Sitting and Sedentary Behaviours: A Public Health Problem?

Vol. 19, No. 1 - March 2012

By Adrian Bauman, Professor, School of Public Health, University of Sydney; Dr. Hidde Van der Ploeg, Senior Research Fellow, School of Public Health; Josephine Chau, Research Officer, School of Public Health

Summary

What are the health risks to the public from too much time spent sitting down or engaged in other sedentary behaviours? An increasing body of evidence is suggesting that an individual’s sedentary behaviours can have a detrimental effect on health, independent of how much physical activity the person does.  This article offers some insights and answers, and presents some recent research findings. 

What are the health risks to the public from too much time spent sitting down or engaged in other sedentary behaviours? This article offers some insights and answers, and presents some of our recent research findings.

An increasing body of evidence is suggesting that an individual’s sedentary behaviours can have a detrimental effect on health, independent of how much physical activity the person does. The evidence also suggests that high volumes of sedentary behaviours might increase the risk of obesity, cardiovascular disease, and in particular, diabetes.

About Sedentary Behaviour

Sedentary behaviour is defined as low intensity activities that consume 1.5 METs of energy, such as sitting and lying down.

The interesting “catch” about sedentary behaviours and physical activity levels is that a person can be both physically active (e.g., by meeting or exceeding recommended physical activity guidelines) and sedentary at the same time. Many people (possibly including you, the reader!) fit this description or category.

For instance, if an adult person walks briskly, runs or skates for 30 minutes or more every day, they will exceed the recommended minimum of 150 minutes/week of moderate- to vigorous-intensity physical activity. However, the same person could be a “high volume sitter” if they spend most of the rest of their waking hours sitting down or being sedentary.

In this example, the person may well obtain health benefits from meeting the physical activity recommendations, but there may be independent detrimental effects from prolonged sitting or sedentary behaviours.

Systematic Reviews

Recently, we have participated in two systematic reviews that have focused on “sitting and health” epidemiology and on “interventions to reduce sitting in the workplace.”

These studies have shown that sedentary behaviour and health research is still in its infancy, evidence is still accumulating and more high quality studies with better measures of sedentary behaviours are needed before we can develop guidelines and implement policy (van Uffelen et al, 2010; Chau et al, 2010).

Workplace-Related Research

Our research group at the Sydney University School of Public Health in Australia, does research on both physical activity and sedentary behaviours. With respect to sitting and sedentary behaviour, we have been interested in measurement, epidemiology and surveillance from a public health perspective. We have developed accurate tools for measuring sitting in populations; and studied the prevalence and correlates of sedentary behaviour and their associations with health outcomes.

We have recently developed and tested a surveillance measure to more accurately assess sedentary and physical activity behaviours during work.

The Occupational Sitting and Physical Activity Questionnaire (OSPAQ) was specifically designed for population health surveys that have limited space for questionnaire items. OSPAQ was recently published in Medicine & Science in Sports & Exercise (Chau, van der Ploeg, Dunn, Kurko, & Bauman, 2012).

We also recently developed and tested a questionnaire, the Workforce Sitting Questionnaire (WSQ), which assesses total sitting time during work, leisure and transportation. This was published in the British Journal of Sports Medicine (Chau, van der Ploeg, Dunn, Kurko, & Bauman, 2011).

Time Use Surveys

Besides a focus on improving the measurement of sedentary behaviour, we do research into the population prevalence and epidemiology of sedentary behaviours. One of the more innovative ways to study changes in the population levels of sedentary behaviours is the utility of Time Use Surveys.

Time use surveys have been collected as early as the 1960s, and have their origin in sociology, but have also been shown to accurately assess physical activity and sedentary behaviours (van der Ploeg et al, 2010).

Our ongoing epidemiological work on the detrimental effects of sedentary behaviours on health has been through longitudinal population cohort studies, which include the 45 and Up study in Australia (the largest prospective cohort study in the southern hemisphere), as well as other studies internationally.

Preliminary findings in our Australian data are similar to the Canadian PALS study, which showed in longitudinal analyses, that time spent sitting was a risk factor for all cause mortality, independent of physical activity level (Katzmarzyk, Church, Craig, & Bouchard, 2009).

Looking Ahead

Sedentary behaviour research is at an early stage, and there are still a lot of unknowns. Importantly, the volume and dose of sitting that is hazardous to health is not exactly identified.

Future epidemiological work will help to quantify the amount of sitting time that is potentially harmful to health and also further our understanding of which health outcomes are related to sitting. The role of breaking up sedentary behaviour to improve metabolic health is also receiving research attention.

Eventually, when we understand how much sitting is hazardous, and what recommendation(s) would be health-promoting, we need to develop policies, guidelines and eventually interventions to decrease sedentary behaviours.

Generally, the development of interventions to reduce sitting time is “work in progress.” Part of this work involves consulting with workplaces, advocating for active transport, and determining what kinds of interventions are feasible and practical, in different settings. As more research and evidence comes to light, it can contribute to a healthier and “upstanding” future.

Key Term

MET: metabolic equivalent or metabolic equivalent of task. The amount of energy used by the body to perform a physical activity or daily task. At rest, the average person has an oxygen consumption of 1 MET (or 3.5 ml/kg-min). If a person works harder and uses more oxygen during an activity, MET values go higher; light activities are those which consume 3 METs, moderate activities (e.g., brisk walking) consume to 6 METs, while vigorous activities, such as running, more than 6 METs.

About the Authors

Dr. Adrian Bauman is Sesquicentenary Professor of Public Health (Behavioral Epidemiology and Health Promotion) in the School of Public Health at Sydney Medical School, University of Sydney, Australia. 

Dr. Hidde Van der Ploeg is Senior Research Fellow in the Cluster for Physical Activity and Health, at the School of Public Health. Ms. Josephine Chau is Research Officer, Prevention Research Collaboration at the School of Public Health.

 
References

Chau, J., van der Ploeg, H., van Uffelen, J., Wong, J., Riphagen, I., ... Brown, W. (2010). Are workplace interventions to reduce sitting effective? A systematic review. Preventive Medicine, 2010, 51, 351–356. doi:10.1016/j.ypmed.2010.08.012

Chau, J., van der Ploeg, H., Dunn, S., Kurko, J., & Bauman, A. (2012). Validity of the Occupational Sitting and Physical Activity Questionnaire (OSPAQ). Medicine & Science in Sports & Exercise, 2012, 44, 118–125. doi: 10.1249/MSS.0b013e3182251060

Chau, J., van der Ploeg, H., Dunn, S., Kurko, J., & Bauman, A. (2011). A tool for measuring workers' sitting time by domain: the Workforce Sitting Questionnaire. British Journal of Sports Medicine, 45, 1216-22. doi:10.1136/bjsports-2011-090214

Katzmarzyk, P., Church, T., Craig, C., & Bouchard, C. (2009). Sitting time and Mortality from All Causes, Cardiovascular Disease, and Cancer. Medicine & Science in Sports & Exercise, 41, 998-1005. doi: 10.1249/MSS.0b013e3181930355

van der Ploeg, H., Merom, D., Chau, J., Bittman, M., Trost, S., & Bauman, A. (2010). Advances in population surveillance for physical activity and sedentary behavior: reliability and validity of time use surveys. American Journal of Epidemiology, 2010, 172, 1199-1206. doi: 10.1093/aje/kwq265

van Uffelen, J., Wong, J., Chau, J., van der Ploeg, H., Riphagen, I., ... Brown, W. (2010). Occupational sitting and health risks: a systematic review. American Journal of Preventive Medicine, 39, 379-388. doi:10.1016/j.amepre.2010.05.024

Innovations in Knowledge Translation: the SPHERU KT Casebook

Vol. 19, No. 1 - March 2012

By Juanita Bascu, MA, Project Coordinator, SPHERU; Fleur MacQueen Smith, MA, Knowledge Transfer Manager, Healthy Children Research Team, SPHERU

Summary

The SPHERU KT Casebook, published in 2011, highlights stories of innovative methods of sharing health research findings. It includes 15 knowledge translation (KT) stories and provides examples of knowledge translation strategies, methods and evaluation from across Canada and beyond. The Casebook will be of interest to academics, researchers, community practitioners, policy makers and others interested in KT.

In late 2009, the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) issued a call for knowledge translation (KT) abstracts, asking researchers, policy makers, community practitioners and others to submit examples under one of the three themes:

• KT strategies;
• KT in action that led to changes in policy or practice; and
• evaluation of KT effectiveness.

Cases were peer-reviewed by a selection committee and several independent reviewers. Summaries of three of the cases are presented herein. The full casebook can be downloaded at www.spheru.ca or www.kidskan.ca/KTcasebook.

1. Bringing together researchers and decision-makers to evaluate a complex health program

In mid-2010, a team of researchers and decision-makers led by SPHERU’s Nazeem Muhajarine wrapped up a three-year evaluation of KidsFirst, the Saskatchewan government’s targeted early intervention program for very vulnerable young children and their families (Government of Saskatchewan, 2007).

This project used integrated KT to engage potential research-users as partners in the research process.

Three strategies were important in establishing and maintaining this community-university partnership: regular interactions, joint funding, and joint authorship of reports.

The research team met in person and by teleconference several times a year, and interacted regularly by e-mail and phone with other team members, research staff, and program managers and staff of the government unit responsible for KidsFirst.

Both the university and government partners provided funding for this evaluation: the university through a grant from a national funding agency, and the government through program funds at the ministry and site levels.

Finally, on the many documents produced as part of this evaluation, people who were not named as authors were credited in the acknowledgements (reports are available at www.kidskan.ca/kidsfirst).

The authors concluded that although collaborative research takes more time than investigator-driven research, it can be more fulfilling as decision-makers can take ownership of the research process, making it more likely that research findings will be put into policy and practice.

2. How a student health survey improved health services in schools and communities

When troubling health disparities based on geography were found in Saskatoon (Lemstra, Neudorf, & Opondo, 2006), the Saskatoon Health Region pursued a program of research to address the disparities and introduce evidence-based interventions using an integrated KT approach.

As part of this work, researchers developed the Saskatoon School Health Survey, and surveyed students in grades five to eight about physical activity, mental health, risk behaviours, bullying and various health determinants.

Results were disseminated through face-to-face interactions with stakeholders, fact sheets, school visits, as well as traditional KT approaches such as peer-reviewed journal articles and conference presentations.

Team members also established a school health committee that brought together senior health region officials and school board staff, and principals and community workers in six low-income neighbourhoods to use the findings to change practices.

Changes included the health region’s reassigning public health staff to these neighbourhoods, opening pediatric clinics at two community schools, and funding ten community schools for after-school programs to promote physical activity and mental health.

The authors concluded that an intersectoral approach, such as bringing together education and health, can be effective if the sectors’ priorities are similar, and that dissemination of research results needs to be comprehensive, and tailored to each audience’s needs.

3. Tracking the dissemination of research findings through interviews and maps

In 2006, a SPHERU team published a Community Health Indicators Toolkit based on an evaluation conducted with nine northern Saskatchewan communities to track progress on community-identified health indicators and inform decision-making (Jeffery et al., 2006).

The toolkit included a Community Health and Wellness Framework comprised of six domains, with 225 potential indicators that reflect northern Saskatchewan views of healthy community, and detailed Program Logic Models for each community-based service.

To determine how this toolkit was being distributed and used, the researchers conducted interviews with people using it. Interview participants discussed how they applied the community health domains and indicators to develop community projects, and those outside of northern Saskatchewan talked about using it as a resource for developing their own indicators. Researchers also mapped when and where the Toolkit was distributed, and included photographs and information on usage in an interactive version of the map.

They concluded that the Toolkit, while developed in partnership with specific communities, has some applicability to communities outside northern Saskatchewan, and that training sessions would increase its use. They also found mapping its dissemination useful to evaluate distribution and provide information about the different uses for the Toolkit.

Key Term

Knowledge Translation (KT): The Canadian Institutes of Health Research (CIHR) define KT as “the exchange, synthesis and ethically-sound application of knowledge – within a complex system of interactions among researchers and users – to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system” (CIHR, 2012).


About the Authors

Juanita Bascu, MA, is a Project Coordinator for SPHERU, and was Managing Editor for the KT Casebook.

Fleur Macqueen Smith, MA, is the Knowledge Transfer Manager for the Healthy Children Research Team at SPHERU, and was Managing Editor for the KT Casebook.

Mike Chouinard, a Research Officer with SPHERU, helped with the preparation of this article.


About the Organization

The Saskatchewan Population Health and Evaluation Research Unit (SPHERU) is a bi-university research unit with offices located across Saskatchewan, in Regina, Prince Albert, and Saskatoon. SPHERU engages in population health research, which is the study of social factors that contribute to the well-being of various groups within the population. Working across various disciplines, SPHERU researchers collaborate with communities, other academics, and policy-makers to undertake this critical research.

References

Canadian Institutes of Health Research. (2012). Knowledge Translation Strategy 2004-2009: section two, Defining and Framing Knowledge Translation. Retrieved from http://www.cihr-irsc.gc.ca/e/26574.html#defining

Government of Saskatchewan. (2007). KidsFirst Strategy: Performance Plan 2006-2007. Retrieved from http://www.education.gov.sk.ca/KidsFirst-Publications

Jeffery, B., Abonyi, S., Hamilton, C., Bird, S., Denechezhe M., … Whitecap, Z. (2006). Community Health Indicators Toolkit. University of Regina and University of Saskatchewan: Saskatchewan Population Health and Evaluation Research Unit. Retrieved from http://www.uregina.ca/fnh

Lemstra, M., Neudorf, C., & Opondo, J. (2006). Health Disparity by Neighbourhood Income. Canadian Journal of Public Health, 97, 435-439.

Outside Looking In: A Recreational Youth Development Program for Aboriginal Youth

Vol. 18, No. 4 - December 2011

By Audrey R. Giles, PhD, Associate Professor, School of Human Kinetics, University of Ottawa; Alana Rovito, BHKin; and Outside Looking In

Summary

This article describes how an arts-based, recreational youth development program called Outside Looking In is part of a new trend that is more inclusive of Aboriginal cultural practices and values, and more focused on addressing the self-determined needs of Aboriginal people.

In Canada, sport and recreation programs for Aboriginal youth have typically used interventions aimed at affecting, modifying or controlling social behaviours. This article describes how an arts-based, recreational youth development program called Outside Looking In is part of a new trend that is more inclusive of Aboriginal cultural practices and values, and more focused on addressing the self-determined needs of Aboriginal people.

About the Program

Outside Looking In (OLI) is a youth development program created by Aboriginal people for Aboriginal people. The program offers Aboriginal youth the opportunity to be involved in arts-based physical and recreational activities. The program is also set up to provide non-Aboriginal Canadians the opportunity to learn about Aboriginal peoples through OLI’s annual multi-media performance in Toronto.

To be eligible for the OLI program, an applicant community must illustrate that they have volunteers and leadership committed to collaborating with OLI, and that they are willing and able to provide a sponsorship (currently $25,000) to aid in supporting the OLI program. Successful applicant communities are chosen by OLI employees and members of its Board of Directors.

OLI Program Planning Begins Early

At the beginning of the school year (September), key players from the participating community meet with OLI representatives. At this stage, plans are developed for the arts-based recreational activities that the youth from the community will later be engaged in, starting in January.

Typically, the key players involved in the program planning include school teachers and principal(s), as well as community volunteers. In the past, the OLI program has been run as an extracurricular activity. As of fall 2011, the program can be run as a high school credit course.

Program Activities

Through the credit course, students are engaged in hip-hop dance activities, with the goal of creating a dance routine. The routine is choreographed and directed by a professional dance teacher. The teacher works with the youth in their communities for 2 to 3 days every other week, for up to 6 months (January to May/June). In between these visits, the school staff and community volunteers continue to help the youth to rehearse and complete all course requirements.

Although dance is the main activity, students also get the chance to take part in photography, videography, painting, journal writing, and choreography, which are also showcased in Toronto.

At the end of the school year, the students travel to the Tim Horton Children’s Foundation camp near Brantford, Ontario for a two-week stay. There, the youth participate in dance rehearsals and a wide range of camp, recreational and educational activities. After camp, the youth then go to Toronto to present their dance and multi-media performance at the St. Lawrence Centre for the Arts. To date, 87 Aboriginal youth from four communities have performed in Toronto.

Objectives

The OLI program aims to build the self-esteem, sense of accomplishment and confidence of Aboriginal youth.

These objectives are partly reflected in OLI’s program policy which requires that:

• youth attend school on a regular basis and commit to achieving good academic standing in tests, exams, and assignments; and
• youth be responsible for attending rehearsal punctually, notifying school staff prior to any absences, and for displaying positive and respectful behaviours during rehearsals.

To remain in the program and earn the opportunity to perform in Toronto, participants must follow these rules, which are further detailed and enforced by the participating community.

Many youth who have been in the program are enthusiastic about it. For instance, one participant named Roni-Lyn stated, “OLI kept me motivated to stay in school all year… it helped me learn that I can actually do something so amazing, even if it takes a lot of hard work.” Anecdotal reports such as this one point to the need for research to understand how and why OLI has been successful.

Research Efforts

Beginning in 2011, under direction from OLI staff and members of the Board of Directors, we will research the history of OLI and the ways in which OLI is able to reflect Aboriginal values. The research will involve:

• obtaining data by interviewing OLI staff and Board members
• participating in OLI teleconferences
• attending OLI performances
• reviewing OLI archives

Through this research project we hope to better understand the ways in which youth development programs for Aboriginal youth can be more culturally-sensitive and contribute to Aboriginal peoples’ self-identified goals.

For example, though it is now commonly understood that self-determination is necessary for any successful health (e.g., Kelm, 1998) or education (e.g., Battiste, 2004) intervention that targets Aboriginal populations, recreation-based interventions are rarely founded in Aboriginal peoples’ self-determined needs.

We are thus particularly interested to learn if OLI – which is an intervention by Aboriginal peoples for Aboriginal peoples – experiences success because of its reflection of and engagement with Aboriginal peoples’ values and cultures.

Key Terms

Culturally-sensitive – Approaches to program initiatives that incorporate and consider individuals’ cultural histories and meanings.

Self-determination – Input and control by Aboriginal peoples.

Aboriginal youth development – The ways in which recreation is used as a means to positively influence and impact Aboriginal youth.

 About the Authors

Audrey R. Giles is an Associate Professor in the School of Human Kinetics at the University of Ottawa.

Alana Rovito holds a Bachelor of Human Kinetics from the University of Ottawa and is currently a Masters student in the Human Kinetics program.

Tracee Smith holds an Honours Bachelor of Arts in Dance and an MBA specializing in Indigenous Economic Development. She is a member of the Missanabie Cree First Nation in northern Ontario and the founder of Outside Looking In.

Stephanie Cressman is the program manager for Outside Looking In.

The research partnership between the University of Ottawa and OLI is one of three research projects funded by the Social Sciences and Humanities Research Council of Canada (SSHRC).

References

Battiste, M. (2004). Animating sites of postcolonial education: Indigenous knowledge and the humanities. Retrieved December 12, 2006, from http://www.usask.ca/education/people/battistem/pdf/csse_battiste.pdf

Kelm, M-E. (1998). Colonizing bodies: Aboriginal health and healing in British Columbia 1900-1950. Vancouver: UBC Press.

Challenges in Meeting Diabetes Nutrition Recommendations in an Elderly Population

 Vol. 18, No. 4 - December 2011

By Ghada Asaad, MSc student, and Catherine Chan, PhD, Professor, Physiology and Human Nutrition, University of Alberta

Summary

This article discusses the findings of a research study that examined the accessibility and availability of food items in the diet plans of low-income, elderly people with type 2 diabetes, living in the City of Edmonton. The findings serve to outline some of the challenges faced by the elderly in following a diabetes diet, particularly those with low income who may experience food insecurity.

The purpose was to investigate the relationship between food security, accessibility to appropriate food and diet adequacy, as defined by the Canadian Diabetes Association (CDA) nutrition therapy guidelines. 

Food Insecurity Related to Diabetes Management

Availability of foods is defined as the presence of food items in stores, while accessibility is the ease of obtaining these items (Farley et al, 2009).  Limited availability or accessibility to foods specified for a diabetes diet may be barriers to adherence to nutrition recommendations. 

These barriers may be higher for low-income elderly people.  For example, a low-income elderly person may be reliant on public transportation to get to food stores, or may not be able to afford certain foods.  Plus, in some cases, they may not have access to larger supermarkets with a good variety of foods.

In Edmonton, so-called food deserts (areas lacking grocery stores) have been identified (Smoyer-Tomic, Spence, & Amrhein, 2006).  Diet quality is negatively affected by the distance to the nearest grocery store (Morland, Wing, Diez Roux, & Poole, 2002). Moreover, perceived cost is a predictor of diet compliance (Monsivais, Mclain, & Drewnowski, 2010). 

In Alberta, 10.7% of households reported moderate to severe food insecurity in 2004 (Health Canada, 2007). Food insecurity is associated with higher prevalence of chronic disease, including diabetes. 

Being food insecure creates a conflict between basic survival and effective diabetes management. Effective diabetes management requires enough income to maintain a high quality diet, purchase blood glucose testing supplies and pay for other items needed to meet health objectives.

Research Methods for this Study

Participants were recruited from retirement homes where residents are eligible for rent subsidies based on their income.  Each participant completed a questionnaire regarding their perceptions of food accessibility and availability.  Participants also completed an assessment of all food and drink consumed in the past 24 hours, a socio-demographic questionnaire and a food security questionnaire (Health Canada, 2007). 

Diet quality was computed using the Healthy Eating Index-Canada system, modified to account for the CDA recommendations and the recommendations for senior citizens included in Eating Well with Canada’s Food Guide.

Results

Participant characteristics

All participants were type 2 diabetes patients with an average age of 71 years and average duration of diabetes of 17 years.  The majority (65%) had a household income of less than $21,000 annually.

Food Accessibility and Availability

Half of the participants owned and drove a vehicle, while the average distance to a grocery store was less than 4 kilometres, suggesting that physical accessibility to appropriate food was not an issue for most.  However, more than half reported spending more money on fruits and vegetables than before their diagnosis.  The majority of people reported they could obtain the foods needed for their diabetes diet at a local grocery store. 

Knowledge is also a component of accessibility. When asked what resources they consulted to determine what they should eat, only 50% said they received advice from a dietitian.  Perhaps as a consequence, only 65% reported being advised to follow Eating Well with Canada’s Food Guide.

Participants’ knowledge of other dietary or nutritional recommendations was even lower; about half reported that they had received advice to avoid high fat foods, while 40% had been advised to eat high fibre foods and only 12% were told to eat low glycemic index foods.

Diet Quality and Food Security

Diet quality was scored out of a maximum of 100, with the average for this group being 66.  All participants were rated as “Needs Improvement” or “Poor”. 

The number of servings of fruits and vegetables, grains, and milk products were all low compared with the recommendations in Eating Well with Canada’s Food Guide (see Figure 1). 

The diet quality score was not related to food accessibility variables, such as mode of transportation or distance from the grocery store. The majority of participants (70%) rated themselves as food secure but the remaining 30% were severely food insecure. 

Curiously, the food insecure group reported higher intake of grains and meat and alternatives than the food secure group, but intakes of other food groups were not affected.

Conclusions

In this study, we found that the low-income, elderly persons with diabetes had generally poor diet quality, despite reasonable accessibility and availability of food. 

However, diet quality was not associated with food security status. This may have been because we purposely selected participants with low income.  Alternatively, people who experience food insecurity may plan food purchases more carefully.

Lack of access to knowledge of diabetes nutrition recommendations, such as those regarding low glycemic index foods, may decrease dietary adherence.  Furthermore, many participants had not received dietary advice from a dietitian. These findings point to the need for recurring diabetes education and greater access to dietitians.

Key Terms

Food Insecurity - A person experiences food insecurity when they cannot obtain the food they need (to reduce or eliminate hunger) because of financial constraints (low income). 

Food Availability – the presence of food items in stores.

Food Accessibility – the ease of obtaining food items in stores.

About the Authors

Ghada Asaad is a Master of Science student in Agricultural, Food and Nutritional Sciences working on the PANDA project.

Cathy Chan is a Professor of Human Nutrition and Physiology at the University of Alberta, and the leader of the PANDA Research Team.

References

Farley, T.A., Rice, J., Bodor, N.J., Cohen, D.A., Bluthenthal, R.N., & Rose, D. (2009). Measuring the food environment: Shelf space of fruits, vegetables, and snack foods in stores. Urban Health, 86, 672-82.
doi: 10.1007/s11524-009-9390-3

Health Canada. (2007). Canadian Community Health Survey, Cycle 2.2, Nutrition (2004) – Income-related Household Food Security in Canada. Retrieved October 13, 2011, from http://www.hc-sc.gc.ca/fn-an/alt_formats/hpfb-dgpsa/pdf/surveill/income_food_sec-sec_alim-eng.pdf

Monsivais, P., Mclain, J., & Drewnowski, A. (2010). The rising disparity in the price of healthful foods: 2004-2008. Food Policy, 35, 514-20
doi:10.1016/j.foodpol.2010.06.004

Morland, K., Wing, S., Diez Roux, A., & Poole, C. (2002). Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine, 22, 23-9.
doi: 10.1016/S0749-3797(01)00403-2

Smoyer-Tomic, K.E., Spence J.C., & Amrhein, C. (2006). Food deserts in the prairies? Supermarket accessibility and neighborhood need in Edmonton, Canada. The Professional Geographer, 58, 307-26.
doi: 10.1111/j.1467-9272.2006.00570.x



Healthy Eating and Active Living for Diabetes in Primary Care Networks

Vol. 18, No. 3 - September 2011

Summary

This article describes the role played by exercise specialists in delivering the HEALD-PCN program and outlines which variables will be tracked to determine the success of the program.

The Healthy Eating and Active Living for Diabetes in Primary Care Networks (HEALD-PCN) program is an innovative research study that will help to inform how decisions are made in Alberta around the delivery of physical activity and nutrition programs for people with diabetes, in a new and emerging model of health care.

The study will comprehensively evaluate clinical, economic and implementation outcomes, and will serve to establish effectiveness of a theory-guided (social cognitive) self-management program for those with type 2 diabetes in a community-based, primary care setting.

Exercise specialists are currently delivering the HEALD program in three different primary care networks in Alberta. Recruitment is now completed in one PCN. There are currently 100 participants in the HEALD-PCN project. Patient recruitment will continue until the winter of 2011-12, with the aim of adding 150 additional participants.

The program is based on a pilot study that showed when people took part in a program targeting total daily steps for 12 weeks and then, for another 12 weeks, walking faster for 30 minutes three times a week, their body weight, blood pressure and resting heart rate were reduced (Johnson, Bell, McCargar, Welsh  & Bell, 2009).

In essence, this earlier research helped to show that a pedometer-based walking program could help ensure that people with diabetes are walking at the right intensity level and speed (i.e., moderate to vigorous) to gain health benefits.

The Link Between HEALD and PCNs

In 2003, Alberta Health and Wellness, the Alberta Medical Association and Alberta Health Services established the Primary Care Initiative (PCI) to improve access to family physicians and other frontline health care providers in Alberta. There are 40 Primary Care Networks (PCNs) operating throughout Alberta, with another five in the planning stages. By 2011, the goal is for 80% of all Albertans to receive care from PCN teams.

The emphasis within these PCNs is health promotion, disease and injury prevention, care of patients with medically complex problems, and care of patients with chronic disease.

Diabetes is a target condition that will be used to evaluate the effectiveness and performance of recently established PCNs.

Study Phases

For the HEALD study, diabetic patients from PCNs located in St. Albert-Sturgeon, Leduc-Beaumont, Devon, Camrose and Fort Saskatchewan, Alberta will be assigned to either a control group where they will receive their usual health care or the HEALD program over a six-month period.

Those who enter the HEALD program will participate in two phases, each lasting 12 weeks.  In the first phase, a certified exercise specialist trained in delivering the HEALD program will lead two one-hour group sessions at a local recreational facility, in each of the communities where the PCNs are located. 

The initial sessions are intended to help patients set individual pedometer-based total daily step goals.  Patients are then encouraged to try to meet their daily step goals for a period of 12 weeks. 

After the initial 12 weeks, patients will attend two group sessions where they learn how to increase their walking speed (with the help of a pedometer) and about how to use the glycemic index to help manage their diet.

All sessions are provided free-of-charge and include day passes to the community recreation facility.

Measuring Results and Cost Effectiveness

To determine the success of the study, a number of variables will be measured:

• Physical activity will be measured with self-report questionnaires and pedometers.
• A food frequency questionnaire will be used to determine dietary intake.
• Clinical (i.e., glycated hemoglobin, lipids, blood pressure, resting heart rate, body weight and waist circumference) and psychosocial variables will be measured at three-month intervals over the study period.

Information on the cost of the program in the primary care context, as well as subsequent health care utilization, will be gathered through linkage with administrative data in the Alberta Diabetes Surveillance System, or ADSS (www.albertadiabetes.ca).

Such information will be used to estimate the cost-effectiveness of the program, using a previously developed diabetes economic forecasting model for Alberta. The RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) approach will be used to evaluate the implementation of HEALD-PCN.

Implications

As an emerging model of primary care in Alberta, PCNs present an ideal environment for enhanced access to care, with specific roles and responsibilities for various aspects of care and education assigned to the most relevant health professionals (e.g., exercise specialists).

Ultimately, the HEALD study (and other studies of this type) will serve as a platform and framework upon which an emerging model of care can incorporate effective and efficient chronic disease prevention and self-management in the primary care setting. Perhaps most importantly, the HEALD study will help to answer questions around program sustainability.

Key Terms

Psychosocial variables in relation to the HEALD project include factors such as planning/implementation, intention, self-efficacy, outcome expectations, pros, cons, attitude, subjective norm, perceived behavioural control, response efficacy, severity, and vulnerability.

RE-AIM stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance. According to the U.S. National Cancer Institute (http://cancercontrol.cancer.gov/IS/reaim/whatisre-aim.html), RE-AIM was originally developed as a framework for consistent reporting of research results and later used to organize reviews of the existing literature on health promotion and disease management in different settings.

About the Authors

Steven T. Johnson is an Assistant Professor in the Faculty of Health Disciplines at Athabasca University’s Centre for Nursing and Health Studies. He is also a collaborator with the Alliance for Canadian Health Outcomes Research in Diabetes (www.achord.ca).

Ronald C. Plotnikoff holds a Chair in Physical Activity & Population Health Education at the University of Newcastle in Australia, where he is also the Director of the Priority Research Centre in Physical Activity and Nutrition.

Jeffrey A. Johnson is a professor in the School of Public Health at the University of Alberta. He holds a Government of Canada Research Chair in Diabetes Health Outcomes and a Senior Health Scholar award from the Alberta Heritage Foundation for Medical Research (now called Alberta Innovates – Health Solutions).

Alberta Health and Wellness and The Lawson Foundation have provided support for this study.

Using Urban Design to Improve Children’s Health – The Smart Cities, Healthy Kids Study

Vol. 18, No. 3 - September 2011

Summary

This article discusses a study that examines the potential for active living in all 60 of Saskatoon’s residential neighbourhoods, as well as how active school-age children are in each of these neighbourhoods. The objective is to determine the links between how urban built environments are developed and how they encourage or discourage children to be active.

The problem of childhood obesity in North America and other advanced countries has reached the point where this generation could face a life expectancy shorter than that of their parents. While there have been numerous studies looking at the causes, the influence of the social and built aspects of neighbourhoods is a relatively new area of study (Oliver & Hayes, 2005).

This article discusses Smart Cities, Healthy Kids, a three-year, multi-phase study that examines the active living potential of all 60 residential neighbourhoods in the City of Saskatoon, Saskatchewan.

Researchers from the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) surveyed students aged 10 to 13 to determine their actual activity levels, and interviewed some children and their families about how they feel their neighbourhood influences how active they are.

Objectives of the Study

The Smart Cities, Healthy Kids study examines how urban planning and design can help encourage more children to be physically active, while helping to reduce the risk of childhood obesity.

There are studies looking at environmental factors that help or hinder active lifestyles (Cao, Makhtarian & Handy, 2009); however, only recently has research been emerging that looks into how our urban built environment – buildings, roads, sidewalks, parks and green spaces – can affect children’s activity levels (Sallis & Glanz, 2006).

SPHERU has a companion study under way that examines the city’s food environment – access to nutritious food – and how this affects children’s health.

Phase 1 - Urban design and measuring neighbourhood active living potential

In the first part of the Smart Cities, Healthy Kids study, the research team looked at how specific planning strategies the city had undertaken over time have now affected the “active living potential” of each residential neighbourhood in the city.

Researchers used two surveys to measure neighbourhoods in terms of how each neighbourhood’s design encouraged or discouraged activity.

First, the team walked through each neighbourhood to measure its active living potential. This involved the use of a 22-item survey (NALP) that covers activity friendliness; safety; density of destinations for work, shopping, and recreation; and universal accessibility (Fuller & Muhajarine, 2010).

The Irvine-Minnesota Inventory (IMI) was also used. This is a detailed survey covering 229 neighbourhood features, which results in a score being calculated in each of five domains: attractiveness; diversity of destinations; pedestrian access; safety from crime; and safety from traffic.

Both surveys, in general, found that older neighbourhoods with grid-style road layout offered more walkable destinations and a wider variety of destinations, which could increase physical activity. However, newer, suburban subdivisions with curvilinear road layouts had advantages in terms of social aspects and traffic safety.

Phase 2 - Measuring physical activity in children

In the second phase, researchers set out to determine the relationship between a neighbourhood’s active living potential with the reported and actual level of physical activity of the children, aged 10 to 13, who live there.

Researchers recruited 1,610 children to complete two detailed questionnaires about their physical activity.

One questionnaire was used to collect data on children’s perceptions of what aids or hinders their physical activity.

The second gathered data on the children’s structured and unstructured activities.

A subgroup of 465 children was also asked to wear accelerometers for a week to gather objective data about their physical activity (Hume, Salmon & Ball, 2005).

Phase 3 - Gauging parents and children’s perceptions of their neighbourhoods

In the final, qualitative portion of the study, the team asked children and their parents about what influence they felt their neighbourhoods had on their activity levels.

Twenty-four families whose children took part in earlier phases of the study were interviewed, and each child was lent a digital camera to take photographs — a method known as photovoice (Aitken & Wingate, 1993) — of places and things they felt helped or prevented them from being active.

Some of the photos showed places that encouraged physical activity, such as high-quality playground equipment, while others showed where they could take part in registered activities or take dogs for walks.

Other photos showed barriers to physical activity such as evidence of drug paraphernalia and gang activity, or construction work.

Research to Help Neighbourhoods Plan for Health

The Smart Cities, Healthy Kids study exemplifies collaborations between university researchers, decision-makers, and the community. The collaboration includes researchers with multiple disciplinary backgrounds, and decision-makers from the Saskatoon Health Region and the City of Saskatoon, program planners, and community-based organizations, among others.

The goal of the study is to produce research that will help Saskatoon and other cities understand how neighbourhood planning, policies and practices can encourage more active lifestyles, and, by extension, improve children’s health today and in the future.

Key Terms

Neighbourhood active living potential (NALP) refers to the concept of a defined place (in this case, a neighbourhood) being conducive for a physically active lifestyle, as well as the tool used for its measurement. The tool is a 22-item neighbourhood observation survey measuring activity friendliness, safety, density of destinations, and universal accessibility.

Irvine-Minnesota Inventory (IMI) is a neighbourhood audit measuring 229 features that fall within the domains of attractiveness, diversity of destinations, pedestrian access, safety from crime, and safety from traffic.

About the Authors

Dr. Nazeem Muhajarine is Professor and Chair in Community Health and Epidemiology, University of Saskatchewan. He is a social epidemiologist and leads SPHERU’s Healthy Children research area.

Tracy Ridalls, MA, is Research Coordinator for the Smart Cities, Healthy Kids project.

Mike Chouinard, a Research Officer with SPHERU, helped with the preparation of this article.

The Smart Cities, Healthy Kids study was funded by the Canadian Institutes of Health Research, the Heart and Stroke Foundation of Canada, and the Health Research Foundation, a national non-profit organization.

About the Organization

The Saskatchewan Population Health and Evaluation Research Unit (SPHERU) is a bi-university research unit with offices located across Saskatchewan, in Regina, Prince Albert, and Saskatoon. SPHERU engages in population health research, which is the study of social factors that contribute to the well-being of various groups within the population. Working across various disciplines, SPHERU researchers collaborate with communities, other academics, and policy-makers to undertake this critical research.