Advertisement

An Urgent Call for Action: Promoting Healthy Behaviour Changes in Canada!

      In this issue of the Canadian Journal of Diabetes, a number of articles addressed diverse aspects of health behaviour changes in people living with diabetes. A single common message has emerged from these original studies: programs or interventions that support or entail healthy behaviour changes are associated with better clinical outcomes in people with diabetes.
      In a focus group survey of university students with type 1 diabetes, several barriers toward healthy behaviour changes and diabetes self-management were identified: lack of healthy food options in campus cafeterias, lack of awareness of diabetes on campus and internal struggles of participants' relationship with diabetes (
      • Hill S.
      • Gingras J.
      • Gucciardi E.
      The lived experience of Canadian university students with type 1 diabetes mellitus (T1DM).
      ). Another article explored the barriers and constraints to physical activity, as an integral component of diabetes care, in those with a serious mental illness who reside in a for-profit group home. Residents living in government-regulated group homes were sedentary, with only 10 minutes of low-intensity physical activity daily. Further, group home policies regulated systems of safety, reporting and financial accountability, and failed to give primacy to health promotion, illness prevention and medical management of prevalent comorbid conditions, such as diabetes (
      • Lowndes R.H.
      • Angus J.
      Diabetes care and mental illness: constraining elements to physical activity and social participation in a residential care facility.
      ). A third article addressed the issue of how low literacy and a lack of awareness of type 2 diabetes negatively impacted the experience of Canadians of African descent at the time of their diagnosis and subsequent management, and importantly on the prevention of diabetes in this community, which is at high risk for the development of the disease (
      • Ekong J.
      • Russell-Mayhew S.
      • Aurthur N.
      Optimizing diabetes literacy: lessons from African Canadians in Calgary about type 2 diabetes diagnosis.
      ). In a longitudinal survey of more than 1183 people with type 2 diabetes, physical inactivity, perception of poor control of body weight and amount of food eaten have been found to be associated prospectively with the development and persistence of depression (
      • Messier L.
      • Elisha B.
      • Schmitz N.
      • et al.
      Changes in depressive symptoms and changes in lifestyle-related indicators: a 1-year follow-up study among adults with type 2 diabetes in Quebec.
      ). The findings of this 1-year follow-up study reinforce the importance of interventions to improve physical activity and perceptions of control, in addition to treatment of depression, to help minimize the development and severity of depression among subjects with type 2 diabetes. Finally, a community-based chronic disease management program, comprising disease-specific and general health patient education, “disease-spanning supervised exercise,” and Better Choices, Better Health self-management workshops, reported that individuals with type 2 diabetes who were enrolled in this education and supervised exercise program had reduced use of acute care facilities and improved clinical outcomes (A1C and lipid profiles) at the 1-year follow-up evaluation compared with baseline (
      • Morrin L.
      • Britten J.
      • Davachi S.
      • et al.
      Alberta Healthy Living Program - a model for successful integration of chronic disease management services.
      ).
      All the earlier-described studies have underscored the importance of incorporating healthy behaviour changes to improve the lives of Canadians with diabetes, but they also provide valuable insights into the enormous challenges and barriers that they have to overcome. As the number of Canadians affected by diabetes continues to increase steadily over the years, it is paramount that we not only identify but also come up with solutions to tackle these barriers, which often are invisible. From this perspective, the Canadian Journal of Diabetes is carrying out the mandate of informing and providing our readers with food for thought and to encourage diabetes researchers and healthcare professionals to contribute innovative ideas and practical solutions.
      It is timely that the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada have placed greater emphasis on the importance of sustained health behaviour changes as the foundational management of both type 1 and type 2 diabetes, as well as in the prevention of type 2 diabetes (
      Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association
      2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
      ). Although both the Canadian Diabetes Association and the Canadian Journal of Diabetes have worked hard through effective evidence-based communication strategies (media, publications, social media, narrated presentations, presentation slides and so forth) and dynamic, interactive point-of-care decision support tools for healthcare professionals and patients to disseminate and implement the clinical practice guidelines, the uptake and changes will evolve slowly, but hopefully faster than anticipated. Our ultimate vision is a world with fewer people with diabetes and even fewer people suffering from diabetes and its complications.
      Whether intensive lifestyle interventions targeting weight loss would decrease cardiovascular morbidity and mortality in overweight or obese people with type 2 diabetes was the primary objective of a large, multicenter, randomized controlled trial funded by the US National Institutes of Health. The Look AHEAD (Action for Health in Diabetes) study randomly assigned 5145 overweight or obese patients with type 2 diabetes to an intensive lifestyle intervention targeting a weight loss of 7% of body weight, or to a conventional diabetes support and education program (
      The Look AHEAD Research Group
      Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
      ). The trial, whose design was modeled after the Diabetes Prevention Program (
      • Knowler W.C.
      • Barrett-Connor E.
      • Fowler S.E.
      • et al.
      Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
      ), was terminated early in September 2012 after a median follow-up period of 9.6 years because of neutral effects of intensive lifestyle interventions on the primary cardiovascular outcome endpoints. The final results have just been released. Although several possibilities have been advanced to explain why lifestyle interventions did not effectively reduce the rate of cardiovascular events in overweight or obese adults with type 2 diabetes, the important message for healthcare professionals is clear. Health behaviour changes through increased physical activity and a modest 2.5% body weight loss by caloric restriction reduce the need for and cost of medications, decrease the rate of sleep apnea, improve urinary incontinence and improve well-being (
      The Look AHEAD Research Group
      Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
      ). The accompanying editorial stressed that physical activity and diet can safely reduce the burden of diabetes and “have reaffirmed the importance of lifestyle approaches as one of the foundations of modern diabetes care” (
      • Gerstein H.C.
      Do lifestyle changes reduce serious outcomes in diabetes?.
      ).
      We now have conclusive and compelling Level 1 evidence that health behaviour changes are safe and important in the long-term management, as well as prevention, of type 2 diabetes. Two recent publications on Canadian children and youth have reminded us of the pressing need for action for a pan-Canadian diabetes prevention strategy and importantly to promote healthy behaviour changes not only in Canadian adults but also in children and youth.
      A cross-sectional 2010–2011 youth smoking survey among Canadian high school students revealed some sobering statistics about these teenagers, who will become the stalwarts and financial supporters of their baby boomer parents in a few years. In this study, data on 7 modifiable health behaviours (tobacco, alcohol and marijuana use, overweight/obesity, physically inactive, highly sedentary, fruit and vegetable consumption) were collected from 31 396 students in grades 9 to 12 residing in 9 Canadian provinces and in Yukon and Nunavut of the Northwest Territories (
      • Leatherdale S.
      • Rynard V.
      A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health?.
      ). One in 5 Canadian youths (22.5%; n=276 100) was considered overweight or obese for their age and sex, with males being substantially more likely than females to be considered overweight or obese (p<0.001). A total of 31.2% (n=464 300) of students did not meet the physical activity guideline, almost 90% (n=1 463 900) were considered highly sedentary and 93.6% (n=1 487 400) reported inadequate fruit and vegetable consumption. The mean number of comorbid risk factors among respondents was 2.9 (±1.2). Among Canadian students in grades 9 to 12, only 0.5% (n=6000) reported having none of the risk factors and 0.3% (n=2800) reported having all 7 risk factors. The finding that large proportions of graduating students fail to meet many or most health behaviour guidelines is alarming and should give us cause for concern. It is evident that intervention strategies to reduce sedentary behaviours and increase fruit and vegetable intake must begin before high school. The authors concluded that there is “an urgent need to improve the health profile of Canadian secondary school students to avoid a large future burden of preventable disease” (
      • Leatherdale S.
      • Rynard V.
      A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health?.
      ).
      A second study used accelerometers to measure moderate- to vigorous-intensity physical activity (MVPA) throughout the week on the health of 745 children and youth aged 6 to 19 years (
      • Janssen I.
      • Wong S.
      • Colley R.
      • et al.
      The fractionalization of physical activity throughout the week is associated with the cardiometabolic health of children and youth.
      ). The participants were divided into 3 groups: insufficiently active, fewer than 60 minutes/day of MVPA on average; infrequently active, 60 minutes/day or more of MVPA on average but exceeding the 60 minute target fewer than 5 days; and frequently active, 60 minutes/day or more of MVPA on average and exceeding the 60 minute target 5 or more days. The percentile scores for 8 cardiometabolic risk factors were determined (physical activity level, body mass index, waist circumference, systolic and diastolic blood pressure values, plasma high-density lipoprotein-cholesterol and triglyceride levels, and insulin resistance by HOMA score). A key finding was that infrequently active children and youth were more insulin resistant than frequently active children. These differences remained after controlling for the weekly volume of MVPA. The results of this study have potential public health implications: 60 minutes of moderate- to vigorous-intensity physical activity on a daily or near-daily basis is beneficial to the cardiometabolic health of children and youth (
      • Janssen I.
      • Wong S.
      • Colley R.
      • et al.
      The fractionalization of physical activity throughout the week is associated with the cardiometabolic health of children and youth.
      ).
      In 2007, the International Diabetes Federation released a “Consensus on Type 2 Diabetes Prevention” document that urged governments of all countries to develop and implement a national diabetes prevention plan focused on controlling modifiable risk factors in 2 target groups: people at high risk of developing type 2 diabetes and the entire population (
      • Alberti K.G.
      • Zimmet P.
      • Shaw J.
      International Diabetes Federation: a consensus on type 2 diabetes prevention.
      ). They recommended that both population groups should be targeted simultaneously with lifestyle modification, with the primary goal through a stepwise approach. The first step is the identification of individuals from the overall population who may be at higher than average risk. The second step is to assess the risk properly by plasma glucose or hemoglobin A1C measurement. The third step is to implement strategies for intervention to reduce the risk. Health behaviour changes, or lifestyle modification, are the first choice to prevent or delay diabetes. Achieving a healthy body weight and avoiding sedentary behaviours by increasing and maintaining regular physical activity for at least 30 minutes of moderate exercise on most days of the week are important healthy behaviours that should be adopted. Pharmacologic therapy, and, more recently, bariatric surgery, also can be considered specific strategies that could be used for diabetes prevention. With respect to the population approach, the promotion of healthy behaviour changes not only reduces the prevalence of obesity and type 2 diabetes, but also other chronic diseases. This large-scale population strategy must be methodical and sustained to be successful. Despite having a national diabetes strategy, Canada does not have a national diabetes prevention plan in place. For its part, the Canadian Diabetes Association and Diabetes Québec issued a joint public release in 2011, entitled “Diabetes: Canada at the Tipping Point,” which summarized the challenges and opportunities to address the tsunami of type 2 diabetes that will affect about a third of the adult population (
      Canadian Diabetes Association
      Diabetes: Canada at the tipping point-charting a new path.
      ). Sadly, the media campaign generated little buzz and there was little follow-up action or movement.
      Dr. Ruth McManus, in a commentary that appeared in last year's issue of the Canadian Journal of Diabetes, issued a call for action for a Canadian proposal for primary prevention of type 2 diabetes mellitus (
      • McManus R.
      Time for action: a Canadian proposal for primary prevention of type 2 diabetes mellitus.
      ). She acknowledged patient, healthcare provider, health systems and research barriers when dealing with diabetes prevention, eloquently articulated opportunities and proposed practical and potentially implementable solutions.
      I strongly echo Dr. McManus's call for a pan-Canadian diabetes prevention strategy, aimed not only at adults but also children and youth, by promoting healthy behaviour changes in Canada, now!

      References

        • Hill S.
        • Gingras J.
        • Gucciardi E.
        The lived experience of Canadian university students with type 1 diabetes mellitus (T1DM).
        Can J Diabetes. 2013; 37: 237-242
        • Lowndes R.H.
        • Angus J.
        Diabetes care and mental illness: constraining elements to physical activity and social participation in a residential care facility.
        Can J Diabetes. 2013; 37: 220-225
        • Ekong J.
        • Russell-Mayhew S.
        • Aurthur N.
        Optimizing diabetes literacy: lessons from African Canadians in Calgary about type 2 diabetes diagnosis.
        Can J Diabetes. 2013; 37: 231-236
        • Messier L.
        • Elisha B.
        • Schmitz N.
        • et al.
        Changes in depressive symptoms and changes in lifestyle-related indicators: a 1-year follow-up study among adults with type 2 diabetes in Quebec.
        Can J Diabetes. 2013; 37: 241-248
        • Morrin L.
        • Britten J.
        • Davachi S.
        • et al.
        Alberta Healthy Living Program - a model for successful integration of chronic disease management services.
        Can J Diabetes. 2013; 37: 254-259
        • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association
        2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.
        Can J Diabetes. 2013; 37: S1-S212
        • The Look AHEAD Research Group
        Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.
        N Engl J Med. 2013; (Epub ahead of print)
        • Knowler W.C.
        • Barrett-Connor E.
        • Fowler S.E.
        • et al.
        Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin.
        N Engl J Med. 2002; 346: 393-403
        • Gerstein H.C.
        Do lifestyle changes reduce serious outcomes in diabetes?.
        N Engl J Med. 2013; (Epub ahead of print)
        • Leatherdale S.
        • Rynard V.
        A cross-sectional examination of modifiable risk factors for chronic disease among a nationally representative sample of youth: are Canadian students graduating high school with a failing grade for health?.
        BMC Public Health. 2013; 13: 569
        • Janssen I.
        • Wong S.
        • Colley R.
        • et al.
        The fractionalization of physical activity throughout the week is associated with the cardiometabolic health of children and youth.
        BMC Public Health. 2013; 13: 554
        • Alberti K.G.
        • Zimmet P.
        • Shaw J.
        International Diabetes Federation: a consensus on type 2 diabetes prevention.
        Diabet Med. 2007; 24: 451-463
        • Canadian Diabetes Association
        Diabetes: Canada at the tipping point-charting a new path.
        Canadian Diabetes Association, Toronto2011
        • McManus R.
        Time for action: a Canadian proposal for primary prevention of type 2 diabetes mellitus.
        Can J Diabetes. 2012; 36: 44-49