Physical Activity and Mental Health: A Holistic Approach

By Graham Matsalla, BScKin, Health Promotion Facilitator, Alberta Health Services; Krista Warners, BEd, BN, RN, MSc, Research Project Coordinator, Alberta Health Services

This article aims to create a better understanding of the links between physical health and mental health. The article highlights some of the known benefits of physical activity in relation to mental health and brain health. It also offers several suggestions to health practitioners and others to help encourage a more holistic approach to the promotion of mental health and physical activity.

What’s in This Article for You?

• Being Physically Active Boosts Mental Health
• Highlights of Physical Activity and Mental Health Research
• Suggested Strategies Towards Promotion of Holistic Health

Today, there is a growing body of evidence that highlights the role that physical activity plays in affecting mental health and brain health. The interconnectivity between physical and mental health can help us to look at health in a more holistic way.

There is no doubt that physical activity is good for us. We know that physical activity can positively impact common health challenges, such as cardiovascular disease, diabetes, high blood pressure, cholesterol, stroke, cancers, osteoporosis, overweight/obesity, and arthritis (Kravitz, 2007). These conditions are commonly associated with health in the physical sense.

Mental health, on the other hand, has for many decades generally taken a “backseat” to physical health, when we think of how people can keep, improve, or manage their health. For example, while most people are aware that clinically diagnosed chronic stress, anxiety and depression can negatively affect their mental health, they are much less aware that normal everyday stress can also impact their physical health.

According to FamilyDoctor.org (2010), when things happen in your life that disrupt your emotional balance and lead to strong negative feelings – such as sadness, anger, and exhaustion – there can be a number of associated physical symptoms. This may include back pain, chest pain, extreme tiredness, upset stomach, dry mouth, palpitations, trouble sleeping, poor memory, poor concentration and/or body aches. 

Being Physically Active Boosts Mental Health

When people are physically active as a regular part of their lifestyle it can positively influence their mental health. This is common sense, which is backed up by research and promoted by many health-related agencies and organizations.

Biddle, Fox, & Boutcher (2000) suggest that physical activity has the potential to contribute to:

• enhancements in mood;
• improved self-perception and self esteem;
• prevention of mental health problems; and
• alleviation of symptoms associated with mental health problems.

Research also shows that physical activity influences mental health through decreased stress, decreased anxiety, decreased depression, increased positive mood, and increased cognitive function (Kravitz, 2007).

Highlights of Physical Activity and Mental Health Research

Generally, there is a direct relationship between physical activity and health; people who are more physically active have a higher health status. For instance, Warburton, Nicol, & Bredin (2006) point out that the greatest improvements in health status are seen in the least fit people, when they become physically active.

The evidence presented below is based on research that studies the associations between physical activity and mental health. These research findings outline the influence of physical activity on cognitive function, anxiety, stress, self-esteem, depression and mood.

Cognitive function: Performing moderate intensity physical activity for 30 – 40 minutes a day, 3 – 4 days per week will push back cognitive decline by 10 – 15 years.

• Ratey & Hagerman (2008) state: aerobic physical activities were seen as the most beneficial; but resistance physical activities can also be beneficial.

Anxiety: The most significant benefits have been seen in those who train aerobically for 10 – 15 weeks; however there is still debate surrounding whether low, moderate or high intensity aerobic physical activity is most beneficial. According to recent research, even a single 5-minute bout of physical activity can be enough to reduce a single anxiety episode (Kravitz, 2007).

Stress: Moderate aerobic physical activity performed 3 times a week for 20 minutes or more, for 12 weeks or longer, shows the most benefit (Kravitz, 2007). Aerobically fit individuals show a reduced stress response. Physical activity is more preventative than corrective when it is used to deal with stress that comes from lifestyle and work (Scully, Kremer, Meade, Graham, & Dudgeon, 1998).

Self-esteem: Aerobic physical activity appears to have a higher effect on self-esteem than other physical activity; however, at this time there is little research on self-esteem and other forms of physical activity (Scully et al., 1998). Studies show there is a stronger effect in self-esteem increases for those with lower self-esteem (Kravitz, 2007). Self-esteem is complex and research suggests there are many contributing sub-components, including perceived sport competence, physical condition, body image, and strength (Scully et al., 1998). Given all of these variables and a lack of clear direction for type and dose, it may be best to follow the current Canadian Physical Activity Guidelines.

Depression: Mead et al. (2009) reviewed data of 25 trials that showed physical activity seemed to improve the symptoms of depression. Subgroup analysis of Mead et al.’s (2009) research showed that moderate anti-depressant effects of physical activity were sustained from 4 to 26 months after the intervention, and that resistance and mixed physical activity reduced depressive symptoms more than aerobic physical activity alone (Gill, Womack, & Safranek, 2010).

One very small clinical trial noted larger decreases in depression scores with patients who were physically active 3 to 5 times per week for at least 30 minutes at 60 to 80% of their maximum heart rate compared to patients who were physically active only once a week (Gill et al., 2010).

While evidence suggests physical activity has an anti-depressant effect, there remains a lack of clear direction for type and dose. At this time, it may be best to follow the current Canadian Physical Activity Guidelines.

Mood: Even a single bout of low, moderate, or high intensity aerobic physical activity (for 25 – 60 minutes) can increase positive mood and decrease negative mood. The implications would suggest that making physical activity a habit would therefore positively influence mood state (Kravitz, 2007).

Aerobic activity and brain health: Although the brain size is small in terms of a person’s total body mass, it demands one-fifth of the body’s resources. These resources come to the brain through the blood. To obtain these resources, the brain takes 15% of cardiac output; this means the cardiovascular system (heart, lungs, and circulatory system) is vital to proper brain function. Kravitz (2010) suggests aerobic physical activity can help the brain, by increasing the blood flow, nutrient delivery, and growth factors which improve the health of the cells. This can help to increase brain plasticity, i.e., the changes the brain makes over time, including the brain’s ability to learn new things and make physical adaptations to ensure optimal functioning.

Suggested Strategies Towards Promotion of Holistic Health

In our view, mental health is an essential part of overall health, and should be a vital (and more recognized) part of our rationale for promoting active lifestyles among all age groups.

By following the Canadian Physical Activity Guidelines published by the Canadian Society of Exercise Physiologists (CSEP), a person can reduce health risks and get health benefits, including mental health benefits.

Here are a few more suggested strategies:

• Educational materials and promotional messages (e.g., by health and fitness practitioners, health-promoting organizations, etc.) should include emphasis on the mental health benefits that can be gained through increased physical activity. 
• Curriculum materials for a wide range of professionals and practitioners should outline the mental health benefits of physical activity. This should include groups such as recreational professionals, physiotherapists, occupational therapists, kinesiologists, doctors, nurses and other health professionals.
• All health-promoting organizations should inform their audiences about active, integrated lifestyles. Research demonstrates that integrated lifestyle approaches involving active living and emotional well-being change, can lessen, and even reverse the progression of chronic diseases and support health in all populations (Guarneri, Horrigan, & Pechura, 2010). 
• Since stress is common for most people, all types of health practitioners should discuss and share information with clients/patients about the benefits of physical activity in relation to stress management and mental health.
• Supportive physical and social environments are required in order to promote physical activity; this can have positive impacts on the mental health of people living in a given community. For instance, communities with ample green space, parks, playgrounds, wide sidewalks and connecting paths can help individuals to be more active and boost social interaction among community members and neighbours. 
• Policies embracing a holistic approach to mental and physical health promotion should be considered and implemented in multiple settings such as workplaces, communities, and organizations.

In our view, the overall evidence is clear; when people are physically active, it can boost mental health! A healthier future for all people includes a holistic focus on physical and mental health.

References

Biddle, S., Fox, K., & Boutcher, S. (2000). Physical activity and psychological well-being. London: Routledge.

Familydoctor.org. (2010). Mind/body connection: How your emotions affect your health. Retrieved from: http://familydoctor.org/familydoctor/en/prevention-wellness/emotional-wellbeing/mental-health/mind-body-connection-how-your-emotions-affect-your-health.html

Gill, A., Womack, R., & Safranek. (2010). Does exercise alleviate symptoms of depression? The Journal of Family Practice, 59, 530-531.

Guarneri, E., Horrigan, B. J. & Pechura, C. M. (2010). The efficacy and cost effectiveness of integrative medicine: A review of the medical and corporate literature. Explore, 6, 308-312.

Kravitz, L. (2007). The 25 most significant health benefits of physical activity and exercise. IDEA Fitness Journal, 4, 54-63.

Kravitz, L. (2010). Exercise and the Brain: It Will Make You Want to Work Out. IDEA Fitness Journal, 7, 18-19.

 

Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A. (2009). Exercise for depression. Cochrane Database of Systematic Reviews, 3, 1-61.

doi: 10.1002/14651858.CD004366.pub4

 

Ratey, J. J. & Hagerman, E. (2008). Spark: the revolutionary new science of exercise and the brain. New York, NY: Little, Brown and Company – Hachette Book Group

Scully, D., Kremer, J., Meade, M. M., Graham, R., & Dudgeon, K. (1998). Physical exercise and psychological well being: a critical review. British Journal of Sports Medicine, 32, 111-120.

doi: 10.1136/bjsm.32.2.111

Warburton, D.E.R., Nicol, C.W., & Bredin, S.S.D. (2006). Health benefits of physical activity: the evidence. CMAJ, 174, 747-749. doi: 10.1503/cmaj.051351

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Children’s Views About the Meanings of Play

By Nicole M. Glenn & Camilla J. Knight, Faculty of Physical Education and Recreation, University of Alberta, Canada

Recently, there has been much discussion and research regarding children’s play activities and the significance of play. This increased focus is partly due to rising obesity and overweight rates among children in Canada and other countries.

This article aims to shed light on children’s views about play, with a particular focus on what children themselves think about play activities and meanings of play.

What's in This Article for You?

Understanding Children's Views
Children Think of Play as Fun
Children Like to Play
Considering Some Contradictions
Parents Can Be a Barrier to Play
Conclusions, Implications & Take Home Suggestions

Background

It has famously been said that play is “the business of childhood” (Piaget, 2007). Given the importance of children’s play, it has often been a focus of public consciousness, policy debate and academic research.

In recent times, there has been a strong interest in children’s play, particularly “active free play,” on the part of governments and other policy-makers, health care agencies, schools, researchers, and many other organizations and stakeholders.

Interested parties have focused their attention on how to better encourage children to be more physically active, and how active play can be a helpful part of reducing overweight and obesity rates among children. As part of this focus, a range of related factors have been examined; such as playground and neighbourhood design, children’s activity programming, and physical activity in school curriculums.

Understanding Children’s Views

Research with parents has shown that play can be organized into three categories: where, what and with whom.

According to parents, children’s play often involves:

• Where: playgrounds and dedicated play spaces
• What: sports and video games
• Whom: with friends

But how much do parents really know about play?

We recently talked to children from a grade school in the greater Edmonton area and asked them what they thought adults meant by the word play.

According to these children, parents and children have different views. Children thought:

• Parents do not understand video games. As one child said, “They [parents] don’t understand video games.” Another child explained, “Parents don’t understand video games ... they think they melt your brain ... and make us stupid.”
• Parents think play must take place outside. One child said, “Um, when my dad says go play, he means go outside.” Another child said, “When you’re playing video games then my mom’s like ‘go outside, ride your bike or something’.”
• For parents, play activities must be healthy. One grade three student said “... parents mean something that’s more healthy.”
• When parents talk about play, they just want children out the way. One of the grade four children explained, “My parents say go play, they mean stop bugging us, or get out of my way, just stop bugging us.” Another stated, “They said go upstairs, shut up and don’t talk to me, so I can do the taxes.”

Children Think of Play as Fun

So what is play to children?

According to the children we talked to, play is any activity that is fun. In fact, their views about this were unanimous, as illustrated in the following conversation:

Interviewer:  What makes something play?
Child A:  You have fun doing it.

Interviewer:  Fun?

Child B:  Yeah.

Child C:  Fun, inspiration.

Child D:  Energy.

Conversely, activities that children considered “boring” were not play. Surprisingly, television fell into this category. As one child explained, watching television is boring because “you lay on the couch like a lazy potato.”

However, video games were not seen as boring or lazy. In fact, children in our study consistently recalled video games as one of their preferred activities. They used terms such as “sweaty” and “energy” to describe their encounter with these technologies.

Children Like to Play

It turns out, based on the views of the children in our study, children will play almost anything, almost anywhere, with almost anyone.

The children in our study indicated the following play preferences:

• outdoor activities
• active, movement-based activities
• video games
• playing with peers
• re-purposed spaces (i.e., spaces not intended for children’s play)

When we asked the children in our study where they preferred to play, the following conversation ensued:

Child A: In the bush, in the mud holes.
Child B: In the basement playing video games.

Child C: On my mud puddle.

Child D: Outside.

Child A: I like to play on this back hill behind my house.

Such responses help to illustrate the point that children like to play almost anywhere.

Considering Some Contradictions

According to our findings, the views of children about play might contradict the views of parents, as reported in other studies. Here are a few examples:

Playgrounds & Designated “Play-Spaces”

Although playgrounds and designated play-spaces were mentioned, they were not the preferred location of play among children. Children in our study preferred to “re-purpose” places and spaces intended for other uses. For instance, rather than use typical or standard playgrounds and equipment, the children in our study indicated they like to use construction sites and sheds as play spaces.

Weather
The cold winter climate of north central Alberta did not appear to have an effect on the preferences for outdoor play among children. Parents may have additional safety concerns associated with the weather – such as excessive cold and icy conditions – however, these factors did not appear to deter the children in our study from desiring outdoor play. Instead, as the weather or seasons changed, it changed what they wanted to play, such as going tobogganing or having snowball fights in winter months.

Parents Can Be a Barrier to Play

Parents who participate in research studies are often asked to comment on barriers to children’s free play and physical activity. Concerns about safety have been most often cited (Carver, Timperio & Crawford, 2008; Davison & Lawson, 2006; Hillman, Adams & Whitelegg, 1990; Veitch, Bagley, Ball & Salmon, 2006).

Common safety concerns include:

• Outdoor darkness
• Dangers or concerns about the neighbourhood (e.g., rundown buildings, etc.)
• Crime
• Street traffic
• Lack of adult supervision

We decided to ask the children what stopped them from playing and, maybe naively, expected responses similar to parents. In fact, no such issues emerged.

Instead, children consistently indicated that it was actually their parents that stopped them from playing.
As one child said, “My mom and dad, they don’t let me play outside … because they want me to go somewhere, because like when I’m playing with my brother, my mom wants to go somewhere, she stops me from playing.”

We found that parents appeared to stop children from playing in a number of ways:

• Parents had other plans for their children
• Children had to come in for dinner
• Children were grounded
• Children had to do homework or chores

A conversation with some grade three children highlighted some of these factors:

Interviewer: And is there anything that stops you playing? Why might you not be able to play?
Participant B: Parents.

Interviewer: When might your parents stop you?

Participant A: When we’re grounded.

Participant C: When its dinner time.

Participant D: When you have to do homework.

The fact that children are sometimes seeing their parents as a barrier to play highlights the importance of talking to children (as well as parents). It also points to the potentially detrimental effect adults might be having on children’s engagement in active free play.

Conclusions, Implications & Take Home Suggestions

Here are some other “take home” suggestions:

• Creating programming and places for children to play should focus on balancing “barriers” (e.g., safety concerns) as perceived by parents and “fun” as perceived by the children. 
• Specific, dedicated, purposeful play equipment is not necessarily desired by children. Children enjoy re-purposing spaces, place and things to suit their interests.
• Adults may create new or different play opportunities by reducing structured activities and providing more free time, often combined with social engagements.
• Children’s perspectives should be considered when creating environments for their use.

Nicole Glenn is a PhD candidate in the Faculty of Physical Education and Recreation at the University of Alberta. Her primary research interests are qualitative methods and obesity/weight-related topics. She is interested in multi-disciplinary, practice-based research as well as intersections of visual and textual expression.

Camilla Knight is a PhD candidate in the Faculty of Physical Education and Recreation at the University of Alberta. Her research interests are concerned with
the psychosocial experiences of children in sport, particularly focused
upon the influence of parents. Recent studies have examined athletes'
preferences for parental behaviours at competitions, coaches'
perceptions of parental involvement in sport, and understanding
the experiences of sports parents.

References

Carver, A., Timperio, A., & Crawford, D. (2008). Playing it safe: the influence of neighbourhood safety on children’s physical activity. A review. Health & Place, 14, 217-227.

Coakley, J. (2006). The good father: parental expectations and youth sports. Leisure Studies, 25, 153-163. doi: 10.1080/02614360500467735

Davison, K. K., & Lawson, C. T. (2006). Do attributes in the physical environment influence children’s physical activity? A review of the literature. International Journal of Behavioral Nutrition and Physical Activity, 3:19. doi: 10.1186/1479-5868-3-19

Factor, J. (2004). Tree stumps, manhole covers and rubbish tins: the invisible play-lines of a primary school playground. Childhood: A Global Journal of Child Research, 11, 142-154.
doi: 10.1177/0907568204043049

Hillman, M., Adams, J. & Whitelegg, D. (1990). One false move...a study of children’s independent mobility. London: Policy Studies Institute.

Miller, E. & Kuhaneck, H. (2008). Children’s perceptions of play experiences and play preferences: a qualitative study. American Journal of Occupational Therapy, 62, 407-415.

Oke, M., Khattear, A., Pant, P., & Sarawathi, T.S. (1999). A profile of children’s play in urban India. Childhood: A Global Journal of Child Research, 6, 207-219.

Piaget, J. (2007). The Child’s Conception of the World: A 20th-Century Classic of Child Psychology, Second Edition. J. Tomlinson & A. Tomlinson (Trans.). Lanham: Rowman & Littlefield.

Rasmussen, K. (2004). Places for children – Children’s places. Childhood: A Global Journal of Child Research, 11, 155-173. doi: 10.1177/0907568204043053

Singh, A. & Gupta, D. (2011). Contexts of childhood and play: exploring parental perceptions. Childhood. Retrieved from http://chd.sagepub.com/content/early/2011/10/18/0907568211413941.full.pdf+html  doi: 10.1177/0907568211413941

Veitch, J., Bagley, S., Ball, K., & Salmon, J. (2006). Where do children usually play? A qualitative study of parents’ perceptions of influences on children’s active free-play. Health & Place, 12, 383-393. http://dx.doi.org/10.1016/j.healthplace.2005.02.009

Listening to People with Diabetes: Findings from a Consensus Conference

By Jessica Walker, B.A., University of Alberta; Tanya R. Berry, PhD, University of Alberta; Catherine Chan, PhD, University of Alberta; Rhonda Bell, PhD, University of Alberta

What's in This Article for You?

• Understanding Diabetes
• About the Type 2 Diabetes Consensus Conference
• Outcomes and Recommendations

This article presents the methodology and recommendations from a consensus conference hosted in May 2011 by the Physical Activity and Nutrition for Diabetes in Alberta (PANDA) research project. The goal of the conference was to create physical activity and nutrition recommendations for people with type 2 diabetes.

The PANDA research project’s mission is to develop practical, convenient and easy-to-use strategies to assist people with type 2 diabetes in living fuller lives. The project involves a multidisciplinary and collaborative team of researchers at the University of Alberta.

Researchers and practitioners can use the recommendations from the consensus conference to implement actions (e.g., launch programs or resources) that meet the needs of persons with diabetes, while the general public can use the recommendations to become more educated about diabetes. 

Understanding Diabetes

Diabetes is a chronic disease which, if left untreated, can result in serious complications such as heart disease, kidney disease, and nerve damage (Canadian Diabetes Association, 2011). Type 2 diabetes is the most common type of diabetes and accounts for approximately 90% of all diabetes cases. Major risks factors for type 2 diabetes include obesity or being overweight.

More than 205,000 Albertans (about 5.7%) have diabetes; the rate of diabetes has increased by about 40% since 1995 (Alberta Diabetes Atlas, 2011).

Type 2 diabetes and its comorbidities place a large financial burden on the Canadian health care system. Physical activity and nutrition are positive behaviours that can aid in diabetes prevention and management (Canadian Diabetes Association, 2011).

The 2008 Clinical Practice Guidelines from the Canadian Diabetes Association outline the most current evidence-based physical activity and nutrition guidelines for persons with diabetes. However, even with this information readily available, adherence to the guidelines is low.

About the Type 2 Diabetes Consensus Conference

A consensus conference is a recognized method to exchange knowledge, identify issues and collaboratively make decisions.

A defining characteristic of a consensus conference is the involvement of the general public as members of a lay panel. They represent the population of interest (e.g., persons with type 2 diabetes) and work to shape the overall outcome of the conference. 

This method is unique because it provides division of power in decision making between professionals and citizens.

The purposes of the PANDA consensus conference were to:

1. involve both diabetes experts and clients in the development of ideal physical activity and nutrition interventions;
2. transfer information from the experts to both the lay panel and the public; and
3. distribute information developed from the conference itself.

Lay panel participants were 17 Albertans living with type 2 diabetes. Time since diagnosis ranged from less than a year to more than 30 years.

Seven participating experts represented a broad range of diabetes specializations including:

• exercise management
• cardiovascular risk factors
• community-based lifestyle interventions
• healthy weight strategies
• the glycemic index
• social, environmental and cultural interactions
• exercise motivation and self-efficacy

The process was divided into three stages and followed consensus conference guidelines created by Nielsen and colleagues (Nielsen, Hansen, Skorupinski, et al, 2007).

1) Planning Meeting

The lay panel met with a professional moderator one month before the conference to develop one area-specific question for each of the seven diabetes experts. Participants also chose eight individuals amongst themselves to comprise a lay panel subgroup.

2) Public Consensus Conference

The conference included a morning session during which each of the seven experts gave a 15-minute presentation answering the questions posed by the lay panel. The presentations were open to the general public and interested professionals were invited.

During the afternoon, the expert and lay panel members worked with the moderator to discuss the morning presentations. They generated suggestions for programs and discussed ways to improve the health care system to better address the needs of persons with type 2 diabetes.

3) Lay Panel Meeting

On the day after the conference, the lay panel sub-group used the suggestions created from the conference to generate a final list of recommendations for the PANDA team.

Outcomes and Recommendations

The lay panel subgroup stressed the need for two-part programs; one part for people with diabetes and another for professionals. They highlighted the importance of the word “program” for future research studies as they believe “intervention” is associated with detrimental lifestyles, such as smoking or drugs.

Participants outlined three overarching themes: diagnosis, education, and support, each of which contained various program ideas.  The group agreed that each of the three themes are separate but that they must work together to be successful.

Diagnosis 

Diagnosis should be made as early as possible so individuals can seek out support and learn to manage their condition. Possible methods to enhance early diagnosis include:

• free blood sugar testing at community or public events; and
• mandatory haemoglobin A1C testing in all medical exams for individuals over 40.

It is crucial to reduce the time between diagnosis and first point of contact with a pharmacist or a doctor so they can provide the necessary information on self-monitoring and outreach.

Diabetes organizations, such as the Canadian Diabetes Association, and/or government agencies could easily enhance diabetes awareness through regular media campaigns. The campaigns could outline diabetes information, such as characteristics, symptoms and consequences, to help individuals monitor their health for signs of diabetes and thereby encourage more people to seek a medical diagnosis.

Education  

Diabetes education should be multidimensional to include diet, exercise, psychological aspects, behavioural counselling, medication and lifestyle coaching.

Periodic refresher courses for diabetics and continually maintained websites can provide progressive and up-to-date information on type 2 diabetes.

Doctors and physicians can also benefit from attending courses or other professional development offerings to boost or maintain their knowledge of type 2 diabetes.

Educating various businesses – such as restaurants, grocery stores or tour companies – about the specialized needs of people with diabetes can help make diabetes management easier. A small emphasis can be placed on statistics, such as informing businesses about the percentage of the population (about 5.7% in Alberta) with diabetes, and how their businesses could benefit if they offered more services that cater to the needs of their customers who have diabetes.

Research is directly linked to education and requires two-way communication. Regular interaction between clients and researchers allows researchers to understand what diabetics need and allows diabetics to learn what researchers are exploring. This conference was a starting point for client and researcher interaction.

Support

Support can be achieved in a variety of ways, such as joining a support group, participating in diabetes-specific classes, or encouraging diabetes associations or organizations to produce dedicated web pages and online discussion groups. However, conference participants also noted that each individual must take responsibility in finding their preferred supports.

Families, community members and employers should be well informed about the complex lifestyle changes associated with living with diabetes and the vital need to support individuals with diabetes.

People with diabetes would like to see an increase in the number of doctors and physicians with specializations in diabetes, along with better access to these professionals, as an additional way to enhance support for individuals who live with diabetes.

Conclusion 

In summary, the PANDA research project’s consensus conference was conducted to give the average citizen living with type 2 diabetes a chance to express what they believe will improve the health care system relative to type 2 diabetes and their overall well-being.

The conference was effective in providing the opportunity for professionals and citizens to discuss relevant topics surrounding type 2 diabetes, hear each other’s points of view, and discuss and create possible solutions together.

Many participants spoke of their excitement and interest in future changes to the health care system, which could arise from their recommendations, and from the work and findings of the PANDA research project overall.  Participants were passionate about the goal of the conference; to create physical activity and nutrition recommendations. They also expressed satisfaction with the conference procedures and enthusiasm about the overall results.

The recommendations and outcomes from the conference will be used by the PANDA team to design and evaluate a physical activity and nutrition program. If these recommendations are effectively implemented, the results will make for a more efficient health care system. The hope is to increase adherence to physical activity and nutrition guidelines to ensure a long and healthy life for all Canadians.

The authors of this article are associated with the PANDA research project which is been funded by the University of Alberta’s Faculty of Medicine and Dentistry and Alberta Health Services. The project aims, in part, to develop, implement and evaluate lifestyle interventions for people living with type 2 diabetes. Team members include researchers in nutrition, physical activity, agriculture, economics, physiology, psychology and health messages. Learn more about the PANDA Research Project at

www.afns.ualberta.ca/en/Research/PANDAResearchProject.aspx

References
Alberta Diabetes Atlas. (2011). Retrieved from http://www.albertadiabetes.ca/AlbertaDiabetesAtlas2011.php

Canadian Diabetes Association, Clinical Practice Guidelines Expert Committee. (2008). Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes, 32, 1-201.
Retrieved from http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf

Canadian Diabetes Association. (2011). Type 2 diabetes: The basics. Retrieved from: http://www.diabetes.ca/diabetes-and-you/living/just-diagnosed/type2

Nielsen, A.P., Hansen, J., Skorupinski, B., et al. (2006). Consensus Conference Manual.
Retrieved from http://www.ethicaltools.info/content/ET4%20Manual%20CC%20(Binnenwerk%2040p).pdf

Involve. (2011). People and Participation, Consensus Conference. Retrieved from http://www.peopleandparticipation.net/display/Methods/Consensus+Conference

Targeting Adverse Cardiovascular Outcomes in Adult Canadians of South Asian Ancestry

By Charlotte A Jones, PhD, MD, Associate Professor, Endocrinology and Metabolism, Departments of Medicine and Community Health Sciences, University of Calgary

What's in This Article for You?

• About the Risk Factors
• Screening for Risk Factors in Calgary's South Asian Community
• Communities are Involved and Concerned
• From Screening to Management
• Missing Out on Physical Activity
• Sustaining the Pyara Dil Program
• Recommendations
• Next Steps in Calgary and Across Canada

Adult Canadians of South Asian ancestry are at increased risk of heart disease and stroke due to risk factors such as higher rates of diabetes, obesity and hypertension (high blood pressure), as well as poorly controlled blood pressure and abnormal cholesterol levels.

This article describes how the Pyara Dil (Love Your Heart) program was promoted to Calgary’s South Asian community, in response to such risk factors, and how the program was linked to the local Multicultural Chronic Disease Management program administered by Alberta Health Services. The article offers several recommendations to health care providers and chronic disease management program leaders.

About the Risk Factors

In Canada, cardiovascular disease (CVD) and stroke are second only to cancer as the leading cause of disability and death.  South Asian Canadians have a higher rate of CVD, which tends to occur up to ten years earlier compared to the general population (Anand et al., 2000) (Sheth, Nair, Nargundkar, Anand, & Yusuf, 1999). 

A greater occurrence of risk factors including diabetes, obesity, hypertension and abnormal cholesterol levels play a significant role in the higher CVD risk for South Asian Canadians (Anand et al., 2000) (Yusuf et al., 2004).

A recent review of CVD risk factors in visible minority populations across Canada (Lui, So, Mohan, Khan, King, & Quan, 2010) and in Ontario (Chiu, Austin, Manuel, & Tu, 2010) revealed that individuals from visible minorities, although less likely to smoke, were more likely to be physically inactive. Specifically, South Asian Canadians were the least physically active of all groups studied. 

Screening for Risk Factors in Calgary’s South Asian Community

In 2007-2008, of the more than 300 South Asian adults (>45 years of age) who participated in an initial community-based screening program in Calgary, about 20% reported that they had diabetes, while 50% had hypertension and 40% had abnormally high cholesterol (Jones, 2009) (Jones, 2010).

Based on these early findings, and in collaboration with the South Asian community, the Pyara Dil program was initiated. Under the program, a second round of screening sessions involving more than 600 participants was undertaken from October 2010 to February 2011. The average age of participants in this round was 62 (range 40-94, median 64); women and men were equally represented.

Although final data analysis from the latest screenings has not been completed, similar trends were found:

• 23% stated they had diabetes
• 54.3% had hypertension
• only 50.3% controlled their blood pressure to target levels (<140/90 and <130/80 for diabetics)
• those with diabetes had significantly poorer control rates (36%) than the non-diabetic participants (60%)
• nearly 10% (13.7% of men, 6.5% of women) of those who did not report any history of diabetes, had results suggestive of possible diabetes (participants with abnormal results were advised to see their family physician for further diagnostic testing)
• based on the International Diabetes Federation proposed waist circumference criteria for South Asians, 88.9% (88.7% of men, 89.2% of women) had abdominal or high CVD-risk obesity

 
Communities are Involved and Concerned

Given the screening results from 2007-2008 and more recently, Calgary’s South Asian community has welcomed the Pyara Dil program. Community volunteers have been actively involved during each stage of the program development and implementation.

For instance, 80 members of the Calgary South Asian community volunteered to receive special training about CVD risk factors and how to run the second round of risk factor screening sessions.  Some of these volunteers were lay persons, while others were health care providers who self-identify as part of the community.

Overcoming language barriers and boosting cultural sensitivity has been a vital part of the program’s overall success.  For example, program volunteers were able to communicate with participants in their chosen language (e.g., Punjabi, Guajarati, Dari, Hindi, English) while screening sessions were held in a range of locations that were most convenient or generally preferred by the community, such as religious facilities and Seniors’ centres.

During the second round of screening sessions, volunteers carried out blood pressure, blood sugar and waist circumference assessments.  The range of demographic data collected included age, sex, ethnicity, education level, self-reported diagnoses of CVD, diabetes, HBP, high cholesterol, smoking and family history of CVD.

From Screening to Management

After the assessments, the screening participants were given a wallet-sized card with their screening values and risk level. They were counselled on their risk factors and asked to follow-up with their family doctor.

Low- or moderate- risk participants were referred to the Multicultural Chronic Disease Management (CDM) program in Calgary (administered by Alberta Health Services) which provides culturally-sensitive programs in different languages, including physical activity components. 

High risk participants were referred directly to their family doctor with a letter indicating their risk levels, as assessed during the screening.

A project volunteer (from the South Asian community) made follow-up phone calls to all high risk participants to ask if they went to their doctor, and if they had attended the CDM program.

The vast majority of Pyara Dil participants reported that they visited their family doctor, or, if referred, a specialty clinic. Participants also expressed a high degree of satisfaction with the Pyara Dil program.

However, no participants accessed the community-based education and exercise opportunities offered through the CDM program. This finding was unexpected. This result came about even though each participant received numerous telephone reminders by telephone, in their preferred language. The reasons for this finding need to be further explored.

Missing Out on Physical Activity

In the CDM program, there is a strong emphasis placed on physical activity (and healthy eating). Given the fact that members of the South Asian community are not currently inclined to participate in the CDM program when referred, it is important that cultural or other barriers be removed.

In fact, the participants in Pyara Dil program noted some of the access barriers that need to be overcome in order to achieve this important goal:

• a majority suggested that the program should be delivered on weekends or evenings, and at more accessible sites such as seniors’ centres, and at more (or all) of their religious facilities
• provision of transportation and help with translation were also suggested

 
Sustaining the Pyara Dil Program

Based on the results of the screenings in late 2010 and early 2011, and the success of the previous screenings, the Pyara Dil program is now a regular activity in many groups within Calgary’s South Asian community.

A dedicated community volunteer is now in charge of maintaining the program and has trained several other volunteers.

Two further screening clinics have been undertaken, in August and September 2011, and plans are underway to continue the screenings on a regular basis.

Recommendations

Based on the challenges and successes related to the Pyara Dil program, here are some general recommendations for health care providers and chronic disease management programs:

• be aware of the increased risk heart disease and stroke faced by South Asian Canadians
• be aware of the need for aggressive risk factor prevention, detection and control (management)
• high risk South Asians (particularly those with diabetes) have significantly poorer HBP control than the general population
• there are substantial numbers of South Asians in the community who likely have diabetes, but do not know it
• using religious and other community facilities may help you reach members of the South Asian community in your region
• aim to host your Chronic Disease Management program elements at times and in places most compatible with participants’ needs
• seek out other ways and means to more strongly engage South Asian community members in educational and physical activity programs

 
Next Steps in Calgary and Across Canada

Partly based on the findings and successes of the Pyara Dil program, a collaborative program (distinct from the Pyara Dil program) between Calgary’s South Asian community, family physicians and the local Alberta Health Services Chronic Disease Management program is currently being designed.

Its specific aim will be to address the high prevalence or burden of CVD risk factors in Calgary’s South Asian community.

Furthermore, partly based on the findings of the Pyara Dil program, and with the support of the Public Health Agency of Canada, similar programs are under development in five other cities across Canada. The mandate of this national program (entitled "Know your numbers. — Track your heart") is to continue the screening and referral elements, and provide a peer support element.

Conclusion

By involving members from Calgary’s South Asian community, we have had great success with the Pyara Dil pre-screening program and we have taken steps to ensure that it will be sustainable on its own. This program success is a good example of how working with one cultural community can help to address important health risks or issues.

Dr. Jones is an endocrinologist currently practicing at the University of Calgary. She teaches at the University of Calgary’s medical school and is the Medical Director at the LIBIN Center of Excellence in Hypertension Prevention and Control.

References 

Anand, S.S., Yusuf, S., Vuksan, V., Devanesen, S., Teo, K.K., Montague, P.A., Kelemen, L., Yi, C., Lonn, E., Gerstein, H., Hegele, R.A., McQueen, M. and for the SHARE Investigators. (2000). Differences in risk factors, atherosclerosis, and cardiovascular disease between ethnic groups in Canada: the Study of Health Assessment and Risk in Ethnic groups (SHARE). Lancet, 356,279-284. doi:10.1016/S0140-6736(00)02502-2

Chiu, M., Austin, P.C., Manuel, D.G., & Tu, J.V. (2010). Comparison of cardiovascular risk profiles among ethnic grops using population health suveys between 1966 and 2007. Canadian Medical Association Journal, 182, E301-E310. doi:10.1503/cmaj.091676

Jones, C. A., Nanji, A., Mawani, S., Davachi, S., Wang, X., & Campbell, N. (2010). Targeting health inequities: Sex-based analysis of the INDO-ASIAN-CHAMP (Cardiovascular Health and Management Program). Canadian Journal of Cardiology, 26, Supplement D: 84D.

Jones, C. A., Davachi, S. Nanji, A., Mawani, S., Faris, P., Wang, X., Lewanczuk, R. & Campbell, N. (2009). Indo-Central Asian cardiovascular Health and Management Program (ICA-CHAMP). Canadian Journal of Cardiology, 25,Supplement B: 100B.

Lui, R., So, L., Mohan, S., Khan, N., King, K., & Quan, H. (2010). Cardiovascular risk factors in ethnic populations within Canada: results from national cross-sectional surveys. Open Medicine, 4,143-153.

Sheth, T. N., Nair, C., Nargundkar, M., Anand, S., & Yusuf, S. (1999). Cardiovascular and cancer mortality among Canadians of European, South Asian, and Chinese origin from 1979 to 1993: an analysis of 1.2 million deaths. Canadian Medical Association Journal, 161, 132-138.

Yusuf, S., Hawken, S, Ôunpuu, S., Dans, T., Avezum, A., Lanas, F., McQueen, M., Budaj, A., Pais, P., Varigos, J., & Lisheng, L., on behalf of the INTERHEART Study Investigators. (2004). Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 364, 937-52. doi:10.1016/S0140-6736(04)17018-9

Exercise and Pregnancy: Canadian Guidelines for Health Care Professionals

By Dr. Michelle F. Mottola, PhD, FACSM & Director, R. Samuel McLaughlin Foundation-Exercise and Pregnancy Lab, University of Western Ontario

What's in This Article for You?

• Getting to Know the Benefits Get to Know the Exercise Guidelines
• About Aerobic Exercise
• Muscle Conditioning Guidelines
• Can Overweight and Obese Pregnant Women Exercise?
• Are There Different Guidelines for Fit Pregnant Women?
• Contraindications to Exercise
• About PARmed-X for Pregnancy
• Medical Practitioners Should Promote Exercise During Pregnancy

In Canada, many pregnant women do not exercise enough, gain too much weight during pregnancy, and develop gestational diabetes and hypertension. Part of the problem is that many pregnant women and their health care providers tend to focus on asking “how much exercise is too much” while at the same time minimizing or not considering the benefits of exercise.

In fact, pregnancy is not the time to “put up your feet and rest” but rather a time for healthy lifestyle change. Pregnant women should not “eat for two”, but rather eat twice as healthy and watch portion sizes.

This article presents some important facts and resources to help medical practitioners, other health care professionals and pregnant women better understand the benefits of physical activity during pregnancy.

Getting to Know the Benefits

Here are some important factors that pregnant women should be informed about.

Prevention:

Increasing physical activity and leading an active lifestyle during a pregnancy will help to prevent:

• excessive weight gain during pregnancy; post partum weight retention; gestational diabetes, and the associated risk of developing type 2 diabetes later in life; obesity; and heart disease (Charkoudian & Joyner, 2004).

Diabetes, cardiovascular disease and obesity are reaching epidemic proportions in our society and thus healthy lifestyle changes initiated early in life (pregnancy) will be beneficial for both mother and offspring. The healthy environment that a mother provides during pregnancy has a profound impact on fetal programming and can prevent chronic disease risk in the adult of the future (Mottola et al., 2010).

Labour: Physical discomfort, as well as complications of labour and birth, may be alleviated in more active women (Kelly, 2005). Being physically active will also give women the stamina to get through labour and the ability to recover more quickly from birth.

Mental Health: A more positive effect on self-image and fewer depressive symptoms occur in active women during and after pregnancy (Wolfe & Mottola, 1993). This is important as being physically active may help prevent postpartum depression.

Get to Know the Exercise Guidelines

Pregnant women should also be informed about relevant exercise guidelines and how to meet the recommendations included in the guidelines.

In Canada, the guidelines for exercise during pregnancy are found in PARmed-X for Pregnancy (Wolfe & Mottola, 2002), published by the Canadian Society for Exercise Physiology (CSEP) in 1996, endorsed by Health Canada, and revised in 2002.

It’s important for pregnant women to know that in a healthy low-risk pregnancy, mild to moderate intensity exercise poses no threat to mother or fetus (Davies et al. 2003).

About Aerobic Exercise

As recommended in the guidelines and by other credible sources, the most important type of exercise is aerobic activity (using large muscle groups).

The most popular form of aerobic activity during pregnancy is walking (Mottola & Campbell, 2003).

PARmed-X for Pregnancy was designed for recreationally active pregnant women and presents the F.I.T.T. principle with the following guidelines: 

Frequency (F) of exercise should begin at 3 times per week, building up to 4 times per week. 

Intensity (I) of exercise is monitored through the use of the target heart rate zones based on age, which represents around 60 to 80% of peak aerobic capacity (Mottola et al., 2006). 

For pregnant women, these target heart rate zones are:

• less than 20 years old – 140 to 155 beats per minute (bpm);
• 20 to 29 years old – 135 to 150 bpm; and
• 30 to 39 years old – 130 to 145 bpm (Wolfe & Mottola, 2002).

Intensity is also monitored by the use of the “Talk Test”, in which a pregnant woman carries on a conversation without becoming out of breath. If the woman is breathless while speaking during exercise, the intensity of the activity must be reduced.

In PARmed-X for Pregnancy, a rating of perceived exertion scale is provided in which a woman rates how hard she thinks she is working. This should be in the 12 – 14 range (somewhat hard) on the perceived exertion scale.

The Time (T) of the activity should start at 15 minutes per target heart rate session with an increase in time of 2 minutes per week until 30 minutes is reached and then maintained. All aerobic activity should begin with a warm-up and cool-down of 5 to 10 minutes of lower intensity.

The Type (T) of activity should include low-impact or non-weight bearing endurance exercise using large muscle groups such as walking, stationary cycling, swimming, aquatic exercise or low-impact aerobics.

Women with low-risk pregnancies who start an exercise program should begin in the second trimester, at the lower end of the target heart rate zones. Those who have been avid exercisers can continue at the higher end of the target heart rate zones.

Muscle Conditioning Guidelines

Women can also do muscle conditioning exercise when pregnant. However, specific precautions should be taken:

• no exercises in the supine position (lying on her back) past 16 weeks of pregnancy;
• avoid bouncing exercises;
• stretches should be controlled;
• avoid abdominal exercise if diastasis recti (splitting of the connective tissue midline in the front abdomen wall) develops.

In addition, correct posture and a neutral pelvic alignment should be emphasized and precautions taken during resistance exercises. A pregnant woman should avoid holding her breath and emphasize her breathing through the exercise. High repetitions (e.g., 12 to 15 repetitions) should be done only with low weights, such that the repetitions can be comfortably done.

Examples of muscular strengthening exercises are listed on page 3 of PARmed-X for Pregnancy.

Can Overweight and Obese Pregnant Women Exercise?

Women with a pre-pregnancy body mass index (BMI) of over 25 kg/m2 can exercise if they have a low risk pregnancy and no contraindications.

The target heart rate zones found in PARmed-X for Pregnancy may be too high for overweight and obese women and thus new target heart rate zones have been validated for this population group (Davenport et al., 2008; Mottola et al., 2010) at a lower intensity (20-39 % aerobic capacity), but still high enough to gain an aerobic benefit.

These target heart rate zones based on age are: 102-124 bpm (20 – 29 years) and 101-120 bpm (30-39 years) and can be used in conjunction with PARmed-X for Pregnancy.

Are There Different Guidelines for Fit Pregnant Women?

For very fit, medically pre-screened pregnant women, the current target heart rate zones may not be appropriate and thus target heart rate zones validated on pregnant women of different fitness levels are also available (Mottola et al., 2006).

For low–risk, fit pregnant women 20 to 29 years old, the target heart rate zone is 145–160 bpm. For low-risk, fit pregnant women aged 30 to 39, a zone of 140–156 bpm may be more appropriate.

To confirm appropriate intensity, these target heart rates should be used in conjunction with PARmed-X for Pregnancy.

Contraindications to Exercise

For some women, there may be times when physical activity may not be appropriate or may need to be modified.  It is important for health professionals to be aware of the contraindications to exercise.

PARmed-X for Pregnancy lists both relative and absolute contraindications (Davies et al., 2003).

 

About PARmed-X for Pregnancy

 

PARmed-X for Pregnancy (Wolfe & Mottola, 2002) is a medical tool for screening pregnant women who are interested in starting an exercise program or who wish to continue being active.

 

In this document you will find some practical resources, including:

• A questionnaire for pregnant clients to complete in order to supply you with important medical history and a recent patient activity profile.
• A convenient list for the medical provider to check for contraindications to exercise.
• Evidence-based practical guidelines and prescriptions for participating in aerobic and muscle conditioning activities.
• A tear-away medical clearance form that can be completed by the obstetric provider and presented to prenatal fitness professionals by the pregnant woman.

Medical Practitioners Should Promote Exercise During Pregnancy 

With the clearly established benefits of physical activity before, during and after pregnancy, it’s vital for medical practitioners to actively encourage pregnant women to be physically active.

 

By using the medical pre-screening tools included in PARmed-X for Pregnancy and by promoting the recommended exercise guidelines included in the document, medical practitioners can play a key role in boosting the physical activity levels of pregnant women, so that they and their offspring can enjoy the health benefits.

 

Dr. Michelle F. Mottola is a Professor at the University of Western Ontario in the School of Kinesiology in the Faculty of Health Sciences and Department of Anatomy and Cell Biology in the Schulich School of Medicine and Dentistry. She is also the Director of the R. Samuel McLaughlin Foundation – Exercise and Pregnancy Laboratory. This is the only lab in North America that specializes in the area of exercising pregnant and postpartum women. Dr. Mottola is a Fellow of the American College of Sports Medicine, a member of the Canadian Society of Exercise Physiology and a co-author of the PARmed-X for Pregnancy.

 

Useful Links

• The Exercise and Pregnancy Lab, University of Western Ontario
• PARmed-X for Pregnancy
• Healthy Pregnancy pages on Health Canada’s website
• Move For Two – Physical Activity and Pregnancy DVD (produced by the Middlesex-London Health Unit)

References

 

Canadian Academy of Sports & Exercise Medicine. (2008). Position statement on Exercise and Pregnancy. Retrieved from http://www.casm-acms.org/Media/Content/files/Exercise%20&%20Pregnancy%20Position%20Paper%20_2008_.pdf 

Charkoudian, N. & Joyner, M.J. (2004). Physiologic considerations for exercise performance in women. Clinics in Chest Medicine, 25(2), 247-255. doi:10.1016/j.ccm.2004.01.001 

Davenport, M., Sopper, M.M., Charlesworth, S., Vanderspank, D., & Mottola, M.F. (2008). Development and validation of exercise target heart rate zones for overweight and obese pregnant women. Applied Physiology Nutrition Metabolism, 33(5), 984-9. doi: 10.1139/H08-086 

Davies, G., Wolfe, L.A., Mottola, M.F., & MacKinnon, C. (2003). Joint SOGC/CSEP Clinical Practice Guideline: Exercise in Pregnancy and the Postpartum Period. Journal of Obstetrics Gynecology Canada, 25(6), 516-22. 

Kelly, A.K. (2005). Practical Exercise Advice During Pregnancy - Guidelines for Active and Inactive Women. Physician and Sports Medicine, 33(6), 24-31. doi:10.3810/psm.2005.06.104 

Mottola, M.F. (2011). American College of Sports Medicine, Guidelines for Exercise Testing and Prescription, 9th edition. Chapter 8, Exercise Prescription for Healthy Populations and Special Considerations (In Press). (Deborah Riebe, Associate Ed.). Philadelphia, PA: Lippincott, Williams & Wilkins. 

Mottola, M.F. & Campbell, M.K. (2003). Activity patterns during pregnancy. Canadian Journal of Applied Physiology, 28(4), 642-653. doi: 10.1139/h03-049 

Mottola, M.F., Davenport, M., Brun, C.R., Inglis, S.D., Charlesworth, S., & Sopper, M.M. (2006). VO2 peak prediction and exercise prescription for pregnant women. Medicine, Science in Sports and Exercise, 38(8), 1389-1395. doi: 10.1249/01.mss.0000228940.09411.9c 

Mottola, M.F., Giroux, I., Gratton, R., Hammond, J., Hanley, A., Harris, S., McManus, R., Davenport, M., & Sopper, M.M.  (2010). Nutrition and exercise prevents excess weight gain in overweight pregnant women. Medicine & Science in Sports and Exercise, 42(2), 265-72.  

doi: 10.1249/MSS.0b013e3181b5419a

 

Wolfe, L.A. & Mottola, M.F. (1993). Aerobic exercise in pregnancy: An update. Canadian Journal of Applied Physiology, 18(2), 119-147. doi: 10.1139/h93-011 

Wolfe, L.A. & Mottola, M.F. (2002) PARmed-X for Pregnancy. pp 1- 4. Ottawa, ON: Canadian Society for Exercise Physiology.