Section four concerted action to prevent diabetes

Diabetes is a serious public health issue that requires immediate and concerted action. Increasing rates of inactivity, obesity and diabetes, together with our rapidly aging population, present a situation that will be difficult not only for the individuals and families affected, but also for the entire health care system. A population health strategy to reduce the prevalence of Type 2 diabetes is a timely and critical response to these challenges.

Section four integrates the information from section one about successful population health promotion programs with what we know about current rates of diabetes (section two) and current efforts to prevent it (section three). It identifies some of the actions required for the development of a population health strategy to prevent diabetes. The section is organized according to the key principles of a population health approach as listed on pages 4 and 5.

Population-wide Programming

A population health approach targets the entire population or significant sub-populations rather than individuals or small groups. The distribution of diabetes in the region tells us that physical inactivity, obesity and diabetes are problems across all sectors of our population: men and women, young and old, rich and poor, and people of every culture. While some people are at greater risk than others of developing diabetes, we are all at risk of developing the consequences of high fat diets and sedentary lifestyles. Preventing diabetes truly requires a population-wide approach.

None of the current activity specifically aimed at preventing diabetes in the region is population-wide. Rather, it is aimed at individuals or delivered occasionally to small groups. Conversely, many of the initiatives to reduce inactivity and obesity are population-wide or have the potential to be so if resources were available. Most of the work of provincial recreation organizations (government and non-government) is population-wide. In the health sector, population-wide initiatives are less often the case, with considerable effort going to initiatives such as individual risk assessment and counselling and to various localized small-group programs aimed at increasing the knowledge and skills of participants. Where population-wide programs do exist, they are more often available in only one health region in a province. Most of the prevention work of health charities has the potential to be population-wide, but these organizations generally have insufficient resources to promote their programs as broadly as they would like.

There is clearly a need to develop population-wide approaches to promoting healthy weight and preventing obesity and to supporting the existing initiatives aimed at reducing inactivity. Whether there is a need to develop population-wide programming for diabetes prevention as such is less certain. As illustrated in Figure 9, programs to prevent the development of the two risk factors, obesity and inactivity, will achieve the same results as diabetes programs. Efforts to address the risk factors without tying them to any particular disease condition will likely be far more effective by reducing duplication and attracting a broader range of partners.

For many professionals in health and other sectors, working with populations rather than individuals requires new knowledge and skills as well as supportive organizational structures. The first step in reorienting prevention work to a population focus will be to build capacity in both organizations and individuals.

Action required:

• Build capacity in organizations and individuals to develop and implement population-wide programs.
• Support or expand existing population-wide programs to reduce inactivity and obesity where they exist.

Intersectoral Collaboration

A population health approach recognizes that the health sector alone can’t accomplish population-wide changes and that those working in the health sector must forge new relationships with groups not normally associated with health but whose activities have an impact on health. Important partners for preventing diabetes include national, provincial and regional government and non-government organizations in the health, recreation, education, social service and environment sectors, the food and food service industries, and communities.

Interestingly, as far as preventing Type 2 diabetes is concerned, much of the current effort is not led by the health sector at all, but rather by the recreation sector. Most of the work of the recreation sector to prevent inactivity is carried out through partnerships. Noteworthy are the province-wide intersectoral partnerships set up in every province in response to a national framework for action on physical inactivity published in 1997.

Even so, there are relatively few examples overall of the health and recreation sectors working together in partnership. Because physical inactivity is one of only two known modifiable risk factors for diabetes it is more important than ever for the health sector to use the expertise of the recreation sector in addressing diabetes.

Making inroads into the second risk factor, obesity, requires improvements in the nutritional quality of our Atlantic Canadian diet. This in turn requires significant changes in the way food is processed, marketed and distributed in the region. So far, only a very few initiatives have involved the food industry as partners. When considered at all the food industry is more likely to be seen as either a problem or a potential funder, not a full partner.

Those working in the health sector need to invite more partners to the decision-making table when planning strategies to address nutrition, obesity and diabetes. The recreation, health and food industry sectors must work together and with others on these challenging issues. By working together across sectors, organizations will multiply the available resources, get a much clearer understanding of what can be done and how, and develop the lasting relationships that can lead to long-term success.

Action required:

• Build capacity in organizations and individuals to work intersectorally to promote population health.
  
• Support existing province-wide intersectoral partnerships to reduce physical inactivity
  
• Develop and/or support province-wide intersectoral partnerships to address healthy weight that include all levels of government and the health, recreation and food industry sectors.
  
• Increase the use of intersectoral partnerships for planning initiatives in the areas of nutrition and healthy weight.

Action on Root Causes

Creating environments that support active lifestyles and healthy weights requires that we look at and act upon the broad range of factors and conditions that have a strong influence on health. This is still a new way of thinking for many people in the health sector; overall, much of the work that contributes to preventing diabetes in the Atlantic region is still aimed at increasing the knowledge of individuals. There appears to be some uncertainty about what is meant by acting on the factors we now call the determinants of health, and a limited range of approaches for doing so. This is probably at least partly a result of the scarcity of multisectoral partnerships. Actions on the determinants of health that can be taken by those in the health sector working alone are clearly limited.

Work on root causes, when it does occur, is primarily aimed at building social support networks or improving social and physical environments. We have a wide variety of examples of ways to improve physical environments, including active transportation programs and programs to develop trails, bikeways and other recreation facilities.

A great deal of research has demonstrated that the determinants of health create conditions for overall health or illness. It is interesting therefore to see, at least in the Atlantic region, that income does not appear to be predictive of the prevalence of diabetes and that education has less impact on the disease here than it does elsewhere. This is a good reminder that the conditions required to create optimum health overall are not likely to be the same conditions that prevent every specific disease condition. Although it would be premature to draw strong conclusions about the relationships between income, education and diabetes from a single study, these unexpected results do point to a need for further investigation in this area.

Action required:

• Build capacity in organizations and individuals to act on the root causes of poor nutrition and inactive lifestyles.
• Increase efforts to create environments that are conducive to healthy eating and physically active lifestyles.
• Investigate the relationship between diabetes, income and education in the Atlantic region.

Multiple Strategies and Sustained Effort

A population health approach recognizes that a population-wide change takes time and that no single intervention will be successful. Achieving complex behavioural changes throughout the population will require a long-term commitment that includes multiple interventions carried out at different levels over a period of time. The range of interventions required includes building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services. No existing organization in the region acting alone has the resources to mount and sustain this kind of effort. Support for infrastructure that can coordinate the action of numerous organizations is clearly necessary.

A few organizations in the region, all broad partnerships, are using multiple strategies for preventing inactivity or obesity. These will be important models that others can learn from, but their ability to sustain these partnership activities over time is uncertain, as few have an ongoing source of funding. Lack of resources for sustaining strategies over sufficient time to achieve an impact is an important issue.

Action required:

• Build capacity in organizations and professionals to use the full range of population-level strategies to improve nutrition and physical activity.
• Support the infrastructure to coordinate the work of numerous organizations.
• Develop long-term provincial strategies to address inactivity and obesity.
• Make long-term commitments to implement these strategies.

Evidence-based Planning

A population health approach bases policy and program decisions on sound evidence. Three kinds of information are essential for a strategy to prevent diabetes: statistical and demographic data to describe and monitor the current situation, evidence of what works based on published research, and community knowledge.

The National Population Health Survey, the Physical Activity Monitor and provincial diabetes registries (where they exist) provide excellent province-wide data for planning and monitoring larger initiatives, as will the forthcoming National Diabetes Surveillance System. Most of the multisectoral partnerships addressing the risk factors in the region recognize the value of local data and a few are gathering baseline data before implementing a strategy.

Measuring outcomes to demonstrate their effectiveness is an important component of several nationally led initiatives and for those associated with university research departments. Many region-wide initiatives are able to demonstrate their success with evaluation data – or hope to once their evaluation is completed. More initiatives are still not evaluated at all – or if they are evaluated, the evaluation looks at process and satisfaction measures rather than outcomes. Given that many of the outcomes associated with health promotion only occur after many years, collecting outcome data requires skills and resources that may be beyond the capacities of many organizations.

While evaluation and access to local data are essential to population health strategies, they are only part of the evidence picture. Both obesity and physical inactivity are complex issues that require complex responses. Any strategy to reduce these risk factors must be based on a clear understanding of what works. While there are no easy answers, the WHO document Obesity: Preventing and Managing the Global Epidemic provides an excellent review of the literature on prevention of overweight and inactivity. Organizations, professionals and volunteer decision-makers all need increased access to the research literature as well as the skills to interpret and use research results to make informed decisions.

Action required:

• Increase access of professionals and decision-makers to the results of research on the prevention of obesity and inactivity.
• Increase the ability of health and recreation professionals to use research results for policy and program planning.
• Increase the capacity of organizations to perform outcome-based evaluation.

CONCLUSIONS

The results of this environmental scan indicate that the population health approach to preventing diabetes is a new way of thinking for many people in the region. To translate this new way of thinking into new ways of acting, it will be necessary to increase the level of commitment and capacity within the organizations that are doing the work. A successful diabetes prevention strategy will thus require concentrated efforts to increase the capacity of organizations and individuals to work in collaboration with other sectors and to create environments and conditions that encourage healthy choices. These efforts must include training, resource material, access to information about what works, and adequate financial and human resources to reorient, coordinate and implement primary prevention programs.

The results also suggest that preventing diabetes will require two separate but related strategies, one for each of the two modifiable risk factors. In every province intersectoral partnerships to reduce inactivity have been created in response to a national policy framework, and work is well underway. These partnerships are an important first step for preventing diabetes, but they will need to take strong, sustained and well-designed measures in order to bring about measurable changes in behaviour. To do so they will need both political and financial support.

Province-wide intersectoral partnerships for improving nutrition are not as well developed. In some provinces, heart health projects have developed strong partnerships and implemented strategies within a single health region. This expertise and the infrastructure that has developed over the past decade are important resources for provincial strategies to improve nutrition. However, achieving a measurable, population-wide impact on obesity will require a policy framework that provides political and financial support to build capacity and coordinate the work of many organizations.

The Canadian Diabetes Strategy provides an excellent opportunity to improve population health for the new century. With adequate support, there already exist within the region all of the resources needed to take coordinated action to prevent diabetes. Major steps taken now will require additional funding, but to do nothing will in the end cost far more. A concerted effort to prevent inactivity and obesity now will bring results that extend far beyond diabetes to the prevention of other non-communicable diseases. In doing so, it will improve quality of life and reduce health care costs for decades to come.

Both government and non-government organizations across the region have developed a wide range of initiatives that contribute to the prevention of diabetes, including partnerships, resource material, services and programs that meet the particular needs of people at each life stage. The programs and the expertise that reside within these organizations provide a foundation for developing provincial population health strategies for reducing inactivity, obesity and diabetes.

While few of the current initiatives can have a widespread impact acting alone, every one of them can play an important role as part of a coordinated policy framework.

 

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