Type 2 Diabetes Prevention and
Health Promotion Strategy

STRATEGY FRAMEWORK

May 2001

Prepared by:

Table of Contents

I. Introduction

• Type 2 Diabetes
• Prevention
• Status and Risk Factors in Newfoundland and Labrador

II. Infrastructure

III. Guiding Principles

IV. Strategic Directions

• Provide Professional Education
• Create Awareness and Increase Education
• Build Capacity
• Create Healthy Public Policy and Legislation
• Increase Research
• Create Supportive Environments

V. Dissemination

I. INTRODUCTION

This strategy was developed through a joint initiative of the Newfoundland and Labrador Heart Health Program (NLHHP) and the Newfoundland and Labrador Division of the Canadian Diabetes Association (CDA). The initiative was funded by Health Canada through the Canadian Diabetes Strategy, and included the completion of a literature review and a consultative workshop. CDA and NLHHP succeeded in bringing together 50 individuals to develop a plan to address Type 2 diabetes prevention and health promotion. The goal of the project was: to enhance inter-sectoral, community based action around the prevention of Type 2 diabetes through the development of a strategy that promotes the achievement of healthy living and the creation of health enhancing policies and environments.

The Strategic Plan focuses on key elements of health promotion including: increased awareness, resource development, skills enhancement and advocacy. The ultimate target population for the strategy will be the general population. However, the immediate target are those people and organizations who are key players in developing and activating strategies to influence the health of the population. Through its development and implementation, the strategy focuses on intersectoral collaboration and builds on existing infrastructure.

TYPE 2 DIABETES

Type 2 Diabetes is a serious health issue affecting Newfoundlanders and Labradorians at an increasing rate. Diabetes warrants attention because of its widespread impact on the health of the population, the susceptibility of specific populations, and the significant social and financial costs incurred due to the complications of the disease. The increased prevalence of Type 2 Diabetes in the younger population, (67, 89, 106, 107, 123, 146, 148, 155, 159, 165, 172) and its critical presence in Aboriginal groups (38, 55, 56, 58, 60, 74, 75, 173, 191, 192, 193, 194) is reason for concern about disease progression and its future impact on Newfoundland and Labrador and on Canada. The estimated $9 billion spent in Canada annually on diabetes health care costs represents only part of the toll for 2.2 million Canadians with diabetes. The number of new cases (currently 60,000) diagnosed each year is expected to rise due to an overweight and aging population. Government attention and intervention is critical to the success of prevention strategies. (6, 14, 15, 43, 52, 63, 64, 65, 66, 68, 71, 72, 73, 77, 98, 99, 105, 106, 118, 142, 149, 157, 174, 184)

Sedentary lifestyles, obesity and poor nutrition put many people in this province at unnecessary risk of developing Type 2 diabetes. Lifestyle changes supported by health-enhancing environments can decrease that risk, reverse pre-diabetic conditions and prevent or delay the onset of Type 2 diabetes.

Type 2 diabetes includes many symptoms that develop over time and may remain undetected for up to ten years. The disease process may begin with genetic abnormalities which predispose individuals to metabolic changes. (3, 85, 86, 90, 94, 95, 97, 150, 187) However, genetic risk can be enhanced or minimized by lifestyle factors. Obesity, poor nutrition, inactivity, smoking and stress increase the risk of developing Type 2 diabetes. Increased physical activity can decrease risk, even in the presence of several other risk factors. Intervening in these lifestyle factors is the role of primary prevention. The likelihood of developing Type 2 diabetes is minimized by modifying unhealthy lifestyles before they have a significant detrimental impact on health. (1, 7, 9, 10, 15, 30, 31, 32, 45, 49, 51, 53, 60, 70, 89, 103, 116, 123, 125, 143, 145, 146, 147, 154, 156, 160, 162, 163, 165, 171, 172, 175, 178, 179, 181, 182, 183, 185, 186, 194)

PREVENTION

Intensive lifestyle interventions to promote health, although difficult for the individual to sustain, are fundamental to disease prevention. These interventions are most successful when the individual does not function in isolation but instead is surrounded by a supportive environment. This health promoting environment enables and reinforces individual change by providing awareness, access, availability, knowledge, motivation, skills, facilities, professional involvement and consistent support. Interventions must be appropriate to the individual's cultural background and to his/her level of readiness to change. (12, 20, 24, 33, 34, 35, 37, 41, 44, 47, 59, 62, 76, 81, 83, 87, 92, 93, 96, 108, 109, 110, 115, 117, 119, 127, 151, 153, 157, 161, 168, 177, 196)

Prevention initiatives have addressed:

• individual efforts to decrease weight, improve nutrition, and increase activity;
• community efforts to increase awareness and education of risk factors and preventive lifestyles; and, to support lifestyle changes by providing facilities and services such as walking trails, community cooking classes, lifestyle clinics and heart smart restaurant choices;
• professional efforts to offer education, counselling and support for lifestyle changes; and to offer testing and screening for pre-diabetic conditions;
• research on the causes and risk factors for developing Type 2 diabetes; and, on the impact of lifestyle changes and drug interventions.

The combination of these initiatives has brought measurable success in awareness, knowledge, behaviour change and physical health indicators. To create significant change in the population as a whole, initiatives will have to be wide-spread and sustained.

STATUS and RISK FACTORS IN NEWFOUNDLAND and LABRADOR

According to available data, Newfoundland and Labrador has a diabetes prevalence of 4.6% compared to the national rate of 3.2%. This is the highest provincial rate in Canada. The rate of diabetes among the Aboriginal population of Atlantic Canada is 6.8%, with females accounting for two thirds of those affected.

In Atlantic Canada, diabetes is associated with higher income (just above 4%) more frequently than with lower income (just below 4%). This is in contrast to Canada as a whole where diabetes is more frequently associated with lower income (4.5%) than with higher income (3%). For other population-based risk factors, the Atlantic Provinces follow national trends. The diabetes rate is 15% among seniors 70 years or more and those who have not completed high school have a prevalence of almost 5% compared to approximately 3.5% of those with some post secondary education.

When considering lifestyle related risk factors for Type 2 diabetes, the prevalence in this province is higher than national rates. For the modifiable risk factors: obesity and inactivity, in the adult population 39% are overweight and 67% are inactive. (105)

II. INFRASTRUCTURE

Resources, already dedicated to health promotion, exist throughout the province. These include the many partners who collaborated on the creation of this strategy:

The Newfoundland and Labrador Heart Health Program (NLHHP) has been active throughout the province since 1990. Its purpose is to promote community awareness of healthy living and to support community action. The NLHHP has supported significant, province-wide, community-based action to promote healthy eating and active living including a well established network of six Regional Coalitions (see Appendix B) involved in sustained local action. Local Health and Community Services offices are major supporters of these coalitions, providing clerical support, supplies, meeting space, travel expenses and staff time. The Labrador Inuit Health Commission and Innu Band Council also support this initiative. A provincial support team also exists which coordinates communication, develops and distributes resources and conducts research into the effectiveness of programming. Local Recreation Commissions and staff of the Department of Tourism, Culture and Recreation contribute to the coalitions as well as providing additional support for community action.

The focus for the Canadian Diabetes Association, Newfoundland and Labrador Division (CDA) has traditionally been on providing research, education, service, and advocacy. Although efforts nationally and provincially were directed toward promoting the health of individuals with diabetes, this emphasis has changed significantly, the Canadian Diabetes Association is now focusing considerable effort and resources on the prevention of Type 2 diabetes. The Newfoundland and Labrador Division of the CDA has a network of fourteen Local Branches (see Appendix B), with seven of those being currently active. Local branch activities include: public awareness, information and education sessions in the workplace and community settings; fund-raising and awareness activities; cooking classes and meal preparation sessions; and summer camp and exercise programs. Community Diabetes Educators are critical in identifying local risk patterns and in engaging those affected by diabetes in this prevention initiative.

The Newfoundland and Labrador Public Health Association membership has extensive knowledge and experience related to community based health promotion and is a resource to promote and disseminate the strategy.

The University supports a variety of clinical and epidemiology research at a university and community level, and in collaboration with Professional Associations, plays an important role in professional education.

Community Volunteers play an important role in ensuring the community relevance of activities and in the sustainability of the strategy.

III. GUIDING PRINCIPLES

Workshop participants developed principles which should guide the development of all initiatives within this strategy.

Respect for all points of view and the development of activities, within an atmosphere of trust and partnership, and with an understanding that the community or individual has ultimate ownership and control are essential. Professionals should help individuals and communities to acquire the knowledge, skills and resources needed to make informed choices. Equitable resources, services and supports are necessary throughout the province. Creative use of technology and other resources will also be essential to success.

Prevention and health promotion initiatives should be the best, most effective strategies possible, and they should be done without added harm. Cultural appropriateness should be a fundamental consideration during planning, as is the use of a population health approach, incorporating concepts of the determinants of health, health promotion, adult education and social marketing. Health promotion initiatives are often dependent on volunteers, they play a role at the community level. They must receive adequate training and support.

A consistent and coordinated integration of beliefs, ideas and actions is important to achieving the goals identified for this strategy. Successful implementation of the strategy will require collaboration among groups committed to the promotion of health and the prevention of Type 2 Diabetes.

IV. STRATEGIC DIRECTIONS

Six Strategic Directions were defined for the province-wide Type 2 diabetes prevention and health promotion strategy. Participants attending the 12-14 March 2001 workshop worked through each direction to establish a broad goal and identify the critical issues and actions that would lead to the attainment of the individual goals for each direction.

Priority areas were identified. The strategy offers a framework to ensure that each area is addressed. Goals, actions and potential leaders were identified under each of the strategic directions with practical suggestions to achieve the goals. The strategy attempts to provide guidance to:

• Provision of professional education;
• Creation of awareness and increased public education;
• Building capacity;
• Creation of healthy public policy and legislation;
• Increased research;
• Creation of supportive environments.

These directions reflect a population health approach which should guide the action of partners throughout the province and contribute to the primary prevention / health promotion component of the Provincial Diabetes Strategy. The strategic directions create a comprehensive pathway that can be used by those who have an interest in the prevention of Type 2 diabetes. As individuals, organizations or in partnerships, they will be able to make an effective and meaningful contribution to prevention. The directions allow the flexibility that will be needed to adapt to different needs and resources and individual or community capacity.

Professional education is a significant component in the overall strategy. For use in this strategy, "professionals" includes individuals who have specific training in health or education and who are in a position to provide direct health service or lifestyle education to the public. The list is not exclusive but includes: physicians, nurses, dietitians, health educators, fitness and recreation directors, early childhood educators and teachers. These professionals influence healthy lifestyle choices and are advocates for supportive environments. Medical practitioners are usually the first contact for individuals experiencing health problems, and it is important that family physicians be well informed about the risk factors and the potential for preventing or reversing clinical conditions which appear prior to the onset of Type 2 diabetes. Other professionals are in a position to recommend, facilitate and reinforce healthy lifestyle choices. Enhanced curriculum and continuing education are key areas for intervention.

Professional Education Goal. . . to support the education of professionals to promote healthy eating and active living in the prevention of Type 2 diabetes.

Six priorities were identified:

#1. Commitment of Resources

#2. Key Target Groups

#3. Universal, Consistent Messages

#4. Accessibility, Increased Opportunity for Education

#5. Continuing Education, Credentials

#6. Educating Professionals

Lifestyle changes have the potential of preventing or delaying the onset of Type 2 diabetes in at-risk individuals. Awareness of the seriousness of Type 2 diabetes and knowledge of how to prevent it are critical pre-requisites to behaviour change. Approximately 30% of individuals who have Type 2 diabetes are unaware of it. Awareness strategies directed toward a general audience include mass media promotions, special events and site specific initiatives such as community, school or workplace programs.

Awareness - Public Education Goal . . . to increase public awareness and education around the prevention of Type 2 diabetes.

Four priorities were identified:

#1. Public Attitude Change

#2. Political Commitment

#3. Consistent Messages and Resources