Reconsideration of the scheme of the international classification of functioning, disability and health: incentives from the Netherlands for a global debate.

PURPOSE: The ICF (International Classification of Functioning, Disability and Health) framework (used worldwide to describe 'functioning' and 'disability'), including the ICF scheme (visualization of functioning as result of interaction with health condition and contextual factors), needs reconsideration. The purpose of this article is to discuss alternative ICF schemes. METHOD: Reconsideration of ICF via literature review and discussions with 23 Dutch ICF experts. Twenty-six experts were invited to rank the three resulting alternative schemes. RESULTS: The literature review provided five themes: 1) societal developments; 2) health and research influences; 3) conceptualization of health; 4) models/frameworks of health and disability; and 5) ICF-criticism (e.g. position of 'health condition' at the top and role of 'contextual factors'). Experts concluded that the ICF scheme gives the impression that the medical perspective is dominant instead of the biopsychosocial perspective. Three alternative ICF schemes were ranked by 16 (62%) experts, resulting in one preferred scheme. CONCLUSIONS: There is a need for a new ICF scheme, better reflecting the ICF framework, for further (inter)national consideration. These Dutch schemes should be reviewed on a global scale, to develop a scheme that is more consistent with current and foreseen developments and changing ideas on health. Implications for Rehabilitation We propose policy makers on community, regional and (inter)national level to consider the use of the alternative schemes of the International Classification of Functioning, Disability and Health within their plans to promote functioning and health of their citizens and researchers and teachers to incorporate the alternative schemes into their research and education to emphasize the biopsychosocial paradigm. We propose to set up an international Delphi procedure involving citizens (including patients), experts in healthcare, occupational care, research, education and policy, and planning to get consensus on an alternative scheme of the International Classification of Functioning, Disability and Health. We recommend to discuss the alternatives for the present scheme of the International Classification of Functioning, Disability and Health in the present update and revision process within the World Health Organization as a part of the discussion on the future of the International Classification of Functioning, Disability and Health framework (including ontology, title and relation with the International Classification of Diseases). We recommend to revise the definition of personal factors and to draft a list of personal factors that can be used in policy making, clinical practice, research, and education and to put effort in the revision of the present list of environmental factors to make it more useful in, e.g., occupational health care.

Taking multi-morbidity into account when attributing DALYs to risk factors: comparing dynamic modeling with the GBD2010 calculation method.

BACKGROUND: Disability Adjusted Life Years (DALYs) quantify the loss of healthy years of life due to dying prematurely and due to living with diseases and injuries. Current methods of attributing DALYs to underlying risk factors fall short on two main points. First, risk factor attribution methods often unjustly apply incidence-based population attributable fractions (PAFs) to prevalence-based data. Second, it mixes two conceptually distinct approaches targeting different goals, namely an attribution method aiming to attribute uniquely to a single cause, and an elimination method aiming to describe a counterfactual situation without exposure. In this paper we describe dynamic modeling as an alternative, completely counterfactual approach and compare this to the approach used in the Global Burden of Disease 2010 study (GBD2010). METHODS: Using data on smoking in the Netherlands in 2011, we demonstrate how an alternative method of risk factor attribution using a pure counterfactual approach results in different estimates for DALYs. This alternative method is carried out using the dynamic multistate disease table model DYNAMO-HIA. We investigate the differences between our alternative method and the method used by the GBD2010 by doing additional analyses using data from a synthetic population in steady state. RESULTS: We observed important differences between the outcomes of the two methods: in an artificial situation where dynamics play a limited role, DALYs are a third lower as compared to those calculated with the GBD2010 method (398,000 versus 607,000 DALYs). The most important factor is newly occurring morbidity in life years gained that is ignored in the GBD2010 approach. Age-dependent relative risks and exposures lead to additional differences between methods as they distort the results of prevalence-based DALY calculations, but the direction and magnitude of the distortions depend on the particular situation. CONCLUSIONS: We argue that the GBD2010 approach is a hybrid of an attributional and counterfactual approach, making the end result hard to understand, while dynamic modelling uses a purely counterfactual approach and thus yields better interpretable results.

Accounting for multimorbidity can affect the estimation of the Burden of Disease: a comparison of approaches.

BACKGROUND: Various Burden of Disease (BoD) studies do not account for multimorbidity in their BoD estimates. Ignoring multimorbidity can lead to inaccuracies in BoD estimations, particularly in ageing populations that include large proportions of persons with two or more health conditions. The objective of this study is to improve BoD estimates for the Netherlands by accounting for multimorbidity. For this purpose, we analyzed different methods for 1) estimating the prevalence of multimorbidity and 2) deriving Disability Weights (DWs) for multimorbidity by using existing data on single health conditions. METHODS: We included 25 health conditions from the Dutch Burden of Disease study that have a high rate of prevalence and that make a large contribution to the total number of Years Lived with a Disability (YLD). First, we analyzed four methods for estimating the prevalence of multimorbid conditions (i.e. independent, independent age- and sex-specific, dependent, and dependent sex- and age-specific). Secondly, we analyzed three methods for calculating the Combined Disability Weights (CDWs) associated with multimorbid conditions (i.e. additive, multiplicative and maximum limit). A combination of these two approaches was used to recalculate the number of YLDs, which is a component of the Disability-Adjusted Life Years (DALY). RESULTS: This study shows that the YLD estimates for 25 health conditions calculated using the multiplicative method for Combined Disability Weights are 5 % lower, and 14 % lower when using the maximum limit method, than when calculated using the additive method. Adjusting for sex- and age-specific dependent co-occurrence of health conditions reduces the number of YLDs by 10 % for the multiplicative method and by 26 % for the maximum limit method. The adjustment is higher for health conditions with a higher prevalence in old age, like heart failure (up to 43 %) and coronary heart diseases (up to 33 %). Health conditions with a high prevalence in middle age, such as anxiety disorders, have a moderate adjustment (up to 13 %). CONCLUSIONS: We conclude that BoD calculations that do not account for multimorbidity can result in an overestimation of the actual BoD. This may affect public health policy strategies that focus on single health conditions if the underlying cost-effectiveness analysis overestimates the intended effects. The methodology used in this study could be further refined to provide greater insight into co-occurrence and the possible consequences of multimorbid conditions in terms of disability for particular combinations of health conditions.

Unhealthy lifestyles do not mediate the relationship between socioeconomic status and incident depressive symptoms: the Health ABC study.

BACKGROUND: The relationship between low socioeconomic status (SES) and depressive symptoms is well described, also in older persons. Although studies have found associations between low SES and unhealthy lifestyle factors, and between unhealthy lifestyle factors and depressive symptoms, not much is known about unhealthy lifestyles as a potential explanation of socioeconomic differences in depressive symptoms in older persons. METHODS: To study the independent pathways between SES (education, income, perceived income, and financial assets), lifestyle factors (smoking, alcohol use, body mass index, and physical activity), and incident depressive symptoms (Center for Epidemiologic Studies-Depression [CES-D 10] and reported use of antidepressant medication), we used 9 years of follow-up data (1997-2007) from 2,694 American black and white participants aged 70-79 years from the Health, Aging, and Body Composition (Health ABC) study. At baseline, 12.1% of the study population showed prevalent depressive symptoms, use of antidepressant medication, or treatment of depression in the 5 years prior to baseline. These persons were excluded from the analyses. RESULTS: Over a period of 9 years time, 860 participants (31.9%) developed depressive symptoms. Adjusted hazard ratios for incident depressive symptoms were higher in participants from lower SES groups compared with the highest SES group. The strongest relationships were found for black men. Although unhealthy lifestyle factors were consistently associated with low SES, they were weakly related to incident depressive symptoms. Lifestyle factors did not significantly reduce hazard ratios for depressive symptoms by SES. CONCLUSION: In generally healthy persons aged 70-79 years, lifestyle factors do not explain the relationship between SES and depressive symptoms.

The disabling effect of diseases: a study on trends in diseases, activity limitations, and their interrelationships.

OBJECTIVES: Data from the Netherlands indicate a recent increase in prevalence of chronic diseases and a stable prevalence of disability, suggesting that diseases have become less disabling. We studied the association between chronic diseases and activity limitations in the Netherlands from 1990 to 2008. METHODS: Five surveys among noninstitutionalized persons aged 55 to 84 years (n = 54,847) obtained self-reported data on chronic diseases (diabetes, heart disease, peripheral arterial disease, stroke, lung disease, joint disease, back problems, and cancer) and activity limitations (Organisation for Economic Co-operation and Development [OECD] long-term disability questionnaire or 36-item Short Form Health Survey [SF-36]). RESULTS: Prevalence rates of chronic diseases increased over time, whereas prevalence rates of activity limitations were stable (OECD) or slightly decreased (SF-36). Associations between chronic diseases and activity limitations were also stable (OECD) or slightly decreased (SF-36). Surveys varied widely with regard to disease and limitation prevalence rates and the associations between them. CONCLUSIONS: The hypothesis that diseases became less disabling from 1990 to 2008 was only supported by results based on activity limitation data as assessed with the SF-36. Further research on how diseases and disability are associated over time is needed.

Trends in activity limitations: the Dutch older population between 1990 and 2007.

BACKGROUND: It is not clear whether recent increases in life expectancy are accompanied by a concurrent postponement of activity limitations. The objective of this study was to give best estimates of the trend in the prevalence of activity limitations among the non-institutionalized population aged 55-84 years over the period 1990-2007 in The Netherlands. METHODS: We examined self-reports on 12 measures of moderate or severe activity limitations in stair climbing, walking and getting dressed as assessed by OECD long-term disability questionnaire or Short Form-36 (SF-36) items, using original data from five population-based cross-sectional and longitudinal surveys (n = 54,847 respondents). To account for heterogeneity between surveys, we used meta-analyses to study time trends. RESULTS: Time trends of 10 out of the 12 activity limitation variables studied were stable. The prevalence of at least moderate activity limitations in stair climbing [odds ratio (OR) = 1.03)] and getting dressed (OR = 1.04) based on OECD items increased over the study period. Age- and gender-stratified time trend analyses showed consistent patterns. CONCLUSIONS: No declines were observed in the prevalence of activity limitations in the Dutch older population over the period 1990-2007. The increase in life expectancy in this period is accompanied by a stable prevalence of most activity limitations.

Late-life depressed mood and weight change contribute to the risk of each other.

OBJECTIVE: Weight change may be considered an effect of depression. In turn, depression may follow weight change. Deteriorations in health may mediate these associations. The objective was to examine reciprocal associations between depressed mood and weight change, and the potentially mediating role of deteriorations in health (interim hospitalizations and incident mobility imitation) in these associations. METHODS: Data were from 2406 black and white men and women, aged 70-79 from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body composition (Health ABC) study. Depressed mood at baseline (T1) and 3-year follow-up (T4) was measured with the CES-D scale. Three weight change groups (T1-T4) were created: loss (>or=5% loss), stable (within +/-5% loss or gain), and weight gain (>or=5% gain). RESULTS: At T1 and T4, respectively 4.4% and 9.5% of the analysis sample had depressed mood. T1 depressed mood was associated with weight gain over the 3-year period (OR:1.91; 95%CI:1.13-3.22). Weight loss over the 3-year period was associated with T4 depressed mood (OR:1.51; 95%CI:1.05-2.16). Accounting for deteriorations in health in the reciprocal associations between weight change and depressed mood reduced effect sizes between 16-27%. CONCLUSIONS: In this study, depressed mood predicted weight gain over three years, while weight loss over three years predicted depressed mood. These associations were partly mediated through deteriorations in health. Implications for clinical practice and prevention include increased awareness that depressed mood can cause weight change, but can also be preceded by deteriorations in health and weight change.

Chronic disease and lifestyle transitions: results from the Longitudinal Aging Study Amsterdam.

OBJECTIVE: This article addresses the association between course of chronic disease and lifestyle. METHOD: We examined differences in unhealthy lifestyles--smoking, excessive alcohol use, being sedentary--and transitions herein after 6 years in prevalent and incident chronic disease categories--lung and cardiovascular disease, diabetes, and osteoarthritis and/or rheumatic arthritis--among 2,184 respondents aged 55 years and older from the Netherlands. We also examined if transitions in lifestyle co-occurred with changes in disease-related symptomatology. RESULTS: Proportions of respondents who smoked decreased over time, whereas proportions of respondents who were sedentary increased. Respondents with incident cardiovascular disease demonstrated more lifestyle transitions than respondents from other disease categories. Respondents demonstrating healthy lifestyle transitions did not differ from those persisting in unhealthy lifestyles in change in disease-related symptoms. DISCUSSION: Health promotion may benefit from these findings in a way that patient groups at risk for not initiating healthy lifestyles might be identified sooner.

Associations between lifestyle and depressed mood: longitudinal results from the Maastricht Aging Study.

OBJECTIVES: We examined whether healthy lifestyles are associated with absence of depressed mood. METHODS: A sample of 1169 adult participants in the Maastricht Aging Study provided baseline and 6-year follow-up data on smoking, alcohol use, physical exercise, body mass index, and mood. We examined associations between lifestyles and depressed mood using longitudinal analyses controlling for baseline depressive symptoms and covariates. RESULTS: Reports of excessive alcohol use at baseline predicted depressed mood at follow-up (relative risk [RR] = 2.48; 95% confidence interval [CI] = 1.08, 5.69), and reports of more than 30 minutes of physical exercise per day at baseline were associated with an absence of depressed mood at follow-up (RR=0.52; 95% CI=0.29, 0.92). Reports of being engaged in physical exercise throughout the 6-year follow-up period were also associated with absence of depressed mood (RR=0.56; 95% CI=0.34, 0.93). CONCLUSIONS: In this relatively healthy population sample, certain lifestyles either predicted or protected against depressed mood. Adopting or maintaining healthy lifestyles might be a starting point in preventing or treating depressed mood over time.

Lifestyle factors and incident mobility limitation in obese and non-obese older adults.

OBJECTIVE: This study examines the association between incident mobility limitation and 4 lifestyle factors: smoking, alcohol intake, physical activity, and diet in well-functioning obese (n = 667) and non-obese (n = 2027) older adults. RESEARCH METHODS AND PROCEDURES: Data were from men and women, 70 to 79 years of age from Pittsburgh, PA and Memphis, TN, participating in the Health, Aging and Body Composition (Health ABC) study. In addition to individual lifestyle practices, a high-risk lifestyle score (0 to 4) was calculated indicating the total number of unhealthy lifestyle practices per person. Mobility limitation was defined as reported difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 6.5 years. RESULTS: In non-obese older persons, significant risk factors for incident mobility limitation after adjustment for socio-demographics and health-related variables were current and former smoking [hazard ratio (HR) = 1.51; 95% confidence interval (CI), 1.20 to 1.89; HR = 1.40; 95% CI, 1.12 to 1.74), former alcohol intake (HR = 1.30; 95% CI, 1.05 to 1.60), low and medium physical activity (HR = 1.78; 95% CI, 1.45 to 2.18; HR = 1.29, 95% CI, 1.07 to 1.54), and eating an unhealthy diet (HR = 1.57; 95% CI, 1.17 to 2.10). In the obese, only low physical activity was associated with a significantly increased risk of mobility limitation (HR = 1.44; 95% CI, 1.08 to 1.92). Having two or more unhealthy lifestyle factors was a strong predictor of mobility limitation in the non-obese only (HR = 1.98; 95% CI, 1.61 to 2.43). Overall, obese persons had a significantly higher risk of mobility limitation compared with non-obese persons, independent of lifestyle factors (HR = 1.73; 95% CI, 1.52 to 1.96). CONCLUSIONS: These results underscore the importance of a healthy lifestyle for maintaining function among non-obese older adults. However, a healthy lifestyle cannot overcome the effect of obesity in obese older adults; this stresses the importance of preventing obesity to protect against mobility loss in older persons.

Determinants of high and low attendance to diet and exercise interventions among overweight and obese older adults. Results from the arthritis, diet, and activity promotion trial.

BACKGROUND: Determinants of adherence to lifestyle regimens are ill understood. Attendance to intervention sessions is crucial for patients to acquire knowledge and skills regarding the core elements of an intervention. Therefore, we explored demographic, health-related, and social determinants of high and low attendance to diet and exercise sessions among overweight and obese patients with knee osteoarthritis (> or = 60 years; N = 206). METHODS: The Arthritis, Diet, and Activity Promotion Trial was an 18-month randomized controlled trial on the effectiveness of dietary weight loss and exercise interventions. We conducted chi-square and t-tests, and logistic regression analyses on categories of short- and long-term attendance to intervention sessions. RESULTS: Over the 18-month duration of the study, 60.7% (+/- 28.5) of diet sessions, and 53.2% (+/- 29.0) of exercise sessions were attended. Not being married, low social participation, and single intervention randomization predicted high attendance to diet sessions during months 1-4. Exercising at home, and single intervention randomization predicted high attendance to exercise sessions during months 5-18. High attendance to sessions early in the intervention was a significant determinant of high session attendance thereafter. CONCLUSIONS: Offering people a choice where to exercise, and stimulating early intervention session attendance can be effective in improving long-term attendance to both interventions. Several determinants we found may be amenable to change to enhance intervention adherence of future randomized controlled trials involving dietary weight loss and/or physical exercise.

Effects of exercise adherence on physical function among overweight older adults with knee osteoarthritis.

OBJECTIVE: To determine whether high exercise adherence improved physical function among older adults with knee osteoarthritis (OA) who were overweight or obese. METHODS: Associations between exercise adherence, changes in 6-minute walking distance in meters, and self-reported disability (Western Ontario and McMaster Universities Osteoarthritis Index function subscale) after 6 and 18 months were examined among an Arthritis, Diet, and Activity Promotion Trial subsample (n = 134) using multiple linear regression models. RESULTS: Higher exercise adherence was associated with greater improvements in 6-minute walking distance after 6 and 18 months and in disability after 6 months. Pain and body mass index (BMI) contributed, to some extent, to explaining the link between exercise adherence and changes in physical performance and self-reported disability. CONCLUSION: Higher exercise adherence is associated with improved physical function in overweight and obese older adults with knee OA. This indicates that promoting adherence is clinically relevant when prescribing exercise regimens that also focus on decreasing pain and BMI.

Impact of depression on disablement in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam.

The main pathway of the disablement process consists of four consecutive phases: Pathology (presence of disease/injury), Impairments (dysfunctions/structural abnormalities), Functional Limitations (restrictions in basic physical/mental actions), and Disability (difficulty doing activities of daily life, ADL). This study determines the presence of the main pathway of disablement in a cohort aged 55 years and older and examines whether progression of the main pathway of disablement is accelerated in the presence of depression. Based on baseline (T1) and two three-year follow-up interviews (T2 and T3) from the Longitudinal Aging Study Amsterdam (LASA) in a population-based cohort of 1110 Dutch persons, we first analysed the intermediate effect of the different consecutive phases of the disablement process by means of multiple regression, adjusted for covariates. Then, depression was used as interaction term in multiple regression analyses linking the consecutive phases of the disablement process. We found that Impairments mediated the association between Pathology and Functional Limitations, and that Functional Limitations mediated the association between Impairments and Disability. Depression significantly modified the associations between Pathology and subsequent Impairments, and between Functional Limitations and subsequent Disability. In sum, the main pathway of the disablement process was identified in our sample. In addition, we found an accelerating effect of depression, particularly in the early and late stages of the model. Reduction of depression may help slow down the process of disablement for persons who find themselves in those stages of the model.

Relationship between changes in depressive symptoms and unhealthy lifestyles in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam.

BACKGROUND: depressed mood is common in late life, more prevalent among the chronically diseased than in the general population, and has various health-related consequences. So far, the association between depression and unhealthy lifestyles among chronically diseased has not been examined longitudinally in older persons. PRIMARY OBJECTIVE: to determine if depressed mood is associated with unhealthy lifestyles in late middle aged and older people, with or without chronic somatic diseases. METHODS: in a sample of 1,280 community-dwelling people from the Netherlands, the associations between depressive symptoms and lifestyle domains were analysed cross-sectionally and longitudinally - using logistic regression analyses and multivariate analyses of variance. RESULTS: after controlling for confounders, depressed people (n=176 at baseline) were more likely to be smokers (odds ratio 1.71; 95% confidence interval 1.17-2.52). A persistent depression was associated with an increase in cigarette consumption (P=0.036). Having an emerging depression (n=155) was most likely to co-occur with a person's change from being physically active to being sedentary (relative risk-ratio 1.62; 95% confidence interval 1.05-2.52), and was associated with the largest decrease in minutes of physical activity (P=0.038). This effect was not modified or confounded by chronic somatic disease. A persistent depression tended to be associated with incident excessive alcohol use (relative risk-ratio 4.04; 95% confidence interval 0.97-16.09; P=0.056). CONCLUSIONS: depression is associated with smoking behaviour, and with an increase in cigarette consumption. An emerging depression is associated with becoming sedentary, irrespective of a person's disease status at baseline, and is associated with decrease in minutes of physical activity.