve objectives in LBD annual plan

Achieve objectives in LBD annual plan

Uptake 2-5 years

(2006-2010)

� Knowledge and Attitudes

� Participation in LBD

� Screening for Diabetes

� Participation in organised management programmes

� Screening for complications

� Knowledge, attitudes and behaviours

� Medication per guidelines

� Intermediate outcomes

Intermediate 5 + years

(2011 on)

� Physical Activity

� Nutrition

� Obesity (Childhood)

� Screening for Diabetes

� Intermediate outcomes

� Complications of Diabetes

� Diabetes-related Mortality

Long term 20 years

(2025)

� Obesity (Adult)

� Other CV risk factors

� CVD mortality

� New cases of Diabetes

� New cases of Diabetes

� Diabetes-related Mortality

At this stage, LBD is four and a half years down the track of a 15-20 year effort. It was expected that changes should be seen in indicators covering years 2-5 (shaded section in table above), including changes in awareness, participation and some trends towards physical change. At an organisation level, it was expected to observe changes in infrastructure engagement and partnerships, and subsequently a community mobilised and working together to bring about change. A snapshot of results covering the 2-5 year indicators follows.


3.2 Key results by KPI and commentary Unless otherwise stated, results in this section come from comparing changes between the two large LBD surveys of Counties Manukau residentsv. It should be noted that:

1. The first (Benchmark) survey took place from November 2006 to February 2007. The second (Tracking) survey took place from July to September 2009. Changes indicated by survey data therefore measure a 2.5 year period, not 4.5 years.

2. The Tracking survey was conducted earlier than originally planned, due to CMDHB financial and timing pressures. Unfortunately, this meant the two surveys were held during different seasons (Benchmark in summer, Tracking in winter), which can introduce design effects on the results as eating and exercise patterns can vary seasonally (e.g. less inclined to go out and exercise during winter).

3. The Tracking survey also took place during a significant tightening of the NZ economy, amidst a worldwide recession. This meant greater unemployment and tighter household budgets than was the case during the Benchmark survey, which can impact attitudes and behaviour around healthy eating and being more active.

For these reasons, changes between the Benchmark and Tracking surveys are only being deemed statistically significant if they occur at the 99% level. This will be shown in this section by the use of � or � to indicate a statistically significant increase or decrease at 99% level. The use of �� or �� will indicate an increase or decrease has been noted, but at the 95% level which is less reliable. The use of ~ denotes no change at 95 or 99% levels. At Risk Population: 1. Uptake KPI (2005 -2010): �� Knowledge and Attitudes Knowledge Measures Selected Indicators Total Maori Pacific South

Asian Other / Euro

1. What can be done for a healthy weight: Control/reduce fat intake 54 � 54 ~ 44 ~ 58 ~ 57 ~

2. What can be done for a healthy weight: Control/reduce portion size 29 � 25 ~ 24� 21 ~ 33 ~

Fewer people (54%) identified reduction/control of fat intake as a means of having a healthy weight, but the decrease is not statistically significant. The number of respondents identifying portion control (serving size) as a means to healthy weight dropped to 29% (this decrease is statistically significant). This drop also occurred in the Pacific group. The table below shows changes in other responses to this question. It is a mixed picture. Fewer identified cutting back on takeaways and junk food, but more noted eating home cooked meals. Drinking water, not cooking in fat, eating food high in fibre and eating less meat increased in some groups, countering the fewer responses on reducing portion size. What can be done for a healthy weight:

Total Maori Pacific South Asian

Other / Euro

Eat less takeaways � ~ � ~ ~ Eat less junk food � ~ ~ ~ � Drink water ~ ~ � ~ ~ Don’t cook in fat/oil –grill ~ ~ ~ � ~ Eat less meat � � � ~ � Eat food high in fibre ~ � ~ � ~ Eat home cooked meals � ~ ~ ~ �


Knowledge Measures Selected Indicators Total Maori Pacific South

Asian Other / Euro

3. What can be done to prevent diabetes: Keep fit/physically active 56 ~ 51 ~ 45 ~ 61 ~ 59 ~

4. What can be done to prevent diabetes: Have a healthy weight 21 ~ 11 ~ 9 ~ 18 ~ 27 ~

5. What can be done to prevent diabetes: Can’t be prevented 11 ~ 8 � 19 ~ 13 ~ 9 ~

The 2009 responses for the 3 selected measures above were not significantly different to those given in 2006/07. While fewer Maori felt that diabetes could not be prevented (from 12% down to 8%), the decrease is not statistically significant. There was, however, a significant increase in those associating a healthy diet with preventing diabetes. The table below highlights big increase in those identifying watching what you eat (from 10 to 39%), supported by significant increases in those highlighting consumption of vegetables (from 27 to 33%), and fruit (from 22 to 28%). An increased number of people mentioned reducing fat (30%, although this is fewer than the 45% who mentioned reducing sugar). There were also increased mentions of healthy lifestyle. These have been key messages in the LBD programme, so this is an important gain in knowledge/awareness. What can be done to prevent diabetes:

Total Maori Pacific South Asian

Other / Euro

Watch what you eat/healthy food � � � � � Eat vegetables � � ~ ~ � Eat fruit � � ~ � � Reduce fat � ~ ~ ~ � Reduce sugar ~ ~ ~ ~ ~ Lifestyle (general) � � ~ ~ � No soft/fizzy drinks ~ ~ � ~ ~ The fizzy drink response is included here as, although not statistically significant, it signals more Pacific people (from 9 to 14%) are starting to hear the LBD “swap fizzy to water” message and associating this with diabetes prevention.

Nutrition-related responses (to the question: What can be done to prevent diabetes?)

36 32 33 34 37

5547

4247

64

0

20

40

60

80

100

TOTAL MAORI PACIFIC SOUTH ASIAN OTHER

%

2006/07 2009


Attitude Measures Selected Indicators Total Maori Pacific South

Asian Other / Euro

1. Interested in eating more healthily 63 ~ 72 � 85 � 77 ~ 52 ~

2. Interested in being more physically active 66 ~ 63 ~ 76 ~ 78 ~ 62 ~

Pacific interest in eating more healthily showed a significant increase from (77 to 85%). More Maori were also interested (from 65 to 72%), but this was not statistically significant. Of the 37% not interested in eating more healthily, most (67%) felt their diet was healthy enough (a significant increase from 59%). The table shows no change in levels of interest in being more active. Of the 34% (total) not interested in being more active, most (69%) felt they were doing enough to be healthy. Of the 23% of Pacific people not interested in being more active, those who felt they were doing enough to be healthy dropped significantly from 80% to 59%. Further, 14% felt they need to do a lot more to be healthy (up from 1%). These big shifts were statistically significant and show a growing Pacific awareness of the need to be more active – even if this has not yet translated into action. The following three areas provide additional attitude markers after 4.5 years of LBD.

1. The first is taken from a July 2009 monitoring survey of 400 Counties Manukau respondents used to measure effectiveness of the LBD social marketing campaign. In terms of assessing attitudes and consideration of making changes, the survey asked whether people were more motivated (as a result of the campaign) about certain attitudes or behaviours.

The results, shown in the two following tables, wer e very positive for LBD, signalling high levels of motivation. The campaign experience itself was also highly valuable, in terms of the knowledge and learning that came with this trailblazing approach. When results were presented, experienced advertising industry players commented that the campaign ‘cut-through’ and success would have had champagne corks popping in the private sector.

CHANGES MADE AS A RESULT OF THE ADVERTISING (LEVEL OF AGREEMENT)

2008 2009

Total sample

Total sample Maaori Pacific South Asian Other

(208) (343) (97) (69) (90) (112)

% % % % % %

I am now more concerned about the issue of obesity 82 77 72 89↑ 92 71

I now feel more motivated to eat healthily 81 81 78 90 96↑ 74

I now feel more motivated to be active 80 79 82 92↑ 96↑ 70↓

I am now more concerned about the issue of diabetes 79 79 84 86 88 74

I am now more likely to have a health check up or test for diabetes 69 68 76 79 85↑ 59

I am now more likely to get someone in my family to have a health check or test for diabetes 75 72 77 90↑ 88↑ 60↓


2. A second area for assessing attitude is the perception people have of their own weight. People are less likely to change behaviour if they do not perceive they have a problem (i.e. being overweight or obese).

In the NZ Health Survey 2006/07, people were measured and weighed, and then overweight and obesity levels calculated. The 2009 LBD Tracking Survey did not take measurements. It asked respondents two sets of questions: 1) whether they thought a doctor checking their body shape and weight would say they were overweight or obese, and 2) to state their height and weight, which allowed overweight and obesity levels to be calculated. While not a strictly accurate comparison (different definitions, dates, etc), the chart below shows the large gaps between perception and reality. The NZ Health Survey confirmed Pacific adults in Co unties Manukau have an obesity rate around 80%. We would have expected Pac ific adults answering the LBD survey to report close to an 80% obesity rate, but only 26% rated themselves as being obese. The LBD BMI calculation s from their reported height and weight were closer (50%), but still well short of 80%. Similarly, we would have expected Maori responses to report an obesity rate around 50%, but only 26% rate themselves as obese (although this did increase from 18% last time). The Other/European adult obesity rate is around 30%, but only 7% think they would be obese.

Obesity prevalence - comparison of LBD 2009 with NZHS 06/07

32

50

79

2925

4450

17 1712

26 26

107

0

20

40

60

80

100

TOTAL MAORI PACIFIC SOUTHASIAN

OTHER

%

NZHS (measured)

LBD (height/w eight est.)

LBD (w hat Dr w ould say)

*South Asian figures were not provided in the NZ Health Survey, only total Asian.

CHANGES MADE AS A RESULT OF THE ADVERTISING (LEVEL OF AGREEMENT)

I now feel more motivated to…

2009

Total sample Maaori Pacific South Asian Other (343) (97) (69) (90) (112)

% % % % %

… drink water instead of fizzy drink 73 73 92↑ 95↑ 60↓

… reduce the amount I eat 62 69 85↑ 83↑ 47↓

… eat more veges 75 77 83 92↑ 64↓

… eat more fruit 76 77 88↑ 90↑ 67

… eat healthier lunches 76 80 83 90↑ 69

… eat a healthy breakfast 79 75 90↑ 93↑ 73

… eat less fried foods or takeaways 68 75 81↑ 84↑ 59


While more Maori are becoming aware that they are o bese, the reality gap for all groups remains a major challenge. It seems most obese adults do not see themselves as being obese, which reduces the likeli hood of them trying to change behaviour to achieve a healthy weight.

3. A third area is tracking concern about health problems from overweight or diabetes. Again, if there is no association between overweight/obesity and health, or about the impact of diabetes, it is harder to motivate people to take action. The table below notes findings from the LBD surveys in this area. It shows a) more Maori are now concerned about family health problem s from being overweight and, b) more people are now concerned about having/ getting diabetes. These increases will assist LBD if it means groups become more conducive to attitude/behaviour change for the better.

Total Maori Pacific South

Asian Other / Euro

Worried that someone in family has/may get health problems from being overweight

40 ~ 64� 64� 49 ~ 28

Concern that self or someone in the family has/may get diabetes

35� 52� 57 ~ 55 � 23 ~

The reduction in Pacific respondents concerned about family health problems from overweight is worrying, albeit now equal to Maori and still well above European.

At Risk Population: 2. Uptake KPI (2005 -2010): �� Participation in LBD Programme Implementation Measures Selected Indicators

Total Maori Pacific

1. Implementation Score (average) 5.5 ~ 6.8� 3.2�

95 � n/a n/a 2. Schools with at least one nutrition Total: and physical activity provider engaged Decile 1 & 2: 65 ~ n/a n/a The implementation score is taken from the School of Population Health LBD Monitoring Report for the period February 2008 to January 2009. The Degree of Implementation variable refers to how much intervention has occurred or whether the goals have been implemented. The overall average Implementation score did not change significantly from 2007, while the Maori action area improved and Pacific dropped (but primarily because of the priority focus placed on planning and delivery of the LotuMoui Games in 2008). An explanation and scores for individual Action Areas are shown in Appendix Five. LBD partners have increased engagement with schools, with 95 primary schools now engaged in the Health Promoting Schools (HPS) programme, up from 62 in 2007. All 65 decile 1 and 2 schools have been engaged in this HPS programme. As noted earlier in this report (and described in Appendix four), in addition to the HPS programme, LBD partners have delivered a substantial amount of funding, resource, support


and encouragement to schools and early childhood education centres across Counties Manukau. It is clear that these education settings have been the focus of increased attention and assistance around nutrition and physi cal activity over this time. Community Engagement Measures Selected Indicators Total Maori Pacific South

Asian Other / Euro

3. GP discussed physical activity 41� 46 � 62� 55� 33 ~

4. Employer supports eating healthily 33 ~ 36 ~ 55 ~ 46 ~ 24 ~

5. Church supports eating healthily 66 ~

6. Marae supports eating healthily 53 ~

7. Doctor supports eating healthily 60� 65 ~ 84� 76 � 50 ~

The KPIs in the table above were chosen to give some indication of whether LBD was making progress in reaching different institutions in society and encouraging them to provide a supportive environment around healthy eating and being active. The results show a statistically significant increa se in the number of respondents (41%) who advised their GP had talked with them abo ut exercise or physical activity in the previous 12 months. This increase was also significant for Pacific and South Asian. There was also an increase in respondents (to 60%) who agreed that their doctor or other medical centre staff encouraged or did things to make it easier for them to eat healthily. Again, the increase was also significant for Pacific (to 84%). On the downside, there was no change in the number of respondents that felt supported to eat healthily by their employer, people at church (Pacific) or people at marae (Maori). The GP indicators above show positive increases. Th is is boosted by an increase in other supporting signals given by doctors or other medical centre staff, as shown below. More of the population received this vital p rimary care support, which is good. Health checks/consultation received in the previous 12 months

Total respondents (n=2,363)

Those who have been to a doctor (n=1,620)

Given a blood pressure test � ~ Given a cholesterol test � � Given a diabetes test � � Measured their weight � � Talked about healthy eating or weight � � Talked about risk of diabetes / heart disease � � Talked about exercise of physical activity � ~ The other point from the indicators table above is the zero increase in perceived support from work, church or marae settings for people to e at better. The employer response is understandable, given LBD was only able to reach a small number (48) of large employers with the Heartbeat Challenge and lacks capacity to reach the much larger number of small to medium employers. To see no change in respondents who felt people at their church (Pacific) or marae (Maori) encouraged or made it easier for them to eat healthily is disappointing – given the range of activities targeted at these settings (e.g. Heartbeat Challenge, LotuMoui church programme, hauora marae, kaiwhakahaere and other projects).


In terms of engaging support from different institu tions and families in Counties Manukau, the news is better when it comes to being physical active. The table shows an increase in respondents acknowledging the various groups that encouraged or did things to make it easier for them to be physically active. This is good progress for LBD. Sources of support for healthy eating and physical activity

Eat Healthily Be Physically Active

Other adults in the household � ~ Wider whanau/family and close friends � � Employer ~ � People work with ~ � People at church ~ ~ People at marae ~ � Doctor/medical centre staff � � The notable exception is the drop in Maori responde nts who felt that people at the marae encouraged and did things to make it easier f or them to be physically active . This needs more investigation, but may be related to the nature of marae and how they are used (most common reasons for going to the marae were to attend tangihanga, family events/weddings/reunions, cultural/arts courses, and meeting/hui. These are occasions where the attendees are not typically oriented around encouraging physical activity. Another possibility is that survey respondents are simply not aware of initiatives and activity going on behind the scenes at marae. On balance then, there have been some useful gains made in shaping an environment in Counties Manukau that people feel is supportive of being physically active, with less progress noted by respondents around support f or eating healthily. At Risk Population: 3. Uptake KPI (2005 -2010): �� Screening for Diabetes The aim of this measure was to show an increase in the proportion of the population tested for diabetes. The LBD surveys asked respondents to confirm whether or not they had received a diabetes test during a health check/consultation in the previous 12 months. Selected Indicators Total Maori Pacific South

Asian Other / Euro

Given diabetes test in prior 12 months 43� 48� 54 ~ 42� 37 ~

The results show a clear increase overall, and for Maori and South Asian. The Pacific rate did not change, although it is higher than all others.


The following set of KPIs for the 2005 – 2010 period of LBD relate to people with diabetes. These are measures directly related to the health sector, signalling how well diabetes is being managed. Data has been collated from several different sources to report against these KPIs, including: Get Checked data, Chronic Care Management (Diabetes module) data, and Diabetes Care Support Service (DCSS) Audit data. The tables below indicate, where possible, whether current results have improved over baseline data established in December 2007. They also show whether the set targets have been met (NB: depending on the data set, there are still 6-12 months to run in the year). The four categories of performance indicators reported here are: • Participation in organised management programmes • Screening for complications • Medication per guidelines • Intermediate outcomes People with Diabetes: 1. Uptake KPI (2005 -2010): �� Participation in organised management programmes

Indicator Group Target set for

2009-10

Update to Nov 2009

Improvement relative to baseline?

Achieved target?

Total 15,517 16,054 �� Maori 2,558 2,669 ��

Diabetes Get Checked (numbers seen)

Pacific 5,521 5,992 �� Total 11,500 9,748 �� Maori 2,025 ��

Diabetes Chronic Care Management (CCM)

(numbers enrolled) Pacific 4,156 �� The number of people with diagnosed diabetes who attended a free Get Checked session has exceeded target. This is good progress. The cumulative number of people with diabetes enrolled in CMDHB’s CCM module has increased over baseline figures, but still below the original target with one year still to go (this data is only to June 2009). People with Diabetes: 2. Uptake KPI (2005 -2010): �� Screening for complications

Indicator Group Target

set for 2009-10

Update to Nov 2009


Achieved target?

Total 90 81 �� Maori 90 86 ��

Urinary microalbumin (proportion of audited patients

with this recorded in their notes) Pacific 90 86 �� Total 72 74 �� Maori 72 76 ��

Retinal screening (proportion of Get Checked

patients screened in last 2 years) Pacific 72 67 �� The use of urinary microalbumin as a screening tool for diabetic renal disease has been increasing, but is still below target with nine months to go. Maori and Pacific rates are currently higher than total, which is good. Retinal screening ratios are also increasing, with the overall rate and Maori rate exceeding target. The Pacific rate is still lower than target.


People with Diabetes: 3. Uptake KPI (2005 -2010): �� Medication as per guidelines

Indicator Group Target

set for 2009-10

Update to Nov 2009


Achieved target?

Total 75 76 �� Maori 80 78 ��

Proportion of people having Get Checked consultations who are on

a Statin Pacific 80 76 ~ �� Very high rates of Statin utilisation have been reached and there would be limited usefulness in aiming to increase their use much further. The target for the overall population has been achieved. The proportion of Maori who had Get Checked consultations and were on a Statin has increased from baseline, but falls slightly short of the target at this point. The Pacific rate has not changed and is still short, with 12 months of data to come before June 2010. People with Diabetes: 4. Uptake KPI (2005 -2010): �� Intermediate outcomes These indicators track glycaemic control, blood pressure control and cholesterol.

Indicator Group Target set for

2009-10

Update to Nov 2009


Achieved target?

Total 59 60 ~ �� Maori 53 54 ~ ��

Proportion of Get Checked enrolments with

HbA1c = 8 or less Pacific 48 58 �� Total 36 40 ~ �� Maori 37 43 ~ ��

Proportion of Diabetes CCM patients with

Systolic Blood Pressure over 130 Pacific 31 37 �� Total 28 40 �� Maori 28 42 ��

Proportion of Diabetes CCM patients with

LDL (bad) cholesterol over 2.5 Pacific 28 44 �� Glycaemic control is difficult to achieve, but the proportion of Get Checked patients with HbA1c levels at 8 or less is on target (NB: the baseline data may have been incorrect). Both blood pressure and cholesterol targets have not been met so far, with cholesterol figures worse than those recorded as baseline data in December 2007. Overall, participation in the Get Checked diabetes management programme is on target, while CCM enrolments have increased but not yet at target levels. Rates for activity around screening for complications and med ication as per guidelines have increased, but only some groups have reached target ed levels. In terms of intermediate outcomes, the proportion o f patients achieving target blood glucose levels is on target, but blood pressure and cholesterol indicators are poor. In particular, the proportion of CCM patients with hig h levels of LDL (bad) cholesterol has not improved from December 2007 baseline data.


3.3 LBD Intermediate term indicators – nutrition an d physical activity As explicitly stated at the outset, LBD was not exp ected to affect nutrition and physical activity levels in the first five years. The short term targets were to concentrate on shifting awareness and attitudes. Survey data on intermediate term indicators – which look for change in behaviour - should therefore not be used to assess LBD performa nce and outcomes to date. There is some value however, in looking at any move ment – as an indication of what lies ahead. The following data is reported here so lely for that purpose. 1. Physical Activity levels This table shows the indicators clearly heading in the wrong direction. Fewer people are regularly physically active (active on 5+ days, averaging 30minutes over those days) and more are sedentary (less than 30 minutes physical activity in the last week). So, although we have had success (shown earlier) in getting increased support from others to be active, it is not enough. Even though 92% of respondents identified that being physically active is something that you can do to have a healthy weight, and 56% identified that being active can help prevent diabetes, action doesn’t follow. When asked to compare their level of activity with recommended minimum levels, the majority of respondents (55%) feel they are not reaching minimum levels. This has increased since the first survey 2.5 years ago, as shown in the table alongside. This acknowledgement is a small reason to be optimistic – it would be much harder if they felt activity levels were fine – but it is obviously not being translated into action. Another small reason for optimism is the commentary reported earlier on the group of Pacific respondents who were not interested in being more active. Fewer felt they were doing enough to be healthy, and more felt they need to do ‘a lot more’ to be healthy. This signals a growing Pacific awareness of the need to be more active. In short, however, the indications are that the problem is not going away, and activity levels are unlikely to improve without more effort from concerned stakeholders.

Change in reported physical activity

levels in last 2.5 years

Regularly physically active

Sedentary

Total 38� 16�

Maori 48 � 17�

Pacific 31� 17�

South Asian 32 ~ 17 ~

Other / Euro 41� 14�

Comparing level of activity to recommended minimum levels

Less More Same

Total 55� 14� 24�

Maori 50 ~ 20 ~ 22 ~

Pacific 56� 14 ~ 26�

South Asian 54 ~ 9 � 31 ~

Other / Euro 55� 15� 21 ~


2. Nutrition As the table shows, fruit and vegetable consumption has not shifted overall. It increased for Pacific (albeit from a low base), consistent with the increased Pacific interest in eating healthily reported earlier. The Other/European rate got worse, as fewer ate the recommended 5+ a day. In terms of fat intake, South Asian have picked up on the message about getting rid of the fat when cooking meat, showing an increase from 42% to 60%. More work is needed to get through to Pacific and Maori. The significant drop in fizzy drink consumption is a pleasant surprise. It has been a key area targeted by LBD, featuring in both Swap2Win and ‘Diabetes’ social marketing campaigns. Those who were drinking also reported drinking on fewer days (down from 3.0 to 2.6). The decrease for Pacific may be associated with their increased awareness of drinking water as a means of keeping a healthy weight (reported earlier).

Consumed fizzy/energy drinks in last 7 days (excl. diet/no-sugar)

49 48

66

42 4540

50 52

3238

0

20

40

60

80

100

TOTAL MAORI PACIFIC SOUTH ASIAN OTHER

%

2006/07 2009

As with physical activity levels, LBD was not expected to achieve population-level change in nutrition habits at this stage. The reduction in fizzy/energy drink consumption in the last 2.5 years is significant, and a success to be celebrated, but the other indicators clearly show there is a long way to go. It is reasonable to conclude that improvement in nutrition and physical activity levels in Counties Manukau is unlikely to happen without further action and interventions.

Change in selected nutrition indicators

in the last 2.5 years

Eat 2 fruit & 3 vege servings or more per day

Usually cook meat with fat removed or drained off (including

corned beef)

Consumed fizzy/energy

drinks in last 7 days (excluding sugar-free and diet)

Total 26 ~ 61~ 40�

Maori 22 ~ 55 ~ 50 ~

Pacific 17� 39 ~ 52�

South Asian 15 ~ 60� 32�

Other / Euro 32� 69 ~ 38�


3.4 Summary – Progress Markers When the LBD five year plan was approved in 2005, it was clearly understood that obesity and diabetes would not be eliminated or “addressed” within 5 years. The expectation was a comprehensive and coordinated effort as the first major step towards a 15-20 year vision. It envisaged obesity and diabetes stabilising before trending down from 2020 onwards. The “Letter from 2020” described the first five yea rs as “ the ‘hard yards’, when there was a lot of effort for little change in outcome. But they pu t in place many of the strategies that continue…today, and most importantly, galvanised co mmitment and action across society.” vi

On balance, the results to date are a mixed bag. LBD has achieved good progress in some areas, but either no movement or some backwards movement in other areas. Partnerships, resourcing, community action, organisation The LBD model, infrastructure, and partnership approach has been effective in attracting substantial investment and resources to focus on obesity and diabetes. The alignment of goals and coordination of initiatives across many diverse parties has been a challenge, but has paid dividends. This success has seen a major combined effort in terms of galvanising action on the ground, in and around communities, to push for the desired change. Considerable time, resource and effort was expended in engaging grassroots groups and community leaders. This was balanced by partnered action with large organisations, both public and private, on community initiatives and activity targeting environmental change. LBD has been able to attract additional investment in related initiatives in Counties Manukau in excess of $10 million. This has assisted greatly with driving significant and increasing volumes of activity across the LBD partners, increasing the levels of contact, support and activity in the community. LBD struggled at times with network management, governance and communication aspects. It also came up against organisational capacity constraints, restructuring and staff turnover issues that often hindered implementation efforts. Nevertheless, the commitment from a core group of partners and their organisations has enabled the programme to persevere and function as a framework for coordinated action. That commitment helped maintain momentum around implementation of the LBD plan. Knowledge and awareness In terms of building awareness and knowledge, LBD has made some gains and taken some losses around what can be done for a healthy weight. There was no change in overall numbers identifying ‘controlling fat intake’, while fewer identified reducing/controlling portion size. This was balanced by more people identifying ‘eating less meat’ (including Maori and Pacific) and ‘eating home cooked meals’. There were increased mentions of drinking water (Pacific), not cooking in fat (South Asian) and eating food high in fibre (South Asian). In terms of knowledge of what can be done for diabetes prevention, there was no increase in those mentioning keeping fit/active or maintaining a healthy weight. There was, however, a very significant increase in those associating a healthy diet with preventing diabetes, including eating fruit and vegetables.


There has been an increase in Pacific people interested in eating more healthily (no other group), but no increased interest by any group in being more physically active. For eating and being active, the majority of those not interested felt their diet was healthy enough or they were active enough to be healthy. Surveys to measure impact of the social marketing campaigns indicated high levels of motivation to do the right thing in terms of nutrition and activity. The Tracking survey confirmed increased concern from Maori that overweight may cause health problems in the family, and an overall increase in concern that someone has or may get diabetes. These concerns may help spark action to do something about food and activity habits. Obesity perceptions There is still a major gap however between perceptions and reality around obesity. It is clear that of the obese adult population (33% of population, 52% of Maori, 80% of Pacific), most do not perceive themselves as obese. The proportions of those who rated themselves obese were much lower (10% of population, 20% of Maori, 21% of Pacific). This is a challenge for LBD. Efforts to build awareness that obesity is associated with health problems and diabetes, and that action can and should be taken to prevent this, will not resonate with this group until that mis-perception is corrected. Supportive environments Reported levels of support and related health advice/checks from doctors and medical centre staff have increased markedly, indicating an increased (positive) influence from the primary care sector. More people noted employers and work colleagues were supportive around being active, but no increase was seen for healthy eating support there. Churches and marae showed no increase as a source of support for either eating or activity (marae actually decreased on the latter). There was, however, an increase in numbers who identified the wider whanau/family and close friends as being supportive for both eating and being active. Looking beyond the short-term KPIs that were agreed to assess LBD performance at this stage, the intermediate term indications show physical activity levels dropping and nutrition habits have changed little. There are exceptions: more Pacific people are eating 5+ fruit and vegetables a day (although fewer Other/Europeans), more South Asian are removing fat from meat when cooking, and there has been a significant drop in reported fizzy drink consumption across the board (with the exception of Maori). Treatment and management Diabetes screening appears to have increased. Participation in the Get Checked diabetes management programme is on target, while CCM enrolments have increased but not yet at target levels. Screening for complications and prescribing medication as per guidelines has increased, but only some groups have reached targeted levels. In terms of intermediate outcomes, the proportion of patients achieving target blood glucose levels is on target, but blood pressure and cholesterol indicators are poor. In particular, the proportion of CCM patients with high levels of LDL (bad) cholesterol has not improved from December 2007 baseline data. Summing up LBD has successfully achieved a large mobilisation of community and partnered efforts. The results to date are variable, with pockets of success balanced by areas that have not shown improvement or have deteriorated. Solid foundations for collective action have been built. Data on nutrition and physical activity levels show s the problems have not gone away. Nor can they be expected to, without further action and interventions.


4. Looking Back - Strengths and Challenges This section touches briefly on some of the key factors that have been strengths and challenges for the LBD programme over the past four years. This insight, learning and experience acquired by the programme has value for the future development of LBD or other programmes of this nature. Further points are identified in Appendix 6.

4.1 Strengths Seven key strengths identified in the LBD programme are listed below. 1. Inclusive model and vision

The broad vision, framework and range of action areas enabled all stakeholders to see the big picture and identify their sphere of interest within it – this proved an effective rallying point for concerted action.

2. Leadership

At the beginning, the vision was championed from the top. CMDHB chairman, CEO and senior managers were visible, permissive and engaged. Leadership from LBD partners and community leaders amplified this. It gave the programme a profile and level of support that opened doors and fostered strong partnership connections.

3. Partnership and community engagement

The LBD programme connected with over 500 organisations and groups across Counties Manukau, opening up access to many diverse communities. LBD, in a sense, became a network of networks. From grass roots community groups to government agencies, the networks helped reach into communities to stimulate dialogue and action.

4. Collective Leverage

The breadth and depth of LBD meant it could harness a wide spectrum of support and expertise. The network proved a highly valuable ‘asset’ to leverage, bringing more than $10 million of additional resource into Counties Manukau. It helped align common resources and messages, reach and influence different audiences, add collective weight to initiatives, and build critical mass in terms of breadth and volume of activity.

5. Flexibility

The LBD broad brush approach, framework and relationships allowed for evolving structures and content, and partners were prepared to flex to accommodate change. It was easy, for example, to fold HEHA and other national policies into this local framework for Counties Manukau or to shift resource around action areas to respond to opportunities or obstacles.

6. Partner perseverance

LBD was a new and bold venture for CMDHB and LBD partners. There was no blueprint on how it would work, from governance aspects to operational funding matters. Five years since consultation first started on LBD, a core set of partners remain at the table, delivering commitment and continuity. Durable relationships count.

7. Building on existing

LBD gained time and value through building on existing community infrastructure and assets, rather than starting from scratch. With established trust and relationships, entities like the Schools Accord group and LotuMoui Pacific church programme were ideal vehicles to help connect LBD with key audiences.


4.2 Challenges Seven key areas of challenge for the LBD programme have been: 1. Partnership governance and oversight

The quality of participation in governance decision-making and oversight varied. This probably reflected the diverse mix of skillsets, experience levels and interests at the table, plus juggling strategic/operational monitoring with appropriate decision-making in a decentralised programme. Balancing unequal funding contributions with the desire for equal power sharing and programme influence also had its challenges.

2. Capacity LBD’s ability to respond to opportunities or implement initiatives was often hindered by capacity limitations, either at an organisational level (resources fully committed) or workforce level (lack of skilled personnel, such as dieticians). Steps taken to build capacity will take time to bear fruit.

3. Whole system coordination

The sheer breadth and scale of LBD was demanding in terms of management and coordination. Initiating, driving and monitoring action across all ten action areas, in a decentralised model, has its challenges. Fostering efficient cross-pollination of ideas and activity across the action areas has also been tricky, with a natural tendency for each group to concentrate on their own area of expertise.

4. Communication

Maintaining effective communication and information sharing became more difficult as the range of partners and initiatives expanded. Each had different information needs and interests, adding to programme reporting, collaboration and accountability requirements. Collecting, dicing and splicing information to get the right parts to the right people in a timely and cost-effective manner remains a work in progress.

5. Whole system learning

A key objective for embedding evaluation activity in LBD was to facilitate learning and continuous improvement across the programme. This was only partly successful, with many initiatives not benefiting from good evaluation design, implementation or subsequent use/dissemination of findings. There is a bias towards action, not reflection.

6. Grassroots reach and impact A key LBD aim was community and grassroots involvement in tackling obesity and diabetes. As a result, LBD has supported a multitude of small community initiatives. The clear benefits of communities taking ownership have so far been limited by the small reach and impact of their initiatives. Over time this may ultimately prove successful, but for now it represents pockets of success, but no system/population-wide impact.

7. Upstream - downstream balance Time and energy spent on ‘whole of society’ engagement around prevention probably overshadowed that spent on lifting the game within the health sector on diabetes treatment and management aspects. LBD struggled for traction within primary and secondary care health services, in terms of engagement, quality of care and driving a continuous quality improvement approach for diabetes across both areas.


5. Current environment This section outlines the current size of the obesity and diabetes epidemics in Counties Manukau, and projected changes over the next 20 years. Several scenarios are outlined that indicate the degree of change (and time) needed to materially change the expected growth. Commentary is provided on costs (pharmaceutical, laboratory and hospitalisation) incurred by CMDHB for diabetes, including potential savings that could be made if LBD partners are effective at preventing some of the increase. Cardiovascular disease is mentioned, as this is closely associated with diabetes from both a prevention and management perspective. Other relevant factors shaping the current environment are also touched on, including tightening of the public purse, major change in the health and local government sectors, and recent government decisions relating to nutrition, activity, obesity and diabetes.

5.1 Obesity, diabetes and cardiovascular disease – size and cost Obesity and diabetes – current size and scale of th e problem In 2004, it was estimated that more than 12,000 people in Counties Manukau were diagnosed with diabetes, with almost double this number likely undiagnosed. In fact, this was a significant underestimate. In 2008, a detailed CMDHB review found the local ‘known diabetes’ population (those known to the health sector as having diabetes) in 2007 was actually around 26,000 with a likely further 9,000 undiagnosed (35,000 in total)vii. Counties Manukau suffers more than other areas. In 2008, the Ministry of Health reported CMDHB as the only DHB “where adults were significantly more likely to be diagnosed with diabetes compared to the total adult population”. The diagnosed diabetes prevalence for adults was 8.2% in 2006/07 compared with the national average of only 5%.viii CMDHB also “had a significantly increased prevalence of obesity compared to the total child and total adult populations” in New Zealand, 12.7% vs 8.3% for children and 33% vs 26.5% for adults. Pacific and Maori feature disproportionately, with adult obesity rates of 80% (Pacific) and 52% (Maori). This equates to 110,000 obese adults in Counties Manukau. Obesity and diabetes – future projections Obesity and diabetes is on the increase. Globally, the number of people with diabetes is 285 million. In the next two decades, this is projected to increase by over 50% to 438 millionix. New Zealand is following that trend, but the scenario for Counties Manukau is much worse. As the Minister of Health, Tony Ryall, stated in February 2009 at the opening of the new renal unit in Counties Manukau (the largest in the country): “There will be a tsunami of people with diabetes coming at us in the future… “x. Projections for Counties Manukau show the number of obese people will increase by 80% in the next 20 years to reach 195,000 (not includi ng obese diabetics) xi. Projections also show the number of people with dia betes will double in 20 years to reach 72,000 by 2027. Of these, 45,400 will be known/diagnosed and 26,800 undiagnosed or marginal diabetes, as shown in the following table.


This means 41% (267,900) of the population in 2027 will either be obese or have diabetes. These are considered conservative estimates, which assume a slowing in the rate of obesity growth from the past 20 years.

2007 % pop 2027 % pop Difference % change

Total population 464,600 100% 648,000 100% 183,000 39%

Obese 108,800 23% 195,800 30% 87,000 80%

Undiagnosed/marginal diabetes 9,700 2.1% 26,800 4.1% 17,100 176%

Known diabetes 25,900 5.6% 45,400 7.0% 19,500 75%

Total all diabetes 35,600 7.7% 72,100 11% 36,500 103%

Total all obese and diabetes 144,400 31% 267,900 41% 123,500 86%

Of those projected to have diagnosed diabetes in 2027:

• around one third had diabetes in 2007 (diagnosed or undiagnosed) • a further third were obese in 2007 • the final third being new migrants or were not obes e in 2007

This means approximately two thirds of the epidemic is already ‘built in’, between the surviving current diabetics and the current obese c ohort (of which a quarter are projected to develop diabetes and still be alive in 2027).

Source of those with diabetes in 2027 Diabetes in 2027

Undiagnosed in 2027

Total in 2027

As % of 2027 known diabetes

cohort Existing diabetes in 2007 (and still alive) 11,900 0 11,900 26% Existing undiagnosed in 2007 4,300 0 4,300 9% Existing obese in 2007 14,500 10,100 24,600 32% Non-obese in 2007 9,700 12,800 22,500 21% Population growth (births and migrants) 5,000 3,900 8,900 11%

Total in 2027 45,400 26,800 72,200 100%

The chart below shows the projected growth path for the total diabetes cohort (diagnosed and undiagnosed). By 2027, 64% came from the current obese and non-obese populations.

0

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2007

2009

2011

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2015

2017

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2023

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2027

diabetes UndxObese non-obesePop Growth


This projected diabetes growth in Counties Manukau will cause major challenges for CMDHB and other health sector partners in terms of the funding, prioritisation, organisation and delivery of services for people wi th diabetes. The new renal unit, for example, has 28 dialysis ma chines and is expected to be able to treat 112 patients on an ongoing basis. With the projected growth in diabetes, it is only a question of time before this is at full capa city and another renal unit is needed. Improvements in diabetes service quality and produc tivity will be vital, making smarter use of primary and secondary health profess ionals and systems to deliver quality care within constrained resources. This also highlights the importance of marshalling effective action against obesity, given that 64% of the total 2027 diabetes numbers c ould be prevented, coming from: - the current obese population, - the population who are not currently obese. Prevention programmes that slow or reduce this obes ity growth have potential to reduce the size of the diabetes cohort in 2027. Obesity and diabetes cohorts – scale of impact to c hange the trajectory A number of scenarios were modelled to see the impact of interventions on the projected diabetes population in 2027xii. Seven are summarised below. They include extreme examples that help convey the timeframes and scale of change. 1. Our school and youth programmes are 100% successful and no further children

became obese, and they stayed non-obese thereafter. If all our teenagers stopped becoming obese from 2007, the total number of obese people would drop by 45,200 over the next 20 years. This would result in 3,300 (5%) fewer people with diabetes by 2027 (diagnosed and undiagnosed). The relatively low reduction in diabetes numbers is due to the timescales involved from when someone becomes obese to onset of diabetes – often 20 years or more. Most of the projected increase in diabetes in the next 20 years is in people who are already obese, or are becoming obese in their middle ages. More benefit would come later on.

Scenario Base Difference

2027 % pop 2027

% pop Pop

% change

Total Population 648,100 100% 648,000 100% 100 0% Undiagnosed/marginal diabetes 24,600 4% 26,800 4% -2,200 -8% Total known diabetes 44,300 7% 45,400 7% -1,100 -2% Total all diabetes 68,900 11% 72,200 11% -3,300 -5%

2. We stopped all obesity growth. No further person became obese in the next 20 years.

This scenario assumes the existing obese population remains, but no one else joins them. This would give 22,500 (31%) fewer people with diabetes by 2027 (diagnosed and undiagnosed), and 1,400 fewer deaths over this period (people who would have died prematurely as a result of diabetes). This still exceeds the numbers/rates in 2007.



2027 % pop 2027

% pop Pop

% change

Total Population 649,400 100% 648,000 100% 1,400 0% Undiagnosed/marginal diabetes 14,000 2% 26,800 4% -12,800 -48% Total known diabetes 35,700 5% 45,400 7% -9,700 -21% Total all diabetes 49,700 8% 72,200 11% -22,500 -31%

3. We kept the obesity rate at the same level as it is now for the next 20 years.

This scenario gives a lower result, as deaths in the existing obese population are ‘replaced’ by more people becoming obese. This would result in 10,300 (10%) fewer people with diabetes by 2027 (diagnosed and undiagnosed), and 600 fewer deaths over this period. The number and rate of diabetes still exceeds those in 2007.


2027 % pop 2027

% pop Pop

% change


4. We stopped the growth of the numbers of obese people AND even managed to reduce

the obese population by 1% every 3 years. This scenario has deaths in the existing obese population being ‘replaced’ by more people becoming obese, but at a reduced rate, so the numbers drop over time. This would result in 14,200 (20%) fewer people with diabetes by 2027 (diagnosed and undiagnosed), and 900 fewer deaths over this period. The number and rate of diabetes still exceeds those in 2007.


2027 % pop 2027

% pop Pop

% change


5. We reduced Maori and Pacific obesity rates to European levels.

If all ethnicities had the same population obesity levels as the European group in 2007, over the next 20 years there would be 15,600 (22%) fewer people with diabetes by 2027 (diagnosed and undiagnosed), and 900 fewer deaths over this period. Almost all this drop is in the Maori and Pacific communities. The currently high Maori and Pacific obesity rates will clearly play a large part in the ongoing diabetes epidemic.


2027 % pop 2027

% pop Pop

% change



6. Diabetes care improved and halved the excess mortality rate (i.e. the difference

between diabetes and non-diabetes halved). Improvements in the care of people with diabetes that successfully halved the mortality differential would see 2,900 people having additional years of life added. The number and rate of diabetes would therefore increase.


2027 % pop 2027

% pop Pop

% change

Total Population 650,900 100% 648,000 100% 2,900 0% Undiagnosed/marginal diabetes 26,800 4% 26,800 4% 0 0% Total known diabetes 48,100 7% 45,400 7% 2,700 6% Total all diabetes 74,900 12% 72,200 11% 2,700 4%

7. Bariatric surgery for 200 people with complicated or uncomplicated diabetes each year

This would result in 2,700 (6%) fewer people with known diabetes by 2027 and 100 fewer deaths.


2027 % pop 2027

% pop Pop

% change

Total Population 648,100 100% 648,000 100% 100 0% Undiagnosed/marginal diabetes 27,100 4% 26,800 4% 300 1% Total known diabetes 42,700 7% 45,400 7% -2,700 -6% Total all diabetes 69,800 11% 72,200 11% -2,400 -3%

Scenario Summary There are currently 35,000 people with diabetes in Counties Manukau (9,000 of these undiagnosed). On the current trajectory, this is expected to double to over 72,000 by 2027 . The seven scenarios illustrate the scale of change needed to have a material impact on the diabetes epidemic in Counties Manukau, and b ring volumes down from 72,000:

• Stopping teenage obesity from 2007 and keeping them non-obese for the next 20 years would only reduce this by 5% (3,300).

• Stopping any other person becoming obese from 2007 would reduce it by 31% (22,500).

• Holding the obesity rate the same for the next 20 years would reduce it by 14% (10,300).

• Reducing the obese population by 1% every 3 years would reduce it by 20% (14,200).

• Reducing Maori and Pacific obesity to European levels would reduce it by 22% (15,600).

• Halving the diabetes excess mortality rate will increase diabetes numbers by 4% (2,700).

• Delivering 200 bariatric surgery procedures per year for people with diabetes will reduce known diabetes numbers by 6% (2,700).


The projected 80% increase in the obese population and 100% increase in those with diabetes in the next 20 years will be felt keenly i n Counties Manukau. With an estimated 41% (267,900) of the population i n 2027 either obese or affected by diabetes, the impact will extend beyond individuals and families to hit communities, employers, local and central government agencies, a nd of course the health sector. Obesity and diabetes cohorts – health care costs CMDHB estimates calculated the total pharmaceutical, laboratory and hospitalisation costs for people with diabetes (15 years and over) as $83 million in 2008, an average cost of $3,100 per person for the 26,581 with known diabetesxiii. This is not the full cost of health care, as it does not include, for example, GP visits, outpatient clinics (including dialysis services for diabetes), Get Checked Diabetes, and Chronic Care Management costs. If one were to apply this average per person cost to the projected number of people with diagnosed diabetes in 2027, costs would rise from $83 million in 2008 to $141 m illion per year by 2027 , an increase of $60 million per annum over 2008 figures. This is a grossly simplified calculation, but it serves to indicate the scale of cost increase CMDHB could face if the current obesity and diabetes trajectory is not altered. The $141 million also only covers annual costs in 2027. The yearly increase in additional costs (i.e. over and above the current $83 million) over the 20 years would mean CMDHB incurs, in 2008 dollar terms, a cumulative additional cost of around $490 million . Obesity and diabetes cohorts – potential health car e savings Given that up to 64% of the projected 2027 diabetes cases is potentially preventable, coming from the currently obese and yet-to-become-obese populations, the potential savings to be made from investing in effective preventative action are significant. Considering only pharmaceutical, laboratory and hospitalisation costs, CMDHB estimated that a person with diagnosed diabetes incurs additional costs of around $2,381 (per person, per year) than a person without diabetesxiv. Put another way, for every person that is stopped f rom getting diabetes, CMDHB saves $2,381 per year in pharmaceutical, laboratory and hospitalisation costs. Extrapolating this across the projected growth in numbers indicates the potential for savings. If the LBD interventions successfully reduced the obese population by 1% every 3 years, this would reduce the projected number of people with diabetes in 2027 by 14,200. This was scenario 4 shown earlier. The reduction would be in 6,200 fewer diagnosed diabetes case and 8,000 fewer undiagnosed. The 6,200 fewer diagnosed diabetes cases would equa te to savings of $14.8 million (in 2008 dollar terms) in that year, 2027. The cumulat ive savings between now and 2027 would be $111 million xv.


0

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($ m

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Annual savings Cumulative savings

Projected cost savings from 1% reduction in obese population every 3 years(in pharmaceutical, laboratory and hospitalisation costs only)

If it was also assumed that those with borderline or undiagnosed diabetes were costing $500 more per year than someone without diabetes (as compared with those with full diabetes costing $2,381 more), then the combined annual savings figure in 2027 would be even higher at $18.8 million , with a cumulative savings total of $141 million . The potential savings are substantially higher once other areas are taken into account, such as savings from:

� Fewer GP visits, outpatient clinics, Get Checked, CCM costs � Fewer new buildings, equipment or staff to cater for increased volumes � Fewer people hit by cardiovascular disease and obesity-related cancers.

Cardiovascular disease Obesity and diabetes are also very strongly associated with cardiovascular disease (CVD). From a CVD prevention perspective, the range of advice and lifestyle changes promoted to achieve better health and reduce CVD risk are very similar to that promoted for diabetes. Current LBD activity has a flow-on benefit in terms of CVD, particularly in the areas of prevention and early detection (screening), while management of CVD patients also includes adoption of healthy lifestyle changes. In terms of CVD prevalence, CMDHB estimates there were 20,357 people in Counties Manukau with existing cardiovascular disease in 2008 (15 years of age or over).xvi This gave an age standardised CVD prevalence rate for adults (aged 15+ years) of 6.6% for males and 4.4% for females. Maori, Pacific and South Asian rates are higher than European. Work has yet to be completed on future CVD trends for Counties Manukau. As an indicator, however, the NZ Medical Journal published a 2006 study into ischaemic heart disease (IHD) mortality in NZ that showed a small projected decline in mortality burden to 2015, but an actual increase among Maorixvii.


The study also suggested an emerging (unfavourable) cohort effect among those born since early 1950s, meaning people born after this time are projected to experience higher underlying risks of mortality than people born earlier. At some stage then, disease and mortality rates may well increase as this younger group move into their older years. It was felt that the most likely explanation for this adverse trend is the emergence since the 1970s of the epidemic of obesity (and consequential type 2 diabetes) in NZ and throughout the developed world, noting similar cohort effects in Australia and Sweden. This may be the first signal of an impact of the obesity epidemic on IHD mortality rates and burdens in NZ. Increasing the profile and emphasis of CVD within the LBD programme particularly in prevention aspects (tackling obesity) would likely boost programme value and return on investment to CMDHB. Diabetes and cardiovascular disease - health care c osts CMDHB estimated there were 40,910 people with diagn osed diabetes or cardiovascular disease in Counties Manukau in 2008. This group accounted for 13% of the total adult population who used the health s ector in 2008, but contributed to 46% of the total inpatient hospitalisation costs xviii . If the analysis was restricted to people aged 35 years and older with CVD or diabetes (95% of the cases), they accounted for 19% of the over 35 years population who used the health sector in 2008, but 54% of the total inpatient hospitalisation costs for this age group. In total, the whole group cost CMDHB $151 million over the 12 month period in 2008, around 15% of the total publicly funded healthcare budget. This cost only counts for inpatient hospitalisations, pharmaceuticals, and laboratory services. GP visits, outpatient clinics, and other CVD or diabetes programme costs (such as CCM) are over and above this figure. Their average per person health care cost of pharmaceutical, laboratory and hospitalisation was more than 5 times the corresponding cost per person without CVD or diabetes.

Total costs of Pharm, Lab, hospital

inpatient services

Number of people

Average cost per person

People with CVD or diabetes $151 million 40,910 $3,700

People without CVD or diabetes $183 million 272,659 $670

Total cost in CMDHB $335 million

After adjusting costs for age differences (CVD and diabetes increases significantly in older age groups), the additional cost to CMDHB associated with CVD and diabetes in 2008 was estimated at $2,381 per person, or $97.4 million in total . Stated differently, CMDHB would save $2,381 in pharmaceutical, laboratory and hospitalisation costs for every person that could be prevented from getting CVD or diabetes. Data is not currently available to run robust 20 year projections for the number of people with CVD in Counties Manukau, so annual and cumulative costs cannot be provided here. Suffice to say, any LBD activity that helps reduce the future number of CVD cases will deliver further savings to CMDHB over and above tho se already reported for diabetes.


5.2 Other key environmental factors Fiscal constraints The New Zealand public health sector, like many other sectors, has come out of a period of steady growth in the economy and government funding. In the current environment, on the back of a global credit crisis and local recession, there are much stronger fiscal constraints on the public purse. Funding to the health sector will be a lot tighter than recent years, but the health care needs of communities remain the same. CMDHB and other publicly funded organisations need to find ways to make ends meet and do better in a tight situation. This will include prioritising, working smarter, making productivity and quality improvements, trimming waste and duplication, leveraging technology and partners, and identifying means of increasing revenue. Health sector change National and regional structures – In January 2009, a Ministerial Review Group was established to recommend how New Zealand might improve the quality and performance of the public health system, to improve the system’s capacity to deliver into the future, and to move resources to support front-line care. Their report was delivered to the Government in July 2009, containing 170 recommendations for changexix. Several recommendations have been accepted by Government and are underway, including

� establishment of a new National Health Board to oversee DHB spending on hospitals and primary care, manage national planning and funding of all IT, workforce planning and capital investment, and take national responsibility for vulnerable health services such as paediatric oncology;

� creating a Shared Services Establishment Board to start consolidating back office administrative functions (such as payroll and purchasing) across the 21 DHBs and regional shared service agencies;

� strengthening regional cooperation in DHB service planning and delivery, and

� devolving further funding from the Ministry of Health to DHBs, where appropriate. This degree of structural, funding and service delivery change (nationally and in the Auckland region) will demand attention and resource from CMDHB in order to understand and assist/translate implementation within the Counties Manukau and Auckland context. This will limit the extent to which senior management resource will be available to advocate for current priorities and business-as-usual activity, including LBD. It also signals the possibility of increased regional collaboration on obesity, diabetes and other work. Primary health care sector - Primary care is also entering a period of significant change, in line with the Government’s Better, Sooner, More Convenient primary health care policyxx. In September 2009, the Ministry of Health called for expressions of interest from primary health care providers who were ready and able to deliver large scale changes to the way they currently deliver health care. More than 70 were received, of which nine were selected to go forward for further development into a detailed business case.


One of the selected proposals is for a Greater Auckland Integrated Health Network (GAIHN), a combined group that covers 274 general practice teams, 11 PHOs and the 3 Auckland DHBS. Like the others, this consortium has until mid-February 2010 to develop a Business Case. If approved by government, it will then move into an implementation phase. The GAIHN proposal aims to significantly improve health sector performance in several key areas over the next three years. To get there, it plans to achieve (among other things) improvements in chronic conditions management, better diabetes and cardiovascular services, better help for smokers to quit, and strengthened clinical leadership and networks to improve models of care and clinical performance. This will clearly be a priority for senior primary and secondary care managers and clinicians during 2010. While this may limit their immediate capacity and willingness to focus on other matters (such as greater support for community prevention initiatives), the improvements sought in diabetes/CVD services and clinical networks is very much in line with LBD goals. Local government change - single Auckland Council In 2007, a Royal Commission of Inquiry into Auckland Governance was established, to investigate and make recommendations on local and regional government arrangements for the Auckland region in the futurexxi. The Royal Commission delivered its report in March 2009, recommending the creation of a single Auckland Council to replace the eight existing councils (Rodney, North Shore, Waitakere, Auckland, Manukau, Papakura, Franklin and the Auckland Regional Council). Following release of the Royal Commission report, the Government made the decision to create a single Auckland Council as the first tier of governance, with up to 20 or 30 local boards across the region as the second tier of governance. Elections for the new council are planned for October 2010. Until then, current councils cannot make major commitments without agreement from an interim body (the Auckland Transition Agency). Existing councils (including the three in Counties Manukau) are diverting time and resource to understanding the new environment and the emerging requirements to transition to a single Auckland Council. This is over and above the business as usual workload. While work is underway to ensure that local community services (recreational facilities, libraries and the like) transition smoothly to the new council and continue to provide usual services after the changeover, there is a degree of uncertainty regarding how these services will fare in the new environment. The balance of power and responsibility between the Auckland Council and the new local boards is also unclear. This is major structural change that directly impacts Counties Manukau. It may well have an impact on the LBD programme, in terms of changing the current level of council support and resourcing that goes towards LBD-related initiatives in Counties Manukau area. This includes, for example:

� Manukau City Council’s Find Your Field of Dreams programme, � the Counties Manukau Active programme (which all 3 local councils are part of), � free access to swimming pools and charges for sports park grounds, � recreation facility provision, � local community funding, � local capability-building initiatives, and � local event support, such as the ASB Secondary Schools Polyfest.


Government and local decisions on nutrition, physic al activity, obesity, diabetes In general terms, there appears to be a general shift of government emphasis and resource from healthy food and nutrition-related programmes to physical activity and exercise. National Health Targets – Introduced in 2007/08, the national performance indicators are designed to improve the performance of health services, and act as a focus for action. There were 10 in 2008/09, of which one was Improving Nutrition, Increasing Physical Activity and Reducing Obesity and another was Better Diabetes and Cardiovascular Services. This was reduced to six national health targets for 2009/10. The diabetes/CVD target remains, but the nutrition/activity/obesity one was dropped as a national health target (although some elements were kept as DHB, rather than national, performance indicators). Healthy Eating, Healthy Action (HEHA) - Of direct relevance to the LBD programme is the currently uncertainty over the future of the national HEHA programme that is funded via the Ministry of Health. The Government has not made any policy announcement about its commitment to HEHA, though a number of broad obesity-prevention initiatives have been cut back or dropped, particularly around nutrition. A significant proportion of LBD funding currently comes from the HEHA programme, so a Government decision to reduce or do away with HEHA will have an impact on LBD. Regional Public Health Units – In mid-2009, Auckland Regional Public Health Service had a 25% cut in HEHA funding for nutrition-related functions and initiatives, reducing their ability to support LBD action and objectives. Fruit in Schools – In October 2009, the Government announced it would continue with the national Fruit In Schools programme for all qualifying low-decile (equivalent of high deprivation) schools, but that the administration component would be cut (including DHB staff to oversee the programme and teacher release time). This gets folded into the Health Promoting Schools programme, which is also run by DHBs. School Tuckshop regulations – In June 2008, changes to the national administration guidelines for schools took effect, directing schools to only serve healthy food and drink options in school tuckshops/canteens. In February 2009, this was rescinded, leaving schools to decide as they see fit. KiwiSport - In August 2009, KiwiSport was launched, a government initiative aimed at increasing participation by children in organised sport. Most of the $82 million funding (over four years) goes directly to schools and regional sports trusts. Some of it was a reallocation of existing funding for school-based sports coordinator roles. Mission On and Push Play – The anti-obesity Mission On programme (including websites and youth ambassadors) and Push Play TV advertising campaigns have been wound down. Green Prescription – This is a written prescription/referral from a doctor or nurse to a patient to increase their physical activity to improve health, with support and encouragement then provided to the patient. In July 2009, this programme shifted from SPARC to the Ministry of Health, which may help integration and penetration with primary care policy and practise. It appears a planned expansion and increase in funding may have been dropped.


Find Your Field of Dreams – Launched in May 2008, this Manukau City Council programme aims to increase opportunities for children and youth to live healthy, active lifestyles and pursue a positive pathway through sport and physical recreation. With funding support from a group of key sponsors, the programme supports a range of free exercise opportunities including swimming lessons, organised sports/recreation in parks, school, inter-school and after-school programmes. CMDHB Health Promotion contracts - CMDHB is currently undertaking a review of all health promotion contracts with a view to seeking improvements in reach and impact. This might be possible, for example, through bundling and/or re-focusing health promotion services on core priority areas, including nutrition and physical activity.


6. Moving Forward: The Next Five Years This section sets out a proposal to continue the LBD programme after the initial five year commitment ends in June 2010. It summarises supporting rationale and proposes key aspects to shape the outline of the next five year plan. A process for development of the next five year plan is also suggested.

6.1 Recommendation to continue Having considered:

a) what LBD set out to do in 2005;

b) what LBD has achieved in the past 4.5 years;

c) future projections of the ongoing obesity and diabetes epidemics;

d) their possible impact on CMDHB and wider community, and

e) the current climate and government direction; the key recommendation of this report is that: CMDHB commits to a further five year plan and fundi ng path for the Let’s Beat Diabetes programme, from 2010 to 2015 .

6.2 Supporting rationale The earlier parts of this report provide the basis for this recommendation. To summarise:

Long term vision Upholding the original vision and logic that affirmed the 2005 LBD five year plan as the first step of a 15-20 year commitment

Programme organisation

Building on the successes in Counties Manukau, including

� Development of a functioning network of community partnerships, relationships and action over the last 4.5 years.

� Large scale mobilisation of community partners and coordinated activity, with over 500 organisations having implemented or supported aligned initiatives in the district.

� More than $10 million in additional funding to assist with these efforts (over and above the CMDHB five year funding commitment).

� Increased conversation and dialogue in the community around obesity and diabetes, nutrition and physical activity.

� Hard-earned experience and accumulated understanding of network management and cross-sector collaboration on a large scale, complex project of this nature.

� Rich new knowledge and insight from evaluation learnings and major LBD population surveys in Counties Manukau.


Leveraging momentum

Seizing the limited window of opportunity to consolidate gains:

� Ensuring the momentum/traction from combined funding investment of $18-20 million and widespread community action over 4.5 year is not lost.

NB: It may be difficult to muster this quantum of collective investment and effort again if action winds down or ceases.

� Building on lifts in awareness, knowledge and attitudes, and targeting key weak spots.

� Strengthening relationships and trust with supportive community leaders and partners by endorsing CMDHB’s long-term commitment to action on this front.

Continuing epidemic(s)

The obesity and diabetes epidemics continue unabated:

� Counties Manukau obesity rates for children (12.7%) and adults (33%) were significantly higher in 2006/07 than the national average. Pacific and Maori adult obesity rates were 80% and 52% respectively. Result: 110,000 obese adults.

� Diagnosed diabetes prevalence for adults in Counties Manukau was 8.2% in 2006/07, significantly higher than the national average of 5%. Result: 35,000 people with diabetes in 2008.

Current trends and future projections indicate:

� The number of obese people in Counties Manukau increasing by 80% in 20 years, to exceed 195,000 by 2027.

� The number of people with diabetes increasing by 100% in 20 years, doubling the current numbers to 72,000 by 2027.

� 64% of the projected 72,000 diabetes cases in 2027 are potentially preventable, being people who are currently obese and others who are not currently obese (but heading that way).

Cost implications

The potential for savings:

� Known diabetes cases cost CMDHB an estimated $83 million in pharmaceutical, laboratory and hospitalisation costs in 2008. If average cost per diabetes patient was the same in 2027, it would cost CMDHB $141 million in that year (up $60 million from 2008).

� For every person prevented from getting diabetes, CMDHB saves an estimated $2,381 per year in those cost categories alone.

� Interventions that reduce the obese population by 1% every 3 years would reduce diagnosed diabetes numbers in 2027 by 6,200. This would equate to savings of $14.8 million in 2027. Cumulative savings between now and 2027 would be $111 million in those cost areas alone.

Potential savings are substantially higher once other areas are taken into account, such as savings from fewer:

� GP visits, outpatient clinics, Get Checked, CCM costs � new buildings, equipment or staff to cater for increased volumes � people hit by cardiovascular disease and obesity-related cancers.


Support of Community Partners

From the beginning, LBD was about community partnerships and action. CMDHB leaders described it as a flagship programme that would help build the identity and place of CMDHB in the wider community. Given the fundamental role of community partners in the LBD model and programme, their commitment and interest has a direct bearing on the future of LBD. During November 2009, the two formal LBD community partnership groups met and discussed the future of LBD. Both were strongly in support of continuing the programm e and affirmed their own commitment to it. The LBD Community Partnership Group has an operational monitoring/overview role for LBD, providing operational guidance and coordination for implementation of the LBD plan and initiatives. Members represent a wider range of partners and typically have a management/service management role in their respective organisations. The Strategic Advisory Group, a recently established high-level strategic forum for LBD, also confirmed a willingness to be advocates for LBD and to assist with pushing/profiling the issues and community-based initiatives. The continued support from these two community partnership groups is vital to building stronger community partnerships and action for the benefit of the wider community.

.

Members of the LBD Strategic Advisory Group include:

Frank Booth Service Manager, Auckland Regional Public Health Service

Len Brown Mayor, Manukau City Council

Colin Dale Chair

Isabel Evans Regional Commissioner, Ministry of Social Development

Peter Goldsmith Deputy Mayor, Papakura District Council

Richard Jeffery CEO, Counties Manukau Pacific Trust (TelstraClear Pacific Stadium)

Geraint Martin CEO, Counties Manukau District Health Board (CMDHB)

Stuart Middleton Director External Relations, Manukau Institute of Technology


6.3 Key aspects of the 2010-2015 Plan From the review and discussions about the shape of the programme in the next five years, the emerging view is one of evolution, not revolution. The core model and approach remains the same, but there are suggested changes to several key elements. An outline of the key elements of the model proposed for 2010 to 2015 follows.

CORE COMPONENTS

The factors below reflect the core vision, model an d approach of the programme and are key strengths that should be retained.

Long term vision High level goals Five year plan

The obesity and diabetes epidemics are long term in nature. Stopping teenage obesity today will not change diabetes statistics until they enter their 40s and 50s (when diabetes manifests itself). A long-term view is needed to guide sustained, effective action over 20 years. Short term and ‘On-Off’ approaches will not turn the tide. Reduce risk, slow (disease) progression, and improve quality of life. These remain relevant, steering strategy, action and measurement. Working to a series of five-year strategies gives the partners a medium-term focus and time to see projects/initiatives through longer life-cycles. It moves towards the 20 year goals in planned, incremental steps with timely points to review and recalibrate. The next five year plan will cover 2010 to 2015.

Whole of Society approach Whole Life course approach

Big drivers of obesity and diabetes lie in lifestyle and general society. Creating lifestyle change at the population level demands the collective efforts and resources of community partners and wider societal influencers. The broad goals and inclusive approach help all stakeholders see the big picture and their place in it. This is the only existing framework for monitoring and accountability across the whole spectrum, avoiding isolated action that gives pockets of success, but system-wide failure. The health linkage with wider community partners reduces silos and offers broader skills/influence. Improving accountability and quality of care across health systems and professionals is also crucial. This model enables monitoring, analysis and enquiry of progress – independent of operational issues.

Reducing Inequalities focus Learning approach

The burden of obesity and diabetes remains disproportionately high among Maori, Pacific, South Asian and low socio-economic groups. Addressing this (and other health inequalities) continues to be a high priority for the health sector. To be effective, the programme must build evidence of what works and what doesn’t, and keep hunting new insight to lift performance. A robust evaluation framework, population surveys and data analyses, learning from others and good information dissemination are all vital planks needed to grow a learning environment for long-term success.


The diagram below reflects the whole society and whole life course approach, as adapted from a model developed by the US Centers for Disease Control and Prevention. This remains relevant to the long-term approach and supporting framework of LBD.

KEY COMMITMENTS

Commitments around funding, evaluation and action a reas are needed to underpin the 2010-2015 five year plan, as outlined below.

Five year funding envelope

The programme needs a baseline funding commitment for the five year period to provide certainty to partners and community, keeping them at the table and sustaining programme momentum. The quantum has yet to be determined and will form part of the CMDHB review of costs and funding priorities. Nevertheless, the scale of investment should reflect the size of the problem and will signal how serious CMDHB is at attacking it. With threatened cuts in HEHA and other funding, a reduced funding commitment is unlikely to maintain, let alone increase, momentum. Importantly, the baseline funding provides a platform from which to go after external investment. This is clearly a high priority. Success here may alleviate CMDHB funding pressures. Providing flexibility in how CMDHB funding can be drawn down over the five year period, as agreed in 2005, will allow resource to be applied effectively (e.g. supporting effective longer term initiatives, or increasing over time as initiatives gain traction).

Protected population

Disease with complications

Disease without

complications

At risk population

Risk development

Disease onset

Disease progression

Death from complications

Risk reduction

Society’s health response

Intensive treatment

General protection

Targeted protection

Disease prevention and

detection

Treatment

Societal responsibility Health sector responsibility

Investment mix?Adapted from model developed by CDC


Five year evaluation programme

Identifying what works and what doesn’t is fundamental to long term success. This includes identifying pockets of success and leveraging them. This might be through consolidating/spreading best practice among peers, or taking a successful initiative and rolling it out. Facilitating an evidence-based learning and continuous improvement approach requires a robust evaluation programme and access to expertise. The current skill sets and toolkits among LBD partners vary considerably in this field, with much room for improvement. A structured evaluation programme should be embedded in the five year plan, scaled to reflect overall programme size, investment and importance. Allowing flexibility in how it is applied annually, to support initiatives that take more than 12 months to deliver results, it needs to build knowledge, skills and toolkits for partners and the community.

Ten action areas International literature and expert opinion still assert the need for a multi-pronged approach to tackle the obesity and diabetes epidemics, covering both environmental influences and personal responsibility.xxii The ten areas address the key elements for creating sustainable change and had widespread acceptance from the Counties Manukau community when developed. They should be kept. Given fiscal pressures however, baseline funding allocation to action areas should be done on a pro rata basis, based on commitments from partners and/or demonstrated potential for change (assessed using criteria such as: reach, impact, degree of control, transferability and sustainability of impactxxiii). If partners or opportunities are lacking, investment in that area should be minimised until the situation alters. There is also a need to balance the emphasis between environmental change and personal responsibility, heeding the shift in government direction towards the latter.


KEY CHANGES

In addition to the core components and commitments identified above, four key changes are proposed for the 2010-2015 five year pl an.

1. Diabetes, CVD and smoking

Explicitly add cardiovascular disease (CVD) and smoking to the programme. Although the current activity already picks up CVD, particularly in the area of prevention, it makes sense to make this a more prominent feature for those that don’t understand the key linkages between CVD and diabetes. This will necessitate a change in title for the Programme. The International Diabetes Federation notes: “In summary, individual countries should aim to develop and evaluate cost-effective, setting-specific diabetes risk identification and prevention strategies based on available resources. These should be linked to initiatives aimed at reducing the burd en of cardiovascular disease, and complemented with popul ation-based strategies focusing on the control and reduct ion of behavioural and cardiovascular risk factors by targ eting their key determinants .”xxiv Smoking also compounds the risks of diabetes and cardiovascular disease. As the findings of a four year study conclude: “Smoking is an independent risk factor for type 2 diabetes mellitus… Given the high rates of smoking and growing burden of diabetes in the world, cessation of smoking should be considered as one of the key factors for diabetes prevention and treatment programmes.”xxv

2. Primary and

secondary care emphasis

The primary care and service integration Action Areas should both be given greater emphasis for 2010-2015. This addresses the imbalance between upstream and downstream activities (one of challenging areas noted earlier), and picks up on the impending structural change in the wider Auckland health sector. As noted earlier, the Greater Auckland Integrated Health Network expression of interest aimed to deliver, among other things:

• improvements in chronic conditions management, with specific targets around diabetes, CVD and smoking, and

• Clinical Networks that strengthen clinical leadership in improving models of care and clinical performance.

This involves a major part of the health sector portion of the Programme framework and model, and is a hugely important development. The enhanced clinical networks have potential to provide strong clinical leadership to the revised Programme and achieve significant care and productivity improvements across the primary/secondary systems. With the proposal being selected to move to the next phase, Business Case development, CMDHB should ensure the revised LBD Programme is linked in, allowing it to maintain an umbrella view with connections across the health sector and wider community partners.


3. Devolved accountability

CMDHB ended up project managing a lot more initiatives in the last few years than originally envisaged, which strained CMDHB capacity and tested relationships. For the 2010-2015 period, CMDHB should shift more responsibility to those partners who are willing and able to manage it, particularly where it aligns closely with their core business. This includes funding and project management functions, so needs to be supported by good relationships and contracts. It will be important to match devolved accountability with appropriate reporting structures and representation on groups, where relevant. This will assist ‘whole system coordination’ and cross-pollination of ideas and activity.

4. Fewer and larger projects

The approach to date involved supporting innovative ideas and community initiatives, with a view to building evidence of what works and gaining community ownership of the issue, down to grassroots. The benefits of community ownership were limited by small reach and impact, plus programme administration of multiple small initiatives. For 2010-2015, while still enabling some innovation, emphasis and resources should be concentrated on driving through a smaller number of larger (best practice or evidence-based) initiatives. It will be important to have community leaders heavily involved in the process of reviewing and selecting the initiatives to be supported. Their continued ownership and leadership is a key success factor.


6.4 The next six months

In the immediate future, five key steps to be addressed include:

1. Developing the revised Programme’s detailed Five Year Plan for 2010-2015

2. Confirming CMDHB five year funding commitment and pursuing external investment

3. Linking with the Business Case development for the Greater Auckland Integrated Health Network (GAIHN), as well as the National Maori PHO Coalition and Health Alliance PHO (Pacific)

4. Engaging with the Auckland Transition Agency and three local councils around the local government landscape after October 2010

5. Developing the revised Programme’s Operational Plan for 2010/2011

1. Development of the revised Programme’s Five Year Plan, 2010-2015 The development of the detailed five year plan will be a big piece of work. It needs to reflect the longer term vision and the journey of LBD to date. The initial five year plan provides a useful framework to guide the strategic thinking and planning process. Beyond that, there are several factors that will need to be sorted or taken into account: • This needs to be a joint effort, involving key stakeholders, community leaders, partners

and experts. The more they are involved, the greater their buy-in and ownership during implementation. The two existing community partnership groups should be used to guide/lead the process, which CMDHB will need to drive.

• It will be important to secure high level CMDHB leadership involvement and visibility in the process, including CMDHB Chairman, CEO and senior managers. Preferably supported by senior leadership from other key stakeholders.

• Community engagement processes should make use of existing LBD networks and also piggy-back on the early community consultation planned around March/April 2010 for CMDHB’s next District Strategic Plan.

• The engagement process should include

a) presenting results and learnings from the last 4.5 years, b) highlighting current state, future projections, and the changing environment, c) fleshing out strategic priorities and focus for the next five, d) identifying opportunities for leverage, and e) confirming leaders and organisational commitments to key areas.

• Assessing the connection with Maori, Pacific and South Asian strategies, policies and

programmes is essential, both within CMDHB and across key stakeholders (including the GAIHN proposal). Identifying the status of these strategies, plans and infrastructure (e.g. LotuMoui, Hauora Marae and Whare Oranga) will help confirm/build common objectives and room for collaboration or leverage.

• Similarly, for other aligned policies and strategies inside and outside the health sector, from central government (e.g. HEHA, Green Prescription, KiwiSport), to partners (e.g. Find Your Field of Dreams) and local/regional groups.


• Seek direction and support from the Ministry of Health and Associate Minister of Health

(Tariana Turia) for continuation of the successful social marketing approach. The campaigns had a population reach the other initiatives could not match, and achieved cut-through with target audiences. Given the low levels of literacy across Maori and Pacific, the carefully tailored messages were effective and proved their value as a health education tool in Counties Manukau, in conjunction with related activity on the ground. This was one of the most successful components to LBD. It is worth fighting for.

• Plan to be signed-off by:

a) Community Partnership Group and Strategic Advisory Group b) POU and PHAC c) CPHAC and CMDHB Board

• Timing:

a) Delivery of Plan for sign-off by June 2010 2. CMDHB five year funding commitment A decision on funding for the 2010-2015 revised Programme needs to take into account CMDHB’s current and projected financial situation. Funding is being squeezed and savings (plus productivity improvements) need to be found. There are three areas that could be actively pursued around funding:

a) Ultimately, it is a strategic funding decision. CMDHB needs to decide on the balance between funding current services and investing in prevention to slow the flow over time. It is a balance between short term and long term costs/savings.

To put it in perspective, the initial CMDHB funding commitment for LBD equated to $2 million per year, approximately 0.2% (i.e. less than a quarter of one percent) of CMDHB’s total annual funding. In 2009, this LBD funding was halved to $1 million. In comparison, as shown earlier, it cost CMDHB an estimated $151 million for pharmaceutical, laboratory and hospitalisation costs alone in 2008 for people with diabetes or CVD. GP visits, outpatients clinics, and other costs are on top of this. A revised Programme budget of, say, $3 million pa would still equate to just 2% of this. Further, assuming no change in average treatment costs, annual pharm/lab/hospitalisation costs for people with diabetes are projected to increase by $60 million in 20 years. The cumulative increase over the 20 year period is estimated to exceed $490 million for pharmaceutical, laboratory and hospitalisation costs alone. Given that two thirds (64%) of the projected diabetes cases in 2027 are potentially preventable, being people currently obese or projected to become obese, the cost savings from effective prevention are substantial – though slow to materialise. Investing in interventions that reduce the obese population by 1% every three years is estimated to generate savings over the next 20 years of at least $111 million. This comes back to a strategic funding decision - balancing a known $1 million today with a possible $100 million down the track.

To aid the decision-making process, further information can be presented on:


i. The cost of not investing in prevention activity, or of insufficient investment. This should reflect the size and projected impact of the current obesity, diabetes, CVD and smoking trends if they continue unabated.

ii. The savings potential and likelihood from interventions that successfully shift current trajectories.

This might include comparison with other services/programmes, comparing relative investment and returns in order to support a rational prioritisation process. There are various tools around to support this approach.

b) Secondly, other current programmes and related policy funding such as HEHA, Fruit in Schools and Ministry of Health public health funding in Auckland should be investigated to determine their likely future and size. The current review of CMDHB health promotion contracts should also provide for some consolidation and prioritised funding.

c) Finally, the revised Programme should seek new avenues for attracting additional investment into the programme. This could include i. corporate sponsorship, ii. charitable funding, iii. high net-worth individuals, and iv. other government agency funding.

The revised Programme will have the advantage of a broad partnership base to

leverage, plus the support and advocacy of several high profile leaders and stakeholders. The issues (obesity, diabetes, CVD, smoking) are widely recognised and have a profile, and there is a track record going back 4.5 years.

If enquiries reveal the significant programme funding grants may be possible from the

likes of the ASB Community Trust and similar funders, it may be prudent to consider setting up the revised Programme under a charitable trust, with CMDHB and other key partners/funders as shareholder trustees.

3. Linking with the Greater Auckland Integrated Hea lth Network (GAIHN) This initial signals a substantial investment of time and resource into improving health sector performance, including an explicit focus on: improving chronic conditions management; improving diabetes, CVD and ‘quit smoking’ services; and strengthening clinical leadership. All three of these areas stand to make positive contributions to the Programme goals of slowing disease progression and improving quality of life. CMDHB should ensure the revised Programme has the opportunity to be linked in with the GAIHN Business Case development, and subsequent implementation (if approved). The GAIHN proposal considerably enhances the potential for service improvement and traction with health professionals that LBD has been striving for, while LBD has acquired rich data and knowledge to feed into the GAIHN process. The revised Programme also offers GAIHN access to an umbrella framework that sits across the whole life course, reaching from the prevention end of the spectrum (with community partners) through to treatment, management and service integration. This framework allows for alignment of objectives, resources and activity between health and wider sectors in the community.


Finally, success with prevention interventions in the wider community means increased financial reward for primary care professionals operating under a capitation funding model (assuming this translates to fewer doctor visits and associated costs). National Maori PHO coalition and Health Alliance PH O (Pacific) In addition to GAIHN, these two expressions of interest from primary health care coalitions were also approved to proceed to Business Case development. Both will have a presence and influence on the revised Programme’s key target audiences in Counties Manukau, from a primary care perspective. It would be prudent to link with these coalitions to explore opportunities for mutual gain. 4. Engaging with Auckland local government Significant planning is currently underway to prepare for the single Auckland Council that will take over from the current district and city councils in October 2010. The intention is that current customer services (libraries, swimming pools, and so forth) will have a seamless transition to the new structure. What happens after that is unknown. There is also uncertainty over the second tier structure, particularly the number and power of local community boards. It has been suggested that Counties Manukau may have up to six of these local boards. These changes could materially affect the revised Programme, in terms of the current level of council support and resourcing that goes towards related initiatives in the area (for example, as noted earlier, free access to swimming pools, the Find Your Field of Dreams programme, Counties Manukau Active, Health Promoting Schools, and the ASB Secondary Schools Polyfest). CMDHB (and partners) should actively engage with the interim Auckland Transition Agency to share information and provide input into decision-making processes around the handling of these initiatives. 5. Development of the revised Programme’s Operation al Plan for 2010/11 Ideally, the five year plan will be finalised and used to guide development of the operational plan for the first year, 2010/11. This may be a challenge given timing issues. CMDHB is required to submit a 2010/11 District Annual Plan (DAP) to the Ministry of Health in early March 2010, setting out key objectives and performance measures for the year. The DAP should include key objectives from the Programme’s Operational Plan, but this will be held up while the five year plan is being developed. The best approach may be to build some flexibility into the DAP commitments around diabetes, CVD and smoking, particularly from a prevention perspective. The 2010/11 Operational Plan can and should be put together in parallel with the development of the five year plan, with a view to submitting both through the sign-off processes (CMDHB and partners) at the same time.


7. Appendices


APPENDIX 1: LBD network and connections The organisations below have contributed to LBD goa ls and activities. This is not a complete list. It provides an indication of the sca le of engagement of LBD. Ministry of Health, Ministry of Education, Ministry of Social Development, Housing New Zealand Corporation, National Heart Foundation, Health Sponsorship Council, Sport and Recreation New Zealand (SPARC)

Counties Manukau DHB, Auckland Regional Public Health Services, Manukau City Council, Papakura District Council, Franklin District Council, Diabetes Projects Trust, Diabetes NZ Auckland, Auckland City Mission, Salvation Army, Plunket, Counties Manukau Sport, Food Industry Group, 48 employers working through workplace initiatives, Fonterra Brands, Goodman Fielder, Foodstuffs (Pak N Save), Progressive Enterprises (Foodtown), Coca Cola, McDonalds Restaurants (21), other food industry companies,

South Auckland Health Foundation, Manukau Institute of Technology (MIT), Massey University, National Heart Foundation, Te Hotu Manawa Maori, Pacific Island Heartbeat, NetFit, University of Auckland (School of Population Health), Phoenix Research

Primary health organisations and primary care providers, Secondary care providers and diabetes specialist services (including Whitiora), Diabetes and Cardiovascular Advisory Group, Primary Health Organisation Health Promotion Working Group

Marae (21), Kohanga reo, Kura kaupapa, Maori Women’s Welfare League

Pacific churches (84), community groups and language nests, Quantum Sport

Schools Accord group, Schools (100+) and early childhood education centres (130+) in Counties Manukau

Small community organisations (e.g. 40+ supported by the Community Action Fund)


APPENDIX 2: Marae running initiatives in Counties Manukau The following marae in Counties Manukau area have, amongst other things, established nutrition, physical activity and healthy lifestyle initiatives: 1. Nga Whare Waatea Marae (MUMA) - Hauora Marae

2. Makaurau Marae - LBD Community Action Fund

3. Puukaki Marae - LBD Planning

4. Te Puea Marae - GP Clinical Services

5. Mataatua Marae - Hauora Marae

6. Manurewa Marae - Whare Oranga

7. Whaiora Marae - Maori Obesity Community Action, Gout

8. Papakura Marae - GP Clinical, Whaanau Services

9. Whaataapaka Marae - Maori Obesity Community Action

10. Ooraeroa Marae - Whare Oranga, Hauora Marae

11. Nga Hau E Wha Marae - Whare Oranga, Hauora Marae

12. Mangatangi Marae - Whare Oranga, Hauora Marae

13. Tahuna Marae - Smokefree Marae, Whare Oranga

14. Whare Kawa, Kaiaua - Hauora Marae

15. Nga Tai E Rua Marae - Haoura Marae

16. Tauranganui Marae - Hauora Marae

17. Te Awamarahi Marae - Hauora Marae

18. Te Kotahitanga Marae - Hauora Marae

19. Tikirahi Marae - Hauora Marae

20. Pakau Marae - Hauora Marae

21. Te Tahawae Marae (School Based) - LBD Community Action Fund


APPENDIX 3: List of LBD evaluation reports from th e School of Population Health LBD evaluation reports produced by the Centre for Health Services Research & Policy, School of Population Health (Auckland University): Report Title Report Description Delivery Date

Year One Evaluation ‐ Let's Beat Diabetes

Summary of progress of focussed studies carried out 2005‐2006: � Process Evaluation of the LBD Maori Initiative � Evaluation of the Redevelopment of Templeton Park � Evaluation of the Community Nutrition Project � Evaluation of the Food Accord - Low Sugar Trial

30‐Jun‐06

LBD Population Level KPIs ‐ Draft Interim baseline Report 1

First of three proposed reports focused on the analysis of diabetes and complications from the NMDS and risk factors from the NZ Health Survey and National Nutrition Survey.

30‐Jun‐06

Overview of LBD Evaluation: Reporting Period 2006/2007

Pulls together all 2007 evaluation reports to provide an overview of the strategic direction of LBD. As well as identifying key themes that will inform the development of LBD.

6‐Mar‐07

Monitoring Report: Reporting period June 2005‐March 2007

Monitors progress of all LBD Action Areas and initiatives using interview data, surveys and documentary evidence.

6‐Mar‐07

A descriptive summary of the LBD Programme progress: Initiative and Action Areas Supplement

Presents written summary of progress on all LBD Action Areas and initiatives using documentary evidence provided by LBD Action Areas.

6‐Mar‐07

Let's Beat Diabetes Population Level KPIs: Summary of Interim Baseline Report 2

Second of three proposed reports, focusing on indicators for diabetes monitoring and diabetes‐related mortality.

6‐Mar‐07

A Literature Review of the Epidemiology of Type II

Diabetes in NZ

Literature review of the epidemiology of Type II diabetes in NZ 6‐Mar‐07

Estimating Diabetes‐Related Mortality using the Mortality Collection and Hospitalisation data

Results of a study using the Mortality Collection and NMDS to more accurately estimate the rate of diabetes‐related deaths in NZ and in each DHB area

6‐Mar‐07

Using Glucose Screening Tests as Proxy Indicators of Diabetes Screening Activity and Glucose

The results of a study using the Labs Data to estimate the level of Type II diabetes screening activity in NZ and in each DHB area

6‐Mar‐07


Monitoring in People with Diabetes

Summary Report ‐ An Evaluation of the McDonald's Low Sugar Drinks Trial: A Let's Beat Diabetes Initiative

Focussed Study: Presents a summary of the final evaluation findings 6‐Mar‐07

An Evaluation of the Community Nutrition Project: A Let's Beat Diabetes Initiative

Focussed Study: Presents final evaluation findings 6‐Mar‐07

A Progress Update Report for the Focussed Evaluation of the Maori Initiative

Focussed Study: Progress update on the evaluation of the Maori Initiative 6‐Mar‐07

A Progress Update Report for the Focussed Evaluation of the Redevelopment of Templeton Park Initiative

Focussed Study: Progress update on the evaluation of the Redevelopment of Templeton Park

6‐Mar‐07

Development of a Knowledge Management System for Let's Beat Diabetes

Presents a model for information transfer 6‐Mar‐07

Overview of LBD Evaluation 2008 Pulls together all 2008 evaluation reports to provide an overview of the strategic direction of LBD. As well as identifying key themes that will inform LBD development.

29‐Feb‐08

Re‐analysis of the CDMHDB Baseline Survey This analysis includes re‐weighting data to include NZDep; comparison of subgroups such as ethnic comparisons; directions for publications.

29‐Feb‐08

Hospital Data Indicators for the Let’s Beat Diabetes

Evaluation: NMDS 2000‐06

The report is intended to be a source of data to inform other activities and reports within the evaluation and the programme itself.

29‐Feb‐08

Monitoring Report: Reporting Period February 2007 to January 2008


29‐Feb‐08

An Evaluation of the ‘Swap2Win’ Social Marketing

Campaign: A Let’s Beat Diabetes initiative

Focussed Study: Focussed evaluation of the 'Swap2Win' social marketing campaign. 25‐Jan‐08

A Process Evaluation of the Let’s Beat Diabetes Maori Work Stream

Focussed Study: Process evaluation of the Maori Action Area. 29‐Feb‐08

An Evaluation of Healthy Kai: A collaborative partnership initiative

Focussed Study: Evaluation of the Healthy Kai initiative. 29‐Feb‐08

An Evaluation of the Fresh for Less Campaign: A Let’s Beat Diabetes and Foodstuffs Ltd initiative

Focussed Study: Summary Evaluation Report of the Fresh for Less campaign.

14‐Feb‐08


Summary Report

An Evaluation of the Diabetes Self‐Management Education Programme

Focussed Study: Evaluation of the DSME programme. 1‐Apr‐08

A Process Evaluation of the Schools Accord: A Let’s Beat Diabetes Partner

Focussed Study: Process evaluation of the Schools Accord. 12‐May‐08

An Evaluation of the Pacific Kai Lelei Programme: A Let's Beat Diabetes Initiative

Focussed Study: Process evaluation of the Pacific Kai Lelei programme 30‐Jun‐08

Focussed study: Year Three ‐ Update on the Redevelopment of Templeton Park

Focussed Study: Evaluation of the redevelopment of Templeton Park. 29‐Feb‐08

An Evaluation of the Active Families Programme in Otara, Mangere and Manurewa

Focussed Study: Process/ outcomes evaluation of the programme 31‐Dec‐08

Learnings and insights from a sample of projects supported by the Nutrition Fund in Counties Manukau

Focussed Study: Evaluation of projects supported by the Nutrition Fund 9‐Sep‐08

Overview of the Let's Beat Diabetes Evaluation 2009

Pulls together all 2009 evaluation reports to provide an overview of the strategic direction of LBD. As well as identifying key themes that will inform LBD development.

27‐Feb‐09

Monitoring Report: Reporting period February 2008 to January 2009


27‐Feb‐09

An Evaluation of the Redevelopment of Templeton Park: An initiative supported by Let's Beat Diabetes

Focussed Study: Final report presenting the results from the process/monitoring evaluation.

27‐Feb‐09

An Evaluation of the ASB Polyfest Healthy Food Policy Initiative: An Initiative Supported by Let's Beat Diabetes

Focussed Study: Process evaluation of the ASB Polyfest Healthy Food Policy Initiative

15‐May‐09

An Evaluation of the Let's Beat Diabetes ‐ Diabetes in Pregnancy Work Stream

Focussed Study: Process evaluation of the Diabetes in Pregnancy Work Stream 15‐May‐09

An Evaluation of the Gardening for Health and

Sustainability Initiative: An Initiative supported by Let's Beat Diabetes

Focussed Study: Process evaluation of the Gardening for Health and Sustainability Initiative

28‐May‐09


APPENDIX 4: Summary of Achievements by action area Action Area 1:

1. Supporting Community Leadership and Action - Whole Population

Introduction

During the development of the LBD plan, many community organisations and groups acknowledged the important role they could play in building healthy, active communities, but resources and support were seen as barriers. In response, CMDHB established an annual $100,000 Community Action Fund. Targeting ‘grassroots’ organisations and groups involved in health promoting activity, the Fund offered small grants (typically up to $5,000) to support local community efforts in improving nutrition and physical activity, as well as awareness and understanding of diabetes.

Achievements

Between 2005 and July 2009, close to sixty grants were allocated to a range of community organisations under the Community Action Fund, including sport and recreation entities; Maori, Pacific and Asian groups; faith-based groups; schools; charitable trusts and youth-oriented community groups. Initiatives ranged from exercise sessions for older people in Clendon; diabetes, Tai-chi and food education/cooking sessions for Indian and Chinese groups; personalised exercise training and healthy eating programmes for youth in Otara, Mangere and Clendon; dance programmes (including Salsa, Hip-hop) happening in Manukau City centre, Otara and Manurewa; healthy lifestyles programmes for teenage mothers and their babies; after-school exercise programmes, waka ama-based programmes and other activity targeting rural areas such as Port Waikato and Pukekohe.

Challenges

Balancing administrative and reporting requirements for grassroots community groups (in return for relatively small grants) was a challenge, with a lot of variation in quality and consistency of initiatives, measures and reporting. Some groups had difficulties completing applications and reports, others struggled with the criteria (legal entity status, not already funded by CMDHB or its providers, avoiding one-off events). An emphasis on Fund flexibility and responsiveness (to community groups) also came at a cost in terms of workload and administration efficiency. This had some impact on grant volumes, which could have been higher. Seeking significant, long-term sustainable change from community groups in return for a relatively small funding injection is unrealistic. While the ‘reach and impact’ of the funded activities is small in terms of the overall Counties Manukau population, the real value was in achieving the desired outcome of enabling local community organisations and groups to put their ideas into action, and to take on a health promoting role within their communities. The challenge remains connecting the pockets of action to gain traction and momentum. Other LBD funding sources became available later on (e.g. Nutrition Fund, plus Maori and Pacific community obesity action funds), which probably reduced demand for this Fund.


1. Supporting Community Leadership and Action - Maori

Introduction

During the development of the LBD plan, Maori community representatives and providers consistently supported Maori cultural and leadership institutions (such as marae, kohanga reo, kura kaupapa, kuia and kaumatua) as key to developing and implementing initiatives to support nutrition and physical activity within their communities, and to lift knowledge of obesity and diabetes. In response, it was agreed to specifically work with these areas to create health promoting environments, Maori leadership and supportive community action.

Achievements

Between 2005 and 2009, a wide-ranging set of initiatives has been undertaken to forge partnerships and build relationships in the community, as well as across other LBD Action areas. A strong emphasis on empowering Maori to take ownership of the issues has seen investment in areas such as:

� Coalitions of key Maori personnel working in these fields in Manukau and Franklin (known as the PANAK and Te Pou Manawa groups respectively), as a forum for information-sharing and connection to community groups across Counties Manukau

� Development of a Maori Physical Activity and Nutrition Directory � Diabetes education workshops delivered to Maori Women’s Welfare League (MWWL)

branches in Counties Manukau and evaluation completed � Development and dissemination of MWWL ‘traditional kai’ healthy recipes cookbook � Delivery of marae-based wananga, which included sessions on diabetes self-

management education, Get Checked programme, Healthy Lifestyle education, and speciality presentations such as foot care, medication and physical activity

� Establishment of men’s support groups for diabetes self-management education, with sessions each month at Manurewa, Papakura and Mataatua marae, plus other venues. Footage of this activity was included in the Silent Killer diabetes documentary screened by Television NZ.

� Establishment of marae-based kaiwhakahaere (healthy lifestyle coordinators) representing the various marae in the Franklin-Port Waikato area

� Diabetes awareness stands at a number of Poukai held on marae in southern Counties Manukau region

� Implementation of CMDHB Maori Health team’s marae-based Whare Oranga strategy � Development and piloting of kohanga reo nutrition resource � Nutrition Fund grants to kohanga reo (24) and kura kaupapa (4) for initiatives such as

food gardens, water fountains and teaching resource support � Food gardening initiatives underway with various marae and Maori community groups � Food gardening DVD developed and distributed to Maori communities � Targeting Maori whanau through sponsorship, participation and support at key major

events such as the 2009 Waitangi Day celebrations (Manukau City), and the ASB Secondary Schools Polyfest (Manukau velodrome) in 2008 and 2009.

� Targeting whole community events by attending and participating as key partner, such as the Tuakau College Whanau Day with 500 children and their families in attendance

� Completion of the kura assessment conducted by Maaori nurse identifying the status of the School health based services provided in kura


Maori-specific initiatives expanded beyond these arenas to include community and workforce development activities such as : � Delivery of 2 x Nutrition, Physical Activity and Diabetes 9 day course by Te Hotu

Manawa Maori to community health workers and Maori personnel working in this field (25 participants each time)

� ‘Train the trainer’ education sessions for marae kaiwhakahaere on diabetes and nutrition (including resource kits complete with lesson plans, healthy recipes, diabetes and nutrition education resources), who then delivered to their marae, community groups and family

� Input and guidance to the development and delivery of tertiary courses at Manukau Institute of Technology (MIT) for Maori community health workers, covering diabetes, nutrition, physical activity, health promotion and related topics

� LBD Nutrition scholarships for Maori tertiary students studying nutrition/dietetics, including workplace experience opportunities

Contracting is currently underway for an additional $800,000 of Maori community action targeting obesity in Papakura, Franklin, Man gere, Otara, Manurewa and Papatoetoe.

Challenges

Implementation progress of initiatives was mixed, with some being quite slow and protracted. This often reflected capacity limitations within Maori communities and the Maori workforce in terms of people with obesity/diabetes knowledge and skillsets who can lead or drive initiatives forward in a meaningful way for a Maori audience. Significant capacity and capability limitations and differences across Maori community organisations and personnel restricted the extent to which increased demand for support, education and resources could be supported, and to which standardised resources could be readily utilised. Tailoring material to various circumstances and contexts cut into limited time and money. CMDHB staff turnover did not help. This area has cycled through five different project staff, which has hindered projects and relationships with key Maori players and groups. Managing alignment, coordination and relationships between groups is important, but has an associated cost in terms of time and resource – project bottlenecks sometimes occurred in terms of working with coalitions or partnerships to find common ground and agreement, or in terms of access to senior managers for approvals where projects involved different divisions (eg. LBD, CMDHB Maori Health, CMDHB Primary Care). Ongoing effort is required to build and strengthen Maori community action – in terms of capacity and capability.


1. Supporting Community Leadership and Action - Pacific

Introduction

During the development of the LBD plan, Pacific community representatives and providers consistently supported Pacific churches and language nests as key to developing and implementing initiatives to support nutrition and physical activity within their communities, to lift knowledge of obesity and diabetes, and to become agents of change. Priority was also placed on working with obese people at risk of diabetes. In response, it was agreed to work with these areas – promoting a community development process of increasing community knowledge and capacity to support Pacific community groups to become leadership hubs for change.

Achievements

Between 2005 and 2009, several key initiatives have been undertaken in partnership with Pacific churches, community leaders and early childhood centre teachers to build relationships in the community and work towards these venues becoming health promoting environments. Achievements that should be noted include: � The CMDHB LotuMoui programme with Pacific churches, based on strong

relationships, trust and partnership approach. 50 churches were implementing healthy lifestyle activities in 2005, building to 83+ churches by 2009. The associated Church Ministers’ Advisory Committee and church Health Action Committees provided a sound organisational platform that supported collective action across the faith-based Pacific community. It also enabled a degree of consistency in approach, programmes and resources across the different Pacific groups.

� Kai Lelei nutrition community education programme developed and 3 hour workshops delivered to Pacific communities and leaders (minimum of 250 people each year, with over 1100 church and non-church members reached in 2008/09)

� Selected church members go on to upskill through the 2 day Pacific Island Heartbeat Nutrition Course

� Kai Lelei modules translated into Samoan and Tongan, with 300 copies requested and delivered to both Auckland and Waitemata DHBs

� Kai Lelei training modules delivered and completed in 28 of the 33 licensed Pacific language nests (early childhood education centres)

� Moui Ola physical activity education programme developed and workshops delivered to Pacific communities and leaders (over 250 people per year from 2007/08)

� Selected church members go on to upskill at NetFit’s Community Coach Course � Healthy nutrition policies and exercise programmes established at many churches.

100% of LotuMoui churches now run physical activity initiatives (walking, aerobics, etc). Very few did so at the beginning of the programme. 70% have 2 or more physical activity sessions per week.

� Organisation and implementation of the inaugural inter-church LotuMoui Games in October 2008, with a turnout of around 3,000 people at the Games. This was preceded by 2 months of organised games and exercise activities within individual churches as preparation and build-up to the Games, putting healthy eating and physical activity in to action.

� Kids in Action programme implemented, working with over 300 overweight or obese children (5-14 year old) at risk of diabetes – and their families - to reduce and/or


maintain weight under clinical supervision � Youth forums held on healthy eating and physical activity themes and ideas for action � Ethnic-specific forums and workshops on diabetes for a range of audiences (such as

ones with up to 50 Pacific church ministers attending) � Pacific diabetes self management education programme piloted and evaluated for

Pacific peoples within church-based settings � LotuMoui churches holding sports day events over holiday seasons � Nutrition Fund grants to Pacific language nests (5) and schools with high numbers or

proportions of Pacific students, for initiatives such as food gardens, water fountains, breakfast clubs, Student Council initiatives, and teaching resources

� Beyond the LotuMoui programme, CMDHB is implementing further aspects of the Pacific Community Implementation Plan that will result in $900k in 2009/10 into various community-based initiatives and health programmes to promote good nutritional practices and increasing physical activities that include:

• Strengthening of ‘community-based’ initiatives through community grants

• Investment for Pacific workforce development through nutrition scholarships and training

• Obesity prevention initiatives for overweight Pacific youth and for Pacific parents

• Pacific language nests to receive nutrition and physical activity training

Challenges

Implementation progress of initiatives was mixed. As with the Maori action area, this was often due to capacity limitations within the Pacific workforce and Pacific communities (in terms of people with appropriate knowledge and skillsets to support the initiatives). Developing the capacity of the local community to support the Pacific health workforce in this area is vital, but progress is slow. LotuMoui churches wish to access a broad range of information on many issues beyond nutrition and activity (such as gout, smoking cessation, cervical and breast cancers, and mental health). The (unresolved) challenge is how to support their interests, while maintaining momentum and traction in improving nutrition, physical activity, and action against obesity and diabetes. CMDHB staff turnover in this area caused delays and tested continuity of strategy. Managing alignment and coordination across different stakeholder groups (eg. LBD and CMDHB Pacific Health Team) was challenging at times in terms of maintaining alignment, coordination and accountability of the workstream, particularly around decision-making, funding, project management and performance. Ongoing effort is required to build and strengthen Pacific community action – in terms of capacity and capability. Supporting the LotuMoui programme and getting value from the relationships and infrastructure that has been cultivated.


1. Supporting Community Leadership and Action – South Asian

Introduction

From 2007/08, the LBD plan explicitly identified working with the South Asian community as a priority, given this population has greater risk of diabetes than most other groups.

Achievements

Between 2007 and 2009, activity in this area included: � Establishment of a South Asian Leadership Group to lead, coordinate and monitor

collective action under a South Asian workstream � Appointment of a project manager to facilitate action � Development of a South Asian Community Action Plan for Counties Manukau � South Asian Community Leadership Course development underway with Manukau

Institute of Technology, aiming to develop a greater capacity for community leadership in South Asian communities.

� Development of a diabetes awareness educational resource (DVD) for use in working with South Asian communities

� Participation in the NetFit Community Coach Programme by selected members from South Asian community groups

� Piloting delivery of the Diabetes Projects Trust Healthy Eating on a Budget programme to three South Asian communities

� Community Action Fund grants approved for community food garden initiatives by 3 South Asian community organisations

� Delivery of healthy lifestyle and self management education training sessions to South Asian groups

� Support development of the Healthy Eating for South Asian People resource by Ministry of Health (MoH)

� Collaboration with MoH, Waitemata and Auckland DHBs on an Auckland-wide campaign, seeking to raise awareness in South Asian communities of their increased risk of diabetes and cardiovascular disease, and how this can be prevented through appropriate nutrition, physical activity and maintaining a healthy weight

Challenges

The South Asian community is diverse, with multiple players within each segment of this population but limited over-arching infrastructure, institutions and providers to work with. The cultural diversity creates challenges around approaches and resource development. There is also a very limited South Asian health workforce to call on, in terms of current workers proficient in the fields of nutrition, physical activity, obesity and diabetes. It will take time to develop capacity in the workforce, as well as capacity and skills in community leadership that will be needed to help empower and drive South Asian communities towards healthier lifestyles. This is an area that has only recently been given focused attention, so is in its early stages of development. Building capacity and capability are key challenges.


1. Supporting Community Leadership and Action – Workplace

Introduction

The workplace is identified in public health literature as a key intervention area to support improved population health. It was agreed to specifically work with employers and employees develop and implement policies and initiatives that support healthy, active workplaces (as health promoting environments).

Achievements

Between 2005 and 2009, activity in this area was lead by the Auckland Regional Public Health Service (ARPHS), with emphasis on delivery of the National Heart Foundation’s workplace programme Heart Beat Challenge to targeted employers in Counties Manukau. � As well as targeting key LBD partners (CMDHB, Ministry of Pacific Island Affairs,

Housing NZ Corporation, plus Franklin and Papakura Councils), ARPHS were requested to target companies in Counties Manukau who were large employers of Maori, Pacific and/or low socio-economic workers.

� Between 2005 and 2009, ARPHS has worked to deliver the Heart Beat Challenge to 48 different companies in Counties Manukau. As at October 2009, 35 organisations are currently being worked with, including LBD partners named above and the likes of Fisher & Paykel, NZ Steel, Foodstuffs Distribution Warehouse, Ford Motor Company, Nestle, Kumfs Shoes, Pacific Flight Catering, Farmers Distribution.

� Case studies developed of successful workplace initiatives at Kumfs and NZ Steel as a resource for promoting Heart Beat Challenge to other employers

� Inclusion of Kumfs Shoes Ltd as role model in Swap2Win social marketing campaign � Scoping report completed on the feasibility of targeting small to medium enterprises

with a wellness programme (decision made not to proceed down this path, due to limited interest by this sector)

� Development of an evaluation tool for ‘blue collar’ workplaces to assess their own wellness programmes

Challenges

Employer interest in workplace health and wellness programmes is variable, often seen as a ‘nice to have’ package unlike safety programmes, which are supported by legislation and enforcement measures. A review of literature to quantify the benefits of workplace wellness programmes found limited data of relevance to the NZ environment. Building compelling evidence and data of direct relevance to NZ employers remains a challenge.


2. Promoting Behaviour Change Through Social Market ing

Introduction

Beating obesity and diabetes requires a change in norms in how we eat, move and live. This means changing environments, attitudes and behaviour – involving government, industry, community, family and individuals. The scale of change required will not occur without substantial investment in the information and knowledge environment for people in Counties Manukau. It was agreed that a broad and comprehensive social marketing strategy was needed, that it had to be effective for Maori, Pacific and high risk populations, and had to integrate with/support the wider LBD programme and activities.

Achievements

Between 2005 and 2009: � Development and sign-off of social marketing and communications strategy

� 2007 implementation of initial Swap2Win campaign and evaluation

� 2008 and 2009 implementation of revised Diabetes campaign and evaluation, including significant targeting of a range of cultural/ethnic audiences

� Presence at most of the larger cultural events within Counties Manukau

� Excellent results from latest phases of the campaign (completed July 2009), including: o Very high recall rates from targeted audiences o Good cut through with groups, including youth o Good levels of discussion as result of the campaign material o 70-80% now feel more motivated to eat better, be more active o 68-77% now more concerned about obesity and more likely to arrange for a

health check for diabetes for themselves or a family member

� Implementation of baseline survey and follow-up tracking survey 3 years later (each of around 2,400 Counties Manukau respondents, roughly split between Maori, Pacific, Asian and Other/European)

� Implementation of major Living with Diabetes survey for 1,200 people with diabetes living in Counties Manukau.

� Supported by increased presence of HEHA messages, particularly the Health Sponsorship Council’s Feeding Our Futures campaign, SPARCs Push Play campaign and the Mission On campaign targeting youth.

� Implementation of a proactive media communications campaign. The above public information campaign was supported by a constant stream of press releases, articles and interviews in the local media.

In the 18 months since March 2008, this coverage included 830 media articles, including 273 LBD-generated items (all media) and 554 related print media articles on physical activity, nutrition, obesity, and diabetes (if radio and TV articles/coverage were included the count would increase considerably). In addition, the LBD website also gets around 3-4000 hits per month.


Challenges

� Targeting the broad range of ethnic-specific audiences within a limited budget

� Getting the message right. There were significant learnings in terms of balancing the need for a campaign ‘look and feel’ that would achieve cut through, while maintaining the support of a wide range of LBD partners and community supporters. The challenge over boxing gloves early in the Swap2Win campaign was a good example, with good feedback from consumer tests countered by strong disapproval by some partners (in the end, the imagery was changed).

� Achieving tight integration of campaign messages with corresponding on-the-ground activity across the other LBD action areas

� Low levels of health literacy among LBD target audiences means the various angles, positions and inconsistent messages in the general media coverage may not necessarily lead to a more informed audience.


3. Changing Urban Design to Support Health, Active Lifestyles

Introduction

The environment we live in can have a large influence on the lifestyles. Urban design can influence the physical environment (like roads and parks), the service environment (shops and public transport) and the social environment (social cohesion and community safety). Urban environment also impacts our lifestyle choices and decisions. There is good evidence that good urban design can increase physical activity. While changing urban design is difficult and slow, due to the expensive and permanent nature of basic infrastructure, it was agreed that it needed to be part of the mixxxvi.

Achievements

Between 2005 and 2009, activity here was lead by Auckland Regional Public Health Services (ARPHS). Achievements included: � Small urban parks exemplar model (Templeton/Volta Park)

� Manukau City Council Parks policy change to be more supportive of physical activity and exercise

� Mangere Town Centre Health Impact Assessment

� McLennan Housing Development (Papakura) Health Impact Assessment

� Auckland Regional Land Transport Strategy Health Impact Assessment

� Manukau Built Form and Spatial Structure Plan Health Impact Assessment

� Health Impact Assessment training for key workers in Counties Manukau

� Ongoing advocacy and submissions on health in to urban design policy and planning

Challenges

� Long timeframes from ideas and planning to project completion, then eventually the positive influence that the environmental changes will assert on the population

� Financial constraints limit the extent to which new/improved models can be tested or the speed at which they can be implemented

� Vandalism on new Templeton/Volta Park playground stalled progress.


4. Supporting a Healthy Environment through a Food Industry Accord

Introduction

Changes to the food environment have contributed to the current obesity epidemic. In 2004, major food producers and retailers signed the Food Industry Accord, committing themselves to supporting the Ministry of Health’s HEHA framework, and recommending that a pilot be instigated in the Auckland region. CMDHB and food industry representatives agreed to collaborate to undertake a ‘demonstration pilot’ of the Food Industry Accord in Counties Manukau, involving a range of practical activities.

Achievements

Between 2005 and 2009: � Sprite Zero sugar-free drinks initiative across 21 McDonald’s restaurants in Counties

Manukau saw a 17% reduction in sugar consumption across the drinks range in 6 months, around 10 tonnes less sugar consumed.

� Partnership with the Food Industry Group (FIG), including a co-funded advocacy position to develop and implement an agreed work programme

� Design, implementation and evaluation of the Fresh For Less fruit and vegetables campaign in PakN’Save supermarkets in Counties Manukau, 2007

� Design and implementation of a more sustainable supermarket fruit and vegetable initiative in 2009, with pricing discounts, promotional activity and meal preparation demonstrations by local community group members in local PakN’Save stores

� White milk: agreement by four big players (competitors) to work together on increasing milk consumption – but with a greater proportion being light blue (low fat) milk.

� Industry-funded research into milk consumption, behaviour and attitudes amongst Pacific, Maori and South Asian to the total value of $37,500.

� Lead to agreement on running a joint campaign on lite blue milk, starting late 2009, targeting community, supermarkets and suppliers.

� Product re-formulation efforts (reducing sugar and fat) � Sponsorship of Swap2Win household mailer, with milk discount coupons � Inclusion of healthy eating and cooking tips in Progressive weekly mailer (nationally) � Secured one of six national food industry positions as part of the Food Industry

Demonstration Pilot and LBD is represented on National Food Industry Demonstration Pilot Steering Group

� Forged strong working relationships with food suppliers, manufacturers and retailers.

Challenges

� Economic environment (recession) during late 2008 and most of 2009 significantly impacted food industry’s progress, as budgets tightened for companies (and families).

� Progress is largely dictated by the extent to which food industry members are motivated to act and dedicate resources.

� Policy or legislative signals from central government influenced this motivation. � Having the right project management personnel in the driving seat also has a big

impact on progress. Several changes in key personnel in this area did not help continuity or maximising potential opportunities.

� Shared responsibility with Food Industry Advocate (advocate for food industry members) created some challenges for how LBD priorities were represented.

� Collaboration with National Heart Foundation, in terms of national food industry demonstration pilots, where preferred objectives, approach and initiatives differed.


5. Strengthening Health Promotion Co-ordination and Activity

Introduction

Health promotion in Counties Manukau is a small sector comprises many providers and multiple funders. During development of the LBD plan, key areas of discussion included funder alignment, workforce capacity, communications and resources, networking and aligned activity, and working with Maori, Pacific and Asian peoples to strengthen health promotion that works within cultural frameworks for these audiences.

Achievements

Between 2005 and 2009:

� Increased collaboration between organisations and groups involved in health promotion, initially lead by and building around CODA (Community Organisations for Diabetes Action) health promotion forum and the PHO Health Promotion Working Group, which evolved to a new structure, the Health Promotion Steering Group.

� Health Promotion/Health Education Core Competencies Framework for diabetes risk factors developed (Upskilling Pathways for Health Promotion), covering 3 sets of primary care and community workers and 3 levels of competency in each set. The report was delivered to CMDHB. It fed into the next three items listed below.

� Input to development of MIT community health worker course, which is now up and running (and aligned with the competencies).

� Development of Performance Management workbook to assist PHO managers with the roll out and management of the competencies framework in their organisations

� Community Health Worker Workforce stocktake undertaken 2008/09, leading to development of business case on ‘safety to practice’ (A Scope of Practice for Primary Care Key Workers), which was approved in July 2009. This will determine the scope of practice/key competencies for CHWs, pilot these, and design training for supervisors/manager of CHWs who implement the scope of practice.

� Diabetes Projects Trust facilitating regular ongoing professional development for people involved in health promotion and education on diabetes prevention and management.

� Review commissioned in 2005 of over 500 diabetes management/diabetes prevention/ complication prevention related health promotion resources available to Counties Manukau providers.

� From the review, two resource folders were compiled for use in Primary Care, one for people at risk of diabetes and one for those with diabetes. 200 sets of these folders were produced and distributed to GP practices (via PHOs) and other key stakeholders. Included the development of new resources in several Pacific and Asian languages.

� Healthy Kai project in Mangere and Otara town centres (with the Mangere initiative winning a national Health Innovation Award).

� Counties Manukau Active – a collaborative project aiming for a sustainable increase in physical activity capacity and involvement in the district, through workforce development and growing activity opportunities in target areas. 3 year project, funded and supported by SPARC, CMDHB, MCC, FDC, PDC, THO, PNM, and CMS.

� Active Families programme operating in Otara, Mangere and Manurewa, aimed at increasing physical activity and improving nutrition for children and families (with emphasis on Maori, Pacific and low socio-economic).


� Healthy food policy initiatives and interventions at major iconic outdoor events in Counties Manukau, including ASB Secondary Schools Polyfest and Waitangi Day.

� 64 new or planned garden initiatives across schools, parks and community centres as at September 2009, under the multi-agency Gardening for Health and Sustainability initiative. This includes 10 established community gardens (with an estimated 600 people participating in these gardens), and planning well underway for 15 more (to start between December 2009 and March 2010), plus 33 established and 6 planned Counties Manukau school and early childhood centre gardens.

� A new MIT NZQA accredited horticulture course developed and approved around the gardening initiative, and ready to start in February 2010.

� Green Prescription regional model for Auckland developed in readiness for GRx expansion

� Initiating and supporting the rollout of Cook’n Kiwi – ‘Healthy Eating on a Budget’ programmes to key community groups in Counties Manukau, with 16 delivered in 2009

Challenges

� Coordination of a multitude of health promotion providers, topics, resources and funding lines remains a work in progress.


6. Enhancing Well Child Services to Reduce Childhoo d Obesity

Introduction

The importance of protecting and promoting the health of our young children was stated as a clear priority for the programme, particularly in terms of protecting future generations from obesity and subsequent disease.

Achievements

Between 2005 and 2009:

� Literature review completed of identifiable risk factors for diabetes and/or childhood obesity that could be factored into the existing Well Child assessment tool. The results highlighted the lack of evidence-based screening tools or measures to identify risk factors for babies and children under five years.

Obesity prevention interventions most useful for this age group were concluded to be those currently promoted: exclusive breastfeeding to age six months, healthy eating including more fruit and vegetables for babies, young children and their mothers, and daily active movement. As a result, it was agreed effort go into a support resource for well child providers.

� Resource developed to help well child providers support young families around nutrition and physical activity needs of growing babies and children. Extensive use of community consultation and pilot groups to identify which messages would be most effective in creating change.

� The resource was piloted in April 2009 with positive feedback. It has since been printed for use by Well Child providers and GP teams who have requested the resource for use at practices.

� Continued delivery of Well Child services across Counties Manukau, with providers using the visits to promote healthy messages

� Breastfeeding action plan developed with implementation underway mainly across Women’s Health, including:

� Middlemore Hospital actively working towards “Baby Friendly Hospital” (BFHI) accreditation. This was a major effort achievement, breaking through many roadblocks on the way. It includes extensive staff education measures (approx 20 hours for each clinical staff member, less for non clinical staff), modification of practices and processes and even some equipment modifications;

� Community maternity units maintaining and renewing their BFHI accreditation;

� Internal and community people supported to gain Lactation Consultant accreditation;

� Breastfeeding policy for staff in organisation – improved staff breastfeeding facilities;

� Local implementation of national breastfeeding social marketing campaign; and

� Support for Well Child provider staff to access Breastfeeding support education programme.

� Support to Oral Health campaigns (including, for example, the ‘no fizzy’ message)

� Input and support to the Swap fizzy to water and Swap to light blue milk initiatives


Other LBD initiatives also contributed to this area, such as:

� fruit and vegetable gardens, and water fountains in early childhood education centres

� cooking classes for mothers of pre-schoolers

Challenges

� BFHI – workforce shortages (in particular Midwives, but also Lactation Consultants) and clinical volumes across maternity and neonatal services

� Data entry issues

� Limited progress apparent in community-based innovative or new connective activities in supporting an increase in breastfeeding.

� Outside of the BFHI and Well child resource, the large volume of other child health initiatives tended to take a greater priority over LBD work. Those priorities included, for example, immunisation campaigns, infant mental health, the trialling of new B4schools checks, newborn hearing screening, and the Kidslink Plus project.

� The nutrition and activity levels of babies and children are often dependent on the health of the mother and actions of older role models and parents in the household. Much of the influence on under five year olds will come from action targeting these groups, which has also been covered by other LBD Action Areas.


7. Working with Schools and Early Childhood Educati on centres to ensure Children are Active, Healthy and Ready to Learn

Introduction

The school and early childhood education centre environments were highlighted as important for the health of growing children. Learnings during these formative years influence choices and decisions in later life, while there is an emerging body of evidence linking physical activity and good nutrition with educational attainment. In 2004, the nutrition and physical activity environments in schools were characterised by multiple providers and programme with no overall coordination or direction. In response, the LBD plan set out to improve coordination between health promotion providers and schools, and to assist schools to become healthy environments.

Achievements

Between 2005 and 2009, achievements in this area included: � Strong and effective Schools Accord hub, connecting education, health, councils,

regional sports trust and other related parties for leadership and coordination plus advisory and steering purposes.

� Commissioned a Literature Review of the Relationship Between Physical Activity, Nutrition and Academic Achievement, (Clinton, J., Rensford, A. & Willing, E.) from Auckland UniServices 2007, and disseminated key findings to schools and stakeholders (no clear evidence of a direct relationship, but strong indications of an indirect link in terms of improved wellbeing increasing students ‘opportunity to learn’).

� Development of a Directory of Physical Activity and Nutrition Service Providers, which was disseminated to all schools, including a Record of Involvement to support future provider coordination.

� CMDHB contract with Youth Line to support the establishment of student-led health councils in all 30 secondary schools in Counties Manukau.

� Development and piloting of the Healthy Tuckshop model for secondary schools by Jude Woolston and Diabetes Projects Trust, which was later overtaken by the NZ Food & Beverage Guidelines and 2008 change in National Administration Guidelines.

� 20 of the 36 secondary schools in the Counties Manukau area involved or offered support by Diabetes Projects Trust for using the Healthy Tuckshop and/or GetWise2Health programmes (which include nutrition and physical activity).

� Coordination with delivery of the National Heart Foundation’s School Food programme (now called Healthy Heart Awards for Schools) and physical activity programmes such as Jump Rope for Heart.

� Coordination with delivery of the Counties Manukau Sport’s Active Schools programme to 39 primary and intermediate schools (many of which achieved awards in the 3 levels of Active Schools) as well as their Sport Fit contracts which have put Sports coordinators into 30 secondary schools in Counties Manukau.

� Delivery of the Health Promoting Schools programme by CMDHB (and Manukau City Council in some Manurewa schools), which includes healthy eating and physical activity. 104 primary schools now in the programme (95 with CMDHB and 9 with MCC)

� Delivery of the Fruit in Schools programme to 65 decile 1-3 (higher deprivation) schools in Counties Manukau between 2005 and 2009. All these schools are in the


Health Promoting Schools programme, and all have been involved in nutrition and physical activity initiatives.

� Supporting activity in the AIMHI (Achievement in Multicultural High School Initiative) secondary schools in Counties Manukau, including Mangere, Tangaroa, Sir Edmund Hillary and Southern Cross colleges (all decile one schools with a high proportion of Pacific and Maori students), including a full health and social needs assessment of all year 9 students and follow-up where appropriate. There are now 13 colleges doing assessments, and all Counties Manukau secondary schools have school-based health services (involving around 50 nurses).

� Over 50 workshops with representatives from schools and ECEs covering a range of topics from the new guidelines, classification system, to LBD, nutrition fund, nutrition information and resources.

� Established and administered a Nutrition Fund for schools and ECEs in Counties Manukau. Between July 2007 and June 2009, $740,000 had been distributed through 200 agreements with schools and ECEs. This included $148k in grants to 132 ECEs (kohanga reo, Pacific language nests, kindergartens, playcentres, and private providers), $570k in grants to more than 90 schools (primary, intermediate, secondary, kura kaupapa), and $51k in teacher release payments (to attend training workshops).

The grants were for items such as drinking water fountains, establishing food gardens, teaching and education resources on nutrition, food preparation equipment for skills development or tuckshops, supporting establishment of breakfast clubs and student-led initiatives, outreach nutrition education meetings with parents/whanau.

� Development of guidelines and implementation package for breakfast clubs in schools based on best practice. Launched June 2008. 500 copies distributed. Also available on the internet.

� Formation of an Early Childhood Advisory Group for CMDHB, to guide LBD and other areas such as oral health, B4School check and so forth.

� Collaboration and information sharing with the five year international Pacific OPIC (Obesity Prevention In Communities) study involving Australia, New Zealand, Fiji and Tonga. Auckland University managed the NZ component, working on obesity intervention strategies with four secondary schools in the Counties Manukau area.

Challenges

� Balancing the Schools Accord interest in all health matters relating to students with the LBD narrower interest in nutrition and physical activity.

� Removal of the recently introduced National Administration Guideline that required schools to make ‘only healthy options available’ where food and beverages are sold on school premises.

� Removal of funding for the Nutrition Fund and shift of emphasis from nutrition to physical activity.

� Increased bureaucracy for secondary schools to navigate when seeking funding to continue to employ their Sports Coordinators.

� Understanding the likely impact of the new curriculum (to be mandated in 2010) on schools and how they work, including their ability to produce school environments that support healthy choices.

� Assisting and leveraging Home-School partnerships, so that what happens at school is supported at home.


8. Supporting Primary Care-based Prevention and Ear ly Intervention

Introduction

Primary care general practice is a key environment for the early identification of risk factors and screening to identify diabetes and cardiovascular disease. Improving this prevention and management was deemed a key component of LBD, with Primary Health Organisations (PHOs) using the Chronic Care Management programme (which supports community-based structured management of high risk people with diabetes/CVD) to improve primary care-based prevention, early identification, patient education and self management. Providing persuasive information to ‘at risk’ people to support lifestyle change, utilising national screening and care guidelines, looking at family-oriented approaches, and improving the Get Checked diabetes programme were also agreed priorities.

Achievements

Between 2005 and 2009, achievements in this area included: � Establishment and support from 2005 of DCAG (Diabetes/Cardiovascular Disease

Advisory Group) as the leadership group for this area (reviewed and revised in 2009)

� Continued delivery of CCM, with over 14,000 enrolments in the diabetes module

� Implementation and evaluation of a Community Nutrition project in two PHOs, a brief intervention aimed at modifying obesity risk factors in a primary care setting. Learnings were picked up by wider primary care activity.

� Trialled the Whanau Support project with Total Healthcare Otara, examining increased use of the family group for addressing obesity risk factors and improving diabetes self management. Evaluated, with good outcomes, and disseminated findings.

� Development and implementation of a Diabetes Self Management Education programme and infrastructure (include clinical governance and SME facilitator peer review processes) across Counties Manukau PHOs. Exceeded 2008/09 target of 750 self management patient enrolments (823 achieved for the year).

� Developed and rolled out the Stanford self management programme for other chronic conditions

� Accredited 15 Master Trainers for the Stanford programme in 2008/09, who then trained 49 course leaders (mostly Maori, Pacific or South Asian)

� Development of framework for implementing the NZ Guidelines for Type 2 Diabetes management across primary care in Counties Manukau

� Developed business case and secured funding to implement annual CVD reviews within PHOs, developed guidelines for PHOs to implement systematic risk screening for diabetes and CVD, and delivered training/support for implementation at all PHOs

� Strengthened access to the Get Checked programme (free annual diabetes review for people with diabetes), with 16,000 reviews undertaken in Counties Manukau in 2008/09

� Through the ‘Known Diabetes’ project, established an accurate health database and count of people in Counties Manukau known to have diabetes


� Reviewed diabetes/CVD education needs in primary care, delivered diabetes education modules to PHO-based clinicians and submitted project recommendations to DCAG regarding ongoing diabetes education of primary care nurses

Challenges

� Retention of newly accredited Master Trainers in the Stanford programme

� Diabetes Get Checked case management rates well below national targets and CMDHB agreed DAP targets

� DHB internal restructuring

� Ongoing workforce capacity issues within primary care


9. Enabling Vulnerable Families to Make Healthy Cho ices

Introduction

Counties Manukau has a high proportion of families that are in difficulty or are ‘vulnerable and may not be far from a crisis. These families, for whom a healthy lifestyle is often a low priority, are at high risk of obesity and diabetes. While many LBD strategies make it easier for families to make healthy choices, on their own this is unlikely to work for vulnerable families. It was agreed a new level of collaboration was required across government agencies at policy and funding levels, and across providers at operational levels, to provide well targeted support for vulnerable families. It was also agreed that Ministry of Social Development (MSD) would take the lead.

Achievements

Between 2005 and 2009, achievements in this area included: � MSD’s Strengthening Families interagency committee as leadership hub

� Referral pathways strengthened between Social and Health provider agencies

� Worked with Salvation Army, Auckland City Mission and food industry to improve food parcels provision and content (foodbanks)

� Training Salvation army staff and volunteer workers in nutrition and brief intervention counselling

� Produced recipe book for foodbanks and distribution to vulnerable families through Family Start and social service agencies

� Workshops and training on nutrition and physical activity delivered to social service agencies (such as Family Start, Strengthening Families coordinators, and MSD-contracted community organisations for provision of information and advice)

� Healthy Eating on a Budget (Cook’n Kiwi) workshop programme

Challenges

� Sustaining participation and input from key stakeholders, such as MSD


10. Improving Service Integration and Care for Adva nced Disease

Introduction

Best practice health interventions and lifestyle change can make a difference to the outcomes of people who have diabetes, including people with advanced diabetes with serious complications. A number of initiatives had been introduced at a national, regional and district level to support more effective care and treatment for people with diabetes. It was agreed that the core focus of this action area was to develop robust and sustainable systems to support effective uptake of best practice processes in the primary care environment, and improved integration and coordination of services with secondary care.

Achievements

Between 2005 and 2009, achievements in this area included: � Strengthened investment in the development of Whitiora Diabetes Service’s role as a

centre of excellence and supporter of system-wide capacity development

� Development and promotion to primary care of three ‘navigational tools’ for people accessing diabetes services (also loaded to the Healthpoint website)

� Major review completed of around Diabetes and Pregnancy services, aimed at improving relationships and developing strong service integration between the many providers and services involved secondary, primary and community care for the comprehensive care of women with diabetes in pregnancy. Multi-disciplinary working group established and further activity progressed along the lines of information systems, models of care and workforce development.

� Successful development, launch and completion of pilot of CVDIS database system in Module 5, Manukau SuperClinic

� Clinical and financial assistance to the development and launch of Predict 2 software application

� Development of agreed entry and exit criteria for referrals from primary care, endorsed by DCAG and circulated to all PHOs

� Adolescent diabetes clinic established

� Clinical support to the development of National Diabetes Retinal Screening Grading System and Referral Recommendations, and to the National Renal Project

� Completed major Living with Diabetes survey

� Point prevalence study within Middlemore Hospital

Challenges

�


APPENDIX 5: LBD Implementation Score LBD Implementation Score This was taken from the LBD Monitoring Report: Reporting Period February 2008 to January 2009, delivered by the School of Population Health in June 2009. The agreed evaluation framework included a series of variables which were used to evaluate LBD, its Action Areas and Workstreams. The key variables were: � Meeting KPIs � Degree of Implementation � Adaptation to Plans � Organisational Development � Collaboration � Cohesion � Sustainability � Evaluation Readiness � Overall Progress The scores designated for each of the variables were based on information made available to the evaluation team through two primary methods of data collection: LBD monthly progress reports and interviews with Action Area and Workstream leaders. SoPH note that it is probable the progress of some Action Areas and Workstreams was not fully represented. The Degree of Implementation variable was chosen as one of the KPIs for assessing participation in LBD. This variable refers to how much intervention has occurred or whether the goals have been implemented. The score in 2007 was 5.5, which is also the score given in 2009 (second bar from the left in the chart below).


This score was an average of the assessed degree of implementation across all the Action Areas during this period. The individual scores of the individual Action area are shown below. The scores should not be used to make comparisons across Action Areas. Variation is expected as they have evolved at differing rates as a function of history and the nature of the initiatives they encompass. For example, some Action Areas have initiatives which predate LBD and would be expected to be progressing further. Likewise, Action Areas encompassing a large number of time-intensive KPIs would be expected to have lower scores. Thus, the scores should only be used to gain an understanding of progress within Action Areas.

As can be seen, the majority of Action Areas were engaged in a moderate degree of implementation, with the exception of the Maori, Education and Primary Care workstreams, which are relatively higher due to the more direct focus of these Action Areas. Urban Design had lower levels of implementation due to the complex nature of the KPIs in that Action Area but also a loss of momentum due to a lack of time and staff resource, internal restructuring, and delays in establishing a leadership hub. Pacific also had lower levels of implementation due to the priority focus placed on planning and delivery of the LotuMoui Games.


APPENDIX 6: Strengths and Challenges To Date

Looking Back - Strengths and Challenges The following tables identify key factors that have been strengths of the LBD programme, and those which have been challenges.

What went well

Vision and model

The broad and inclusive nature of the LBD model has been a key factor in bringing the wide range of partners together. The ‘whole society’ and ‘whole life course’ approach made it easy to identify common goals and for each to see their place in the big picture.

As programme implementation progressed, discussions and decision-making continually referenced the broader framework and common goals to ensure activity was aligned and supported

Top level leadership

Top level leadership came on board from the beginning, senior players of key stakeholders who were willing and able to champion the cause and approach. They were visible, permissive and engaged. This gave the programme a profile and level of support that opened doors and fostered strong partnership connections. As community leaders (church ministers and the like) endorsed the goals and supported their own initiatives, their mana and authority added emphasis and impetus to LBD.

Shared priorities Within the big picture vision, the identification of common priorities by willing partners built commitment and resource allocation.

Community ownership

Collective action was helped by community focus and direction, the ‘whole of society’ approach, in which there was a place for everyone, from grassroots to environmental/policy level efforts.

Patience Taking the long-term view (15-20 years) allowed an approach and timing that assists building trust and relationships, as well as accommodating differing planning and budget cycles.

Flexibility

It has been advantageous to have a programme framework able to flex to accommodate change or respond to opportunities.

Emphasis and resource has been shifted across or within action areas, reflecting changes in the environment or emerging opportunities/challenges such as new funding streams (like the national HEHA programme), or reduced capacity or engagement in other areas (as occurred in the Vulnerable Families area).

Leveraging resource

More than $10 million of additional resource has been attracted into aligned initiatives and action in Counties Manukau, considerably boosting the initial CMDHB commitment of $10 million over 5 years.

Balancing evidence and

The model and action areas were shaped by local/international evidence, frameworks and knowledge. It remains consistent with


innovation current expert advice (see 2009 US strategies for tackling obesityxxvii). This was balanced by planting many seeds, testing and evaluating new ideas. Evaluation was built in from the beginning.

Perseverance

LBD was a new and bold venture for CMDHB and LBD partners. There was no blueprint on how it would work, from governance aspects to operational funding matters.

Through the many challenges, differences and testing times for the partners, the commitment and perseverance of a core set of key stakeholders has been critical in holding LBD together and continuing to move forward. Durable relationships count.

Clinical input At the start, LBD clinical leadership (DCAG) included public health, primary care and secondary care expertise. This supported a view across the health systems, not restricted to a single sector.

Highlights

HEHA support

LBD benefited significantly from the national Health Eating, Healthy Action (HEHA) programme. Timing was advantageous, as HEHA funding to DHBs started during the early years of LBD, adding resource and related activity that aligned strongly with LBD goals and efforts.

Auckland-wide HEHA forum

The set up of an Auckland regional HEHA forum and strategy increased collaboration and helped re-focus Ministry of Health (Auckland) service expenditure on priority areas aligned with LBD.

Social marketing campaign

The reach and impact of the social marketing campaigns added significant value to LBD partner efforts to stimulate population level change. A large increase in association between healthy eating/diet and prevention of diabetes, and the significant drop in fizzy drink consumption, are examples of change clearly linked with the ‘Diabetes’ campaign. Good reach, cut-through and relevance.

Knowledge gain

The large amount of evaluation and survey work produced key information, knowledge and insight for LBD partners. This includes baseline attitude and behavioural data, project-specific learnings, and vital programme-level insight in areas such as collaboration, participation and communication channels into local communities.

Experience

There has been huge learning in terms of building and leading complex multi-agency networks on a large scale multi-pronged programme. The network and programme management experience gained to date is invaluable for CMDHB and partners given that multi-agency collaborative efforts are probably here to stay.

Partnership in action

LBD partners built a range of partnerships in Counties Manukau that have boosted the infrastructure and potential for change. Examples include the Counties Manukau Active programme (3 councils, 2 PHOs, CMDHB, Counties Manukau Sport, SPARC),


CMDHB’s LotuMoui church programme (84+ Pacific churches), the inter-agency Gardening for Health and Sustainability programme, and Manukau City Council’s Find Your Field of Dreams.

Increased conversations

There has been an increased level of talk and conversation in Counties Manukau communities about obesity, nutrition, physical activity and diabetes as a result of LBD and HEHA. The combined efforts of partners, agencies, providers, community groups, social marketing and media have all contributed to this.

Food industry LBD has learnt how to work with big players in this sector and find common business/positioning for mutual gain. Their reach is large.

Chronic disease link with lifestyle

LBD connects nutrition, activity and obesity with diabetes. This chronic disease element goes ‘deeper’ than HEHA and other ‘healthy lifestyle’ initiatives. It strengthens leverage in terms of providing rationale (‘the why’) for people to heed the messages, and harnesses the authority of primary care and other health professionals in influencing patients and local communities.

What was challenging

Keeping leaders engaged

Over time, the active and visible engagement of senior leadership in the programme lessened (either stopped or diluted through delegation downwards), which had an adverse impact on LBD profile and support.

Organisational commitment

LBD support was often driven by key individuals in organisations. Generally this worked fine, but when individuals moved on or restructuring / retrenchment took place, LBD commitments often suffered. On another note, it frequently required a lot of effort and perseverance to translate verbal support into resource commitment.

Governance

Over time, some tension emerged around participation of partners in LBD governance and decision-making processes. The strength of the DHB at the table, partners’ relative contributions (resource or governance), the separation of governance from operational oversight, and the changing requirements of an evolving programme were key points that lead to governance changes.

Balancing decision-making and information sharing (for coordination and monitoring purposes) has been a challenge. As has finding structures/processes that enable effective and efficient cross-pollination of ideas and activity for such a broad programme.

DHB as driver

CMDHB ended driving more projects than was envisaged, often due to capacity or funding constraints of partners, limited budgets, lack of leadership or decisions to handle things internally. While pragmatic, it was less than ideal, placing strain on DHB personnel (workload) and occasionally testing partner perceptions or interests.

Joint/shared accountability

The loose or fluid nature of LBD partnerships came under pressure from time to time around shared accountability for funding streams (such as HEHA funding for Maori and Pacific community action on


obesity, where responsibility sat between LBD and Pacific Health, or LBD and Maori Health). Negotiation and decision-making around strategy or implementation matters often took more time than anticipated, slowing progress.

Integration cost

There were challenges in making sense of the multiple national and local programmes (e.g. HEHA, Mission On, Feeding Our Futures, LBD, LotuMoui, CM Active, CCM). Planning and managing the integration of different funding streams, strategy, policy, branding, messages and action on the ground required significant management attention and resource.

This was an overhead not originally factored in. Work on integration aspects also distracted management from driving current priorities and implementation.

Performance management

Where performance in any area was poor or less than expected, LBD had limited ability to move beyond a monitoring role into managing some form of corrective action and performance improvement.

That role lay with the individual partner organisation (outside of those initiatives where LBD held contract and funding mechanisms in place), so performance management across the programme was often handled on a high-level ‘collegial’ basis.

Whole system coordination

The sheer breadth and scale of LBD, with more than 70 concurrent initiatives underway at one stage, placed considerable demands on governance and management. Driving, coordinating and monitoring action on all fronts, while maintaining strategic overview and direction across the workstreams and partners, has been quite challenging. Not insurmountable, but challenging nonetheless.

Communication

Maintaining effective communication and information sharing became more difficult as the workload and range of partners expanded. Different information needs and interests needed to be catered for – programme governance and management, action area management, and project/initiative-specific needs. Achieving this in a cost-effective and efficient manner remains a challenge.

Capacity - organisational and workforce

LBD competes for resource with ‘business as usual’ and other organisational priorities. In tight times, groups found they had limited capacity to progress LBD priorities. Uneven capacity / capability across the partners also meant mixed ability to respond/flex to opportunities or initiatives. As a result, progress often varied in terms of speed or depth of implementation.

The other key limiting factor is shortages in the skilled workforce around nutrition, physical activity and diabetes expertise. Training programmes, scholarships and up-skilling courses have been introduced, but it will still take time to build the numbers.

Grassroots reach and impact

The LBD strategy had a deliberate commitment to community and grassroots engagement, plus trialling innovative approaches (where no clear evidence or models existed). In practise, this meant LBD got behind and supported a multitude of small initiatives.


The benefits of this community group and grassroots involvement were countered however by their limited reach (and therefore population impact). Pockets of success, but no system/population-wide impact.

Uncertainty

LBD implementation suffered from changes in the wider environment. The change in government plus internal restructuring and re-focusing of CMDHB and other partners introduced policy and funding uncertainties.

This had flow-on impact in terms of delays in decision-making, contracting, and progress at workstream level. This uncertainty has also lead to short-term outlook and commitments only. This has created friction with community groups and organisations that are strongly critical of ‘here today, gone tomorrow’ projects and initiatives.

Personnel changes

Relationships and implementation progress take a hit when there are changes in key personnel. Since 2005, turnover of project staff across several LBD action areas was higher than expected, causing progress delays each time.

LBD also had to navigate through a change of the top CMDHB leadership that backed LBD from the very beginning (including CMDHB Chairman, CEO, and Chief Planning & Funding Officer). This has had a gradual impact on the profile and positioning of LBD.

Evaluation activity

Evaluating a large scale, complex and long-term programme like LBD is a challenge. The range and variable quality of evaluation results reflects this. Poor design/implementation of initiatives or evaluation activity reduced evaluation value, as did the annual contract structure which caused a bias towards process rather than outcome evaluations (the full impact of projects such as the Templeton Park urban design exemplar initiative can only be measured over time).

The decision to end the evaluation contract one year early (i.e. after year 4) also set LBD back in terms of an independent appraisal of progress and building knowledge to guide future directions.

Whole system learning

A key objective for embedding the evaluation activity in the programme structure was to facilitate learning and continuous improvement across initiatives, partners, communities and interested stakeholders.

In practice, it was a struggle to ensure project leaders or leadership groups took the time to disseminate key evaluation findings, reflect on them and build in the improvements. The biggest obstacles appeared to be time and breaking down findings into simple points for wide spread distribution/discussion.

Upstream vs. downstream

Over time, fostering community partnership connections and prevention activity incurred a greater portion of LBD management attention and resource allocation, and probably overshadowed time and resource concentrated on improving collaboration and systems


across the treatment and management of diabetes.

Quality of care -primary/secondary

LBD struggled for penetration and traction in both primary and secondary care health services, in terms of quality of care and driving a Continuous Quality Improvement approach for diabetes across both sectors.

By way of example, accessing/sharing data from different health systems in order to analyse or support initiatives/improvements across the systems often proved problematic. Referrals to diabetes specialist services for basic advice and support that should be handled at primary care level highlight inefficiencies in the system – and room for improvement.

Clinical leadership

The role of DCAG (Diabetes Cardiovascular Advisory Group) as a source of clinical leadership for LBD and improvements in the treatment/management of diabetes diminished over time, with the group’s attention becoming somewhat dominated by primary care-specific issues and a lower level focus on specific initiatives – with less emphasis on broader quality of care and integration discussions across primary and secondary care systems.


8. References i CMDHB report by Andrew Lindsay, 2003. Diabetes Rates by Census Area Unit in Counties Manukau. ii CMDHB (2005). “Let’s Beat Diabetes – A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau.” iiiThis was adapted from an approach and model developed by the US Centre for Disease Control and Prevention promoting the use of a ‘whole-system’ strategy. iv CMDHB. Let’s Beat Diabetes annual Operational Plans: 2005/06, 2006/07, 2007/08, 2008/09, 2009/10. v LBD Surveys conducted by Phoenix Research, including: LBD Baseline Survey 2006/07, LBD Tracking Survey 2009, LBD Living with Diabetes Survey 2009, LBD Social Marketing surveys 2008 and 2009. vi Extract from ‘A Letter From 2020’, Let’s Beat Diabetes – A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau. vii2008 CMDHB report by James Smith, Gary Jackson, Dean Papa - Diabetes in CMDHB and northern region: Estimation using routinely collected data. viiiThe Ministry of Health published A Portrait of Health. Key Results of the 2006/07 New Zealand Health Survey which included comparative analyses between district health boards on a range of health issues ix IDF Diabetes Atlas (4th edition, 2009) published by International Diabetes Federation www.diabetesatlas.org x Press release from Health Minister, Tony Ryall, 19 February 2009 (www.beehive.govt.nz/release/Health Minister Opens Country's Largest Renal Unit at Counties Manukau DHB) xiSee CMDHB’s report compiled by Gary Jackson Let’s Beat Diabetes System Dynamics Model (Ongoing), September 2009 xii CMDHB report by Gary Jackson Let’s Beat Diabetes System Dynamics Model (Ongoing), September 2009 xiii October 2009 CMDHB report by Wing Cheuk Chan, Gary Jackson and Dean Papa: Health care costs related to cardiovascular disease and diabetes in CMDHB in 2008 xiv Ibid. xv Gary Jackson, CMDHB xvi See October 2009 CMDHB report by Wing Cheuk Chan, Gary Jackson and Dean Papa: Health care costs related to cardiovascular disease and diabetes in CMDHB in 2008 xvii NZMJ article - How low can it go? Projecting ischaemic heart disease mortality in NZ to 2015 (21 April 2006, Vol 119 No 1232 M.Tobias, K.Sexton, S.Mann, N.Sharpe) xviii October 2009 CMDHB report by Wing Cheuk Chan, Gary Jackson and Dean Papa: Health care costs related to cardiovascular disease and diabetes in CMDHB in 2008 xix Ministerial Review Group report, 31 July 2009: Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand. xxBetter, Sooner, More Convenient - 2007 National Party health discussion paper, written by Hon Tony Ryall, National Party Health Spokesman, on how to improve healthcare in New Zealand. xxi Terms of Reference for the Royal Commission on Auckland Governance, November 2007 (see www.royalcommission.govt.nz) xxii See, for example: World Health Organisation (2004): Global Strategy on Diet, Physical Activity and Health ; US Centers for Disease Control and Prevention: Recommended Community Strategies and Measurements to Prevent Obesity in the United States (July 2009); and G Mensah: Eliminating disparities in Cardiovascular Health: Six Strategic Imperatives and a Framework for Action (Circulation. 2005; 111:1332-1336). xxiiiThese are criteria set out in the report from US Centers for Disease Control and Prevention: Recommended Community Strategies and Measurements to Prevent Obesity in the United States (July 2009). xxivBackground paper to the IDF Diabetes Atlas (4th edition, 2009): International Diabetes Federation: an update of the evidence concerning the prevention of type 2 diabetes xxvAjou University School of Medicine, Korea. Cigarette smoking is an independent risk factor for type 2 diabetes: a four-year community-based prospective study. Abstract available from US National Library of Medicine (see www.ncbi.nlm.nih.gov/pubmed/19508609) xxviCMDHB (2005). “Let’s Beat Diabetes – A Five Year Plan to Prevent and Manage Type 2 Diabetes in Counties Manukau.” Page 33, Changing Urban Design. xxvii Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, July 2009 report: “Recommended Community Strategies and Measurements to Prevent Obesity in the United States”. Identifies strategies that communities and local government can use to plan and monitor environmental and policy-level changes for obesity prevention.