Case Study: A Man-Made Blue Zone in the Netherlands

A Man-Made Blue Zone in the Netherlands

The key factors in this case study are vision, innovative concept, mission and strategy, planning, operational output, and leadership.

Since 2006 the mission and vision of the University Medical Center Groningen (UMCG) have been dedicated to the topic of Healthy Aging. This includes a focus on the specific demographics of the Northern Netherlands and more broadly on the projections of a globally aging population with enormous consequences for many societies. Because these consequences go beyond healthcare and medicine alone, the University of Groningen – a university with a strong research record – has adopted Healthy Aging as one of its three societal themes. The Healthy Aging Network Northern Netherlands (HANNN) has been formed as a 'triple-helix' network organization, with partners in research institutes, government bodies, and business. Together we are building the 75-acre Healthy Aging Campus as the locus of our core activities. 

International networks have been developed to carry out research and educational activities within the framework of the Alliance of Healthy Ageing. This chapter focuses on our values, objectives, and challenges, and our ambitions to achieve a maximal societal impact by building the Future of Health, with the realization of a manmade Blue Zone in the three Northern provinces of the Netherlands as the ultimate goal.

Source: Folkert Kuipers, https://archive.org/details/Breakthrough2180910/page/n131/mode/2up
This work is in the Public Domain.

Introduction

The major demographic changes that are occurring globally are resulting in a rapid increase of elderly people in virtually every society: by 2050, 20 per cent of the global population will be over the age of 60 and the number of people over the age of 80 will have tripled compared to 2010. Overall, this shift is related to increased life expectancy, as a consequence of improved hygiene, better nutrition, and better medical care, but it is also a consequence of declining birth rates.

Specific regions may be particularly affected because of additional emigration of the young for economic reasons and/or socio-economic and political trends in society. The topic "Healthy Aging" is therefore broadly recognised as one of the greatest societal challenges affecting most countries in every continent over the next decades. Indeed, the consequences of aging societies are manifold and will affect individuals, communities, and economies.

Aging is the leading risk factor for nearly all major chronic diseases, such as type 2 diabetes, neurodegenerative diseases, cardiovascular diseases and dementia, and also for cancer. These chronic diseases constitute an increasing cause of morbidity and hence a major driver of healthcare costs now and increasingly so in the near future.

Conceptually, it is important to emphasize that healthy aging is not only about elderly people: in fact, healthy aging starts in the womb and at various stages in early life. For instance, nutritional status or exposure to pollutants can have a strong impact on health outcomes later in life due to "metabolic programming". Programmes aimed at promoting healthy aging should therefore address the entire course of life in all its aspects. The goal is to promote healthspan rather than lifespan (see Figure 1).

Healthspan is defined as the years lived without chronic age-related conditions that allow people to live an active life and hence to contribute to society. Lifespan refers only to life expectancy.

Yet our understanding of the biological mechanisms that influence human aging and its relation to disease development remains limited. This knowledge is essential to define strategies that extend healthspan. The societal impact of ongoing demographic changes is also evident from "the 10 facts on aging and the lifecourse" as defined by the World Health Organization (WHO). In short and modified form:

1. The world population is rapidly aging.
2. The number of people aged 80 and older will quadruple in the period 2000 to 2050.
3. By 2050, 80 per cent of older people will live in low- and middle-income countries.
4. The main health burdens for older people are from non-communicable diseases.
5. Older people from low- and middle-income countries carry a greater disease burden than those in the rich world.
6. The need for long-term care is rising.
7. Effective, community-level primary health care for older people is crucial.
8. Supportive "age-friendly" environments allow older people to live fuller lives and maximize the contribution they make.
9. Healthy aging starts with healthy behaviors in earlier stages of life.
10. We need to reinvent our assumptions of old age.

It is evident that, in the end, a meaningful extension of healthspan for all citizens around the globe will take an enormous effort in the fields of life sciences and (bio)medical sciences, as well as of social sciences, nutritional sciences, economics, and spatial sciences. With respect to the latter, it is becoming increasingly clear that the built environment has a strong impact on the course of an individual's life, not only with respect to the indoor environment of houses and public buildings (air quality, light, etc.), but also the surrounding infrastructure, (playgrounds, bicycle lanes, meeting points, etc) and local availability of healthcare facilities.

It is also evident that economic and cultural differences between countries will have to be taken into account as an additional layer of complexity. The maintenance of a healthy lifestyle from birth onwards (or even prior to birth) is key, but it has proven to be difficult to achieve a focus on primary prevention and it will require increasing health literacy in all communities.

This process, in turn, will be strongly influenced by socio-economic and cultural differences between communities. In addition, early detection of markers of disease, preferably of biomarkers for a group of age-related diseases rather than for each one separately, is necessary for early and effective treatment (secondary prevention). Application of novel consumer-tailored eHealth tools can be of great value in this respect.

Finally, improved treatment strategies for most of the chronic, age-related diseases are still in urgent need of the recognition that each patient should be considered as an individual that requires a personalized, individualized, or "precision medicine" approach.

Novel technologies in genetics, analytical chemistry, imaging, and bioinformatics provide, in theory, the tools for personalized medicine but full application of Big Data in public health and clinical care is still in its infancy. Consequently, more research into these issues, as well as harmonization of data and applications, is urgently needed.

The University Medical Center Groningen

The University Medical Center Groningen (UMCG) was established in 2005 as a joint project by the University of Groningen and the Academic Hospital Groningen. At present, the UMCG is one of the largest hospitals in the Netherlands and by far the largest employer in the Northern Netherlands. More than 10,000 employees provide patient care, are involved in medical education, and perform cutting-edge scientific research. Research and education at the UMCG are funded through the University of Groningen, while the Faculty of Medical Sciences functions as an integral part of the university.

More than 3,400 students of the University of Groningen study Medicine, Dentistry, or Human Movement Sciences, while more than 340 physicians are doing their specialty training at the state-of-the-art facilities of the UMCG. In addition, in collaboration with the Faculty of Mathematics and Natural Sciences, UMCG is strongly involved in bachelor education in Life Sciences and Technology, while the Graduate School of Medical Sciences runs a highly selective Top Master programme on Innovative Medicine with dedicated tracks, including, amongst others, Food and Health, Biology of Ageing, Oncology, and Neurosciences.

With its curricula, the UMCG is a leading academic education center the Netherlands. Groningen is not only renowned for its successful modernisation of academic education, as exemplified by the new medical curriculum based on four Learning Communities (G2020), but also for its innovative approach to nursing studies and in-service training, courses, and training programmes for (para)medics and nursing staff. The fact that we are front-runners in the development of education and training is further exemplified by the presence of the modern Wenckebach Skills center.

The Vision Of The UMGC: Healthy Aging

The University Medical Center Groningen has adopted a single focus for its activities in care, education, and research: Healthy aging, the only one among the eight university medical centers in the Netherlands to do so. This was the focus from the very beginning in 2005 when the Faculty of Medical Sciences of the University of Groningen and the Academic Hospital Groningen merged to found the UMCG.

The strategic decision by UMCG leadership at the time also aimed to unify the corporate identity of our newly-founded organization around a single overarching theme. It was based on a number of considerations that were discussed by groups of selected professionals:

Healthy Aging Also The Focus Of The University Of Groningen

The University of Groningen, founded in 1614, is an ambitious international research university (ARWU ranking position in 2017 – 59, up from 72 in 2016 – puts it in the top 1 percent of global universities) with strong roots in the Northern Netherlands. In its strategic plan of 2010, the University of Groningen formulated three research priority areas for societal impact: Energy, Sustainable Society, and Healthy Aging.

The university creates and shares knowledge through outstanding research and education, and thus benefits society. The Healthy Aging programmes across the various faculties allow for the initiation of new entities at the crossroads of expertise areas, e.g, the Center of Expertise Healthwise (a collaboration between the Faculty of Economics and Business and UMCG), in which research is conducted in the field of Health(care) Economics, Business, and Management. Research topics include quality, safety, and patient logistics, organizational change, e-health, pensions, the mechanisms of the healthcare market, and consumer behavior in the use of medication.

Implementation Of Healthy Aging Policy

Obviously, it has taken and still takes considerable efforts to implement Healthy Aging into the veins of our organization, to involve professionals that are active in care, education, and/or research, and to define specific goals that are based on the Healthy Aging concept. The dedicated Healthy Aging Team, as well as teams within the communication department and the Center for Development and Innovation, are continuously active in lobbying and branding within and outside the UMCG, organizing meetings and lectures. They initiate activities such as Healthy Aging in the Clinic, interactions with private partners, and new educational programmes such as the Summer School on Healthy Aging.

A New Concept Of The UMCG

In hindsight, it is possible to pinpoint the concept and the critical factors that underlie the successful implementation of the Healthy aging profile in the UMCG and in the region. The concept of the new UMCG is based on four pillars of infrastructure and networks:

1. Development Of A Research Infrastructure

The first pillar of the new concept of the UMCG is: "Establishment of eye-catching, internationally oriented research infrastructures for healthy aging research, i.e. the biobank and population cohort study LifeLines and the European Research Institute for the Biology of aging (ERIBA)".

LifeLines is one of the most valuable multidimensional cohort studies and biobanks in the world. LifeLines offers a unique data resource for scientific use to study a broad scope of (epi)genetic, biomedical, environmental, and psychosocial factors in relation to healthy aging, disease development, and general well-being.

LifeLines has evolved into a big data research infrastructure comprising an elaborate, longitudinal cohort, a biobank including a data warehouse and biomaterial, a dynamic research programme, and a collaborative network including other data- and biobanks.

The cohort study started in 2006. It is now the largest infrastructure performing scientific population-based studies in the Netherlands, with 167,000 individuals who will be followed for 30 years. It covers information on environmental exposures, (epi)genetics, and psychological and social factors, as well as data on healthcare use to cover societal impact. Thanks to this wide scope, the high number of participants, and the long follow-up time, the LifeLines data set lays down a broad foundation for important breakthroughs in the screening, prevention, diagnosis, and treatment of (chronic) diseases as well as in the understanding of the etiology of disease.

The developed infrastructure enables UMCG researchers to perform large-scale, genetic epidemiological studies in a broad range of multifactorial diseases.

The approach is based on curiosity, communication, and collaboration. Group leaders and their teams working with unique model systems and technology platforms meet regularly and share their knowledge and expertise to accelerate discoveries.The wider aim of the European Institute for the Biology of aging (ERIBA) is to better understand what causes aging. Studies are focused on the mechanisms that result in loss of cells with age and the decline of function in old cells and tissues. The aim is to develop novel strategies to prevent and combat age-related disease and to provide evidence-based recommendations for healthy aging.

Studies in ERIBA are specifically focused on the molecular mechanisms that trigger the age-related decline in the function of nondividing cells and the regulation of self-renewal and (epi)genetic stability in cells from tissues with continuous turnover. Many studies have documented diminished control of gene expression and protein activity in old cells compared to young cells. The resulting loss of cells and tissue function is a major component of normal aging. Key factors are likely to differ between cells that do not divide much after childhood (such as most cells in the heart or the brain) and cells that continue to divide over a lifetime (such as stem cells of renewing tissues and lymphocytes).

ERIBA investigators address questions about aging using collaborative, multi-disciplinary, technology-oriented approaches, which include next-generation sequencing and bioinformatics, flow cytometry, live cell imaging, and studies of suitable genetic model systems. ERIBA aims to become a world-class research institute, internationally renowned for cutting-edge research. It aims to attract top-level scientists of all levels of seniority.

Staff scientists are expected to publish their papers in high-impact journals with quality prevailing over quantity. There is ample opportunity to explore uncharted territory and embark on high-risk projects that can yield major breakthroughs.

The development of novel tools and technology required to answer fundamental questions is a key element of this strategic focus. Long-term investment in developing a strong research programme is favored over short-term activities leading to incremental results. Staff scientists define their own research agenda, but are expected to collaborate with fellow scientists in ERIBA and its affiliated local and distant Institutions.

Aspiring scientists will find that ERIBA provides an excellent training platform which prepares them very well for the internationally competitive field of life sciences in the 21st century. ERIBA scientists participate in programmes aimed at disseminating new scientific knowledge related to the biology of aging to society at large.

ERIBA researchers are therefore expected to be contacted frequently by the press and media to comment on new research findings. ERIBA scientists are also expected to advise politicians and policy-makers in general. Teaching programmes for high school students and teachers will be implemented, and sharing knowledge with the lay audience through a variety of activities is strongly encouraged.

On the ground floor the ERIBA Science Hall hosts a permanent exhibition showing the research activities of staff scientists.

ERIBA is a research institute which will focus on fundamental biological problems through basic research. It is therefore also likely that new knowledge acquired through this research agenda will repeatedly generate potentially commercially relevant and lucrative intellectual property.

The protection of such intellectual property is strongly encouraged and will be facilitated by a proactive patent office. The nearby presence of the newly developed Healthy aging Campus will further enable future commercial activities.

2. Building The Healthy Aging Campus Netherlands

The second cornerstone of the new concept of the UMCG is: "Realisation of the Healthy aging Campus Netherlands on the premises of the UMCG".

The Healthy aging Campus Netherlands is located on and around the University Medical Center Groningen, on the east side of Groningen city center. It covers an area of around 75 acres and is the beating heart of the Healthy aging programme.

The campus is designed to be an inspiring ecosystem where high-quality researchers and entrepreneurs work together with a range of partners on innovative medical technology and devices; special molecules and materials; and on developing, testing, and (bio) analyzing new pharmaceuticals. With the focus on 'how to grow old in a healthy way', campus participants have developed excellent research and expertise in various areas.

3. ESTABLISHING THE HEALTHY AGING NETWORK NORTHERN NETHERLANDS (HANNN)

The third pillar of the new concept of the UMCG is the 'triple helix' network organization Healthy aging Network Northern Netherlands (HANNN), which represents the wider knowledge and development cluster in the field of healthy aging. Within this network, the private sector, government organizations and (care) knowledge institutions are brought together to find answers to fundamental questions such as: Why do some people reach a healthy old age while others do not?

The UMCG is also a participant in this collaborative venture. This systematic approach to cooperation aims to contribute to the development of a better quality of life in old age, but will also create a basis for substantial economic and social activities. The challenge of staying healthy longer through innovation calls for fundamental breakthroughs in core areas that determine sickness and health, in particular in the field of life sciences, food and nutrition, medical technology, care and cure, and healthy lifestyle.

Thanks to the scale of the approach, the natural cohesion in the region, national and international cooperation, the available knowledge, and the short lines of communication with the private sector, the Northern Netherlands is a logical trial area for innovations and new care concepts.

4. Establishing The Alliance For Healthy aging (Aha) With The Noaber Foundation, Vita Valley, And The Mayo Clinic

The fourth and final pillar of the new concept of the UMCG is: Establishing strong international research, innovation and educational networks, with partners from the EU, Asia, and USA, as exemplified by the Alliance for Healthy aging (AHA) with Noaber Foundation, Vita Valley, Mayo Clinic and UMCG.

The objective of the Alliance for Healthy aging is to advance the development of tools that enable older individuals to live independently by bringing together clinicians, engineers, and scientists and providing a forum for the exchange of ideas. The Alliance includes the Mayo Clinic's Robert and Arlene Kogod Center on Aging (Rochester, Minnesota, USA), the University Medical Center Groningen (Groningen, The Netherlands), the Noaber Foundation (Ede, the Netherlands), and VitaValley (Ede, the Netherlands).

The Alliance for Healthy aging organizes annual meetings dedicated to translational research on aging, alternating between the USA and the Netherlands.

UMCG/HANNN also participate in various EU networks, including the European Innovation Partnership on Active and Healthy aging (EIP-AHA). The European Commission has identified active and healthy aging as a major societal challenge common to all European countries, and an area which presents considerable potential for Europe to lead the world in providing innovative responses to this challenge. European Innovation Partnerships (EIPs) have been set up for this reason. These partnerships pursue a triple win strategy for Europe by:

This will be realized in the three areas of prevention and health promotion, care and cure, and active and independent living of elderly people. The overarching target of this partnership will be to increase the average healthy lifespan by two years by 2020. The Northern Netherlands is active in several action groups of the European Innovation Partnership.

Results

The UMCG's organization-wide, dedicated and sustained focus on healthy aging represents a gradual and long-term innovation and breakthrough process to address the grand societal challenges associated with aging populations. The merger that formed the UMCG in 2005 and the vision articulated by the University of Groningen in its research priorities have resulted in a new concept for the UMCG. This applies to the organization as a whole, in its infrastructure, core research activities, and partnership networks, as well as in branding, corporate identity, and the UMCG's international position.

It also applies internally by creating awareness for staff active in all the key areas of care, education and research. This concept turned out to be very fruitful within UMCG, as well as for the University of Groningen as a whole, in terms of research funding and scientific output.

One clear result is the significant rise of the University of Groningen in the ARWU global rankings to 59 in 017. In the years 2005-2012 Groningen was in the 100-150 range, but the 2010 strategy started paying off when in 2013 Groningen jumped to 92, in 2014 to 82, in 2015 to 75, and in 2016 to 72 and in 2017 to 59th in the world.

The process has also been fruitful for the region of the Northern Netherlands, which, through the activities of HANNN and the Healthy aging Campus Netherlands, has seen a wave of innovations and economic development. There is continuity of leadership, and clarity of vision is key: the UMCG Mission and Vision document 2015-2020, entitled Building the Future of Health 2020, reiterates the continuous focus on Healthy aging. And for good reasons: proven success is the most effective stimulus to continue implementing these policies.

Ten years after the establishment of the UMCG in 2016 an evaluation of outcome parameters reveals that for UMCG and for the region of the Northern Netherlands their decisions and their dedication have been fruitful.

For instance, external research funding, particularly from the EU, has more than doubled; there is a 90 per cent increase in the number of published theses; and recruitment of staff and students has improved. These are tangible results of a focused research policy.

Dedicated educational programmes have been developed, apart from the innovations in regular curricula, such as dedicated summer schools (aging Brain; Healthy aging: from Cell to Society) with international partners (Newcastle, Coimbra, Copenhagen) and EU-funded PhD Student International Training Networks focusing on aging and age-related diseases.

Equally important, in July 2016 the European Commission presented a ranking of European Reference Regions in the field of Active and Healthy aging. It appears that the Northern Netherlands region leads the pack in Europe when it comes to Healthy aging. No fewer than 78 regions from 22 member states were evaluated. The Northern Netherlands, under the leadership of HANNN, achieved the highest possible score of four stars, an honor bestowed upon only a very select group of reference sites.

This recognition of excellence in Healthy aging in the Northern Netherlands creates exposure and collaboration opportunities for its knowledge institutes and companies, making it easier to export innovations in the area of healthy and active aging. The Northern Netherlands is the only Dutch region to receive this coveted four-star status.

This will, in the years to come, be translated into additional activities in the Northern knowledge institutes but also in EU-supported economic initiatives, e.g., those embedded in the Knowledge and Innovation Consortium (KIC) Health, a multibillion euro programme under the umbrella of the European Institute for Innovation and Technology (EIT), a body of the European Union.

A Blueprint For The Future

It is evident that during the last decade a lot of work has been done to promote Healthy aging activities in the Northern Netherlands, leading to enhanced scientific, educational, and economic activities.

Yet this does not fulfill our ambitions: the North also aims to become the first man-made Blue Zone in the world.

The term Blue Zone comes from National Geographic. In 2004 research was carried out into areas where people live extremely long lives. These areas include Okinawa (Japan), Sardinia (Italy), and a few others which have been named Blue Zones. The Northern Netherlands is currently far from being a Blue Zone. People living in the north die – on average – a few years younger than people in the urban centers of the western and central Netherlands ("Randstad"). In the north, there is a relatively large number of people who smoke and drink too much. In addition, the population in the Northern Netherlands is relatively old. aging became a priority for the north and this contributed to the need to establish HANNN several years ago.

Figure 1: schematic representation of the life-course approach that is characteristic for the healthy aging programmes of the umcg/university of groningen. A relatively small enhancement of the overall healthspan will already have tremendously large societal benefits. 

The food industries, partners in HANNN, intend to make healthier products, and local employers have launched sports and exercise programmes. However, it is a serious problem that 'especially fit and slim people want to participate'. It is a real art to develop programmes in which everyone participates: therefore we have high expectations for the programme on Health Literacy. According to HANNN there is a lack of knowledge about health in general. It is the ambition of HANNN to address the following challenges:

1. Life expectancy in the Northern Netherlands is below the national average due to an unhealthy lifestyle (increase in diseases like obesity, cancer, COPD, cardiovascular diseases, and diabetes).
2. The population of the Northern Netherlands is aging rapidly, while population growth is at a virtual standstill.
3. Age-related (chronic) illnesses are rising.
4. Because of demographic change, there will be a shortage of healthcare professionals.
5. But these challenges offer excellent societal and economic opportunities in the field of Healthy aging.

How to realize HANNN's ambition to actually make these opportunities happen? There are several aspects that need to be fulfilled to be able to adapt to a Blue Zone, including: innovative housing (houses of the future for multiple generations), ICT-driven excellent care, innovative concepts of care in the region, E-health, M-health, Telecare 5G and Big Data; improving a healthy lifestyle (health literacy, healthy diets with regional food industry, lifestyle adaptations through quantified self-technology); and the creation of healthy societal networks (involving initiatives such as "Grip & Glans", an interactive programme aimed at encouraging self-management in groups of elderly people, and their evaluation via LifeLines, the world's largest and deepest population study).

More work needs to be done. We believe that national and international cooperation, within the new initiative of the Noaber Foundation, the Healthy Life Alliance, provides a platform to initiate and execute these existing novel and future developments.

Conclusion

The paradigm shift that the UMCG has gone through during the last decade, from a 'disease-focused' to a 'health-focused' vision, has taken time and a great deal of effort from its leadership. And while it is still far from complete in some aspects, such as programmes for employees, there have already been significant successes both for the UMCG and the University of Groningen as a whole. A knowledge-based institution with thousands of highly-trained professionals behaves like an oil tanker in the open sea: a course adjustment only gradually becomes visible: the implementation of the 2010 strategy for Groningen has led to an ongoing rise up the global rankings since 2013.

The rapid conversion of key leaders within the organization has led to their acknowledgement that, by opting for Healthy aging, the UMCG is now a forerunner in current thinking about healthcare. This success has rapidly created a supportive atmosphere. Indeed, since Healthy aging translates into Preventive, Predictive, Personalized, and Participatory (P4) Medicine, this choice has created a leadership role for the UMCG in various respects that has translated into visible and quantifiable outcome parameters.