npdi diabetes services physical guidelines

� National Pacific Diabetes Lifestyle Guidelines

Physical Activity Guide

� NPDI Physical Activity Guide

AcknowledgementsNational Pacific Diabetes Initiative (NPDI) steering group wish to acknowledge and thank the following people for their valuable contribution to the development of this lifestyle guide:

• Jordan Salesa, author of this lifestyle guide

• NPDI Lifestyle Guide Team - Linda Mulitalo Tasi, Stephanie Erick-Peleti and Karen Fukofuka for their support, commitment and dedication to working on this project.

• Josephine Samuelu, Project Manager NPDI and Lincoln Papali’i, CMDHB.

• The team from Intra Pacific Development Trust – Yvonne Timaloa and Karyn Ne’emia

• The regional NPDI summit attendees in Christchurch, Wellington and Auckland for their feedback and comments.

• Rob Cook – Project Manager from the New Zealand Guidelines Group

• Diana O’Neill from SPARC for critiquing this work.

• Dave Driscoll from the National Heart Foundation for his input in to the physical activity hand book.

• The Ministry of Health for their vision and commitment to improving health outcomes for Pacific people.

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PrefaceCounties Manukau District Health Board, together with a national NPDI steering group, are leading the development of a National Pacific Diabetes Framework to help improve the understanding and effectiveness of approaches and interventions that:

• Improve uptake and utilisation of Diabetes services by Pacific populations diagnosed with diabetes and their families

• Document and expand awareness of approaches that have an impact on the health status of Pacific populations diagnosed with diabetes

• Identify the cost implications for services that are targeted at Pacific populations diagnosed with diabetes and the capacity to be maintained by Pacific providers and

• Support Pacific provider development ensuring best practice approaches are integrated into service provision

This guide is one of the key activities undertaken as part of the National Pacific Diabetes Initiative to support diabetes health workers deliver consistent and effective lifestyle messages to improve diabetes care and management for Pacific people diagnosed with type 2 diabetes.

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Executive SummaryThe prevalence of type 2 diabetes within the Pacific population in New Zealand has reached an alarming level. Significant lifestyle changes are required to reverse or at the very least halt the increasing incidence of diabetes. Increasing physical activity levels of Pacific peoples is one part of this complex puzzle.

Key Points:• Pacific peoples in New Zealand are significantly less active than the rest of the New

Zealand population.

• Physical inactivity is a significant risk factor for diabetes.

• Physical activity is defined as 30 minutes of moderate-intensity activity on most if not all days of the week.

• The benefits of increasing physical activity levels among Pacific peoples can reduce the onset and prevalence of diabetes.

• Pacific people’s concepts of physical activity and exercise in the New Zealand setting may be a barrier to increasing physical activity levels.

• Physical activity interventions must take into account politico-economic and social policies along with more direct barriers such as time, financial constraints, language, knowledge, other responsibilities (e.g. church, family), motivation and fear of change.

• Re-focusing or re-defining mainstream physical activity interventions to tailor Pacific needs is important.

• Developing adequate ‘Pacific specific’ physical activity resources that support existing Pacific physical activity programmes that are based around visual mediums.

• Providing sound education and increasing the number of Pacific physical activity leaders is essential to bridging the gaps in ‘Pacific specific’ physical activity and lifestyle programmes.

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Purpose of the physical activity guideThe purpose of this guide is to provide health workers with current, basic and practical information on physical activity methods and approaches to help improve the care and management of Pacific people diagnosed with type 2 diabetes and their families.

Diabetes care and management is unequivocally linked to lifestyles. This guide forms one part of the lifestyle approach adopted by National Pacific Diabetes Initiative. Together with the nutrition and smoking cessation guides a three pronged lifestyle management approach has been developed to assist Pacific peoples with preventing and managing diabetes.

Although this guide is specifically aimed at the Pacific people with type 2 diabetes and their families, the information is also useful for the general Pacific population.

The information in this guide can also be used as a basis for small group education sessions or for educating patients one-to-one and tailoring it to suit specific individual needs.

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ContentsACKNOWLEDGEMENTS 2

PREFACE 3

EXECUTIVE SUMMARY 4

PURPOSE OF THE PHYSICAL ACTIVITY GUIDE 5

CONTENTS 6

INTRODUCTION 7

BACKGROUND 8

Importance and Benefits of Physical Activity for Pacific Peoples 8

Diabetes and Physical Activity / Inactivity 8

What is Physical Activity? 8

Pacific Specific Benefits 10

Pacific concepts of physical activity and exercise 10

Barriers to Physical Activity for Pacific Peoples 12

The role of the family in Physical Activity 14

Places for Physical activity (Who is doing what?) 15

Physical Activity Programmes that work for Pacific People 17

Physical Activity, Behavioural Change and Pacific Peoples 18

Making Pacific Physical Activity Delivery Better 19

RESOURCES 20

5 Step Physical Activity Process 20

Physical activity guide for Pacific people with type 2 diabetes 21

Information Leaflets 23

Websites or Pages 24

REFERENCES 26

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IntroductionThe prevalence of type 2 diabetes within the Pacific population residing in New Zealand is a growing concern. The reasons for this are many and varied. The complexities and magnitude of the problem have been collated in a comprehensive literature review commissioned by the National Pacific Diabetes Initiative (NPDI) (Schaaf & Schaaf, 2005).

Stopping or preventing the onset and impact of diabetes on Pacific peoples will not be easy. This guide forms one part of a three pronged lifestyles approach to beat the diabetes epidemic among Pacific people. There is significant evidence to show that lifestyle alterations can both prevent and improve the management of diabetes.

Physical in-activity of Pacific peoples in New Zealand does play a role in this diabetes epidemic. This document examines more closely the role of physical activity, the level of in-activity, Pacific peoples’ concepts of physical activity and exercise, and the roles family and communities play. There are always barriers to change. These are discussed along with where to access physical activity programmes and how to improve its delivery to Pacific peoples.

Finally, linkages to the NPDI physical activity handbook for health workers are made along with some resources, links and recommendations to aid the health worker in delivering effective diabetes management to increase physical activity particularly for those who are diagnosed with diabetes and their families.

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Background

Importance and Benefits of Physical Activity for Pacific Peoples

Diabetes and Physical Activity / Inactivity

The Ministry of Health (MoH, 2004) publication Tupu Ola Moui: Pacific Chart book tells a chilling story. Pacific children and adults are less likely to be physically active than their New Zealand counterparts (52% versus 68% and 63% versus 68% respectively). The burden of disease and premature death attributed to physical inactivity is significant. It is associated with 8% of all deaths and is estimated to account for over 2000 deaths per year and physical in-activity is second only to smoking as a modifiable risk factor for poor health (NZGG, 2003).

There is a strong correlation between physical inactivity and the incidence of type 2 diabetes. An estimated 11,500 New Zealanders are diagnosed with diabetes, with that number expected to increase to 16,000 over the next 20 years (NZGG, 2003). The prevalence of people diagnosed with diabetes is higher in Maori and Pacific people and the complications are more severe (NZGG, 2003). Pacific male adults and females have significantly higher prevalence rates and the lifetime risk of being diagnosed with diabetes is 25%, compared with 9% of New Zealand Europeans (MoH, 2004).

The benefits of physical activity are clear. Physical activity can reduce the risk factors of many major diseases, such as cardiovascular disease, obesity, diabetes, certain cancers, osteoporosis and possibly depression (MoH, 2003). Lifestyle change prevents or delays the occurrence of type 2 diabetes in high risk groups, and modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high-risk persons by about 40% to 60% (Knowler et al, 2002, Williamson et al, 2004). Physical activity also reduces morbidity and mortality amongst diagnosed diabetics (MoH, 2003).

What is Physical Activity?

Sport and Recreation New Zealand (SPARC) categorises physically activity (or inactivity) based on 150 minutes per week (see table 1). These categories were used in the Sport and Physical Activity Surveys (1997/98, 1998/99, 2000/01) looking at the patterns of physical activity among New Zealanders (SPARC 2003).

Table 1. Catergories of Physical Activity / Inactivity. Adapted from MoH DHB Toolkit: Physical Activity 2003.

Active / Inactive Category Description

Physically inactive Sedentary No sports/activities in the previous seven days

Relatively inactive Took part in some leisure-time PA in the previous seven days, but less than 2.5 hours in total

Physically active Relatively active Took part in at least 2.5 hours of leisure time PA in the previous seven days

Highly active Took part in five hours or more of leisure time PA in the previous seven days

The Hillary Commission (now SPARC) developed physical activity guidelines for adults (table 2) which are very similar to current worldwide thought (Kriska, 2002). In addition to these recommendations, SPARC recommends that children and adolescents should do three 20 minute

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sessions of vigorous activity per week.

Table 2. Hillary Commission Physical Activity Guidelines for Adults. Adapted from DHB Toolkit: Physical Activity 2003.

• View movement as an opportunity, not an inconvenience.

• Be active every day in as many ways as possible.

• Put together at least 30 minutes of moderate-intensity physical activity on most, if not all, days of the week.

• If possible, add some vigorous exercise for extra health and fitness

Specific concepts have emerged from the campaigns used to get the recommendations into the wider community. Snacktivity is one such concept. Research has shown that moderate-intensity physical activity broken up into parts of 30 minutes, such as 3 lots of 8-10 minutes, can have the same effect as a continuous bout of moderate-intensity physical activity (MoH, 2003).

The manner in which one achieves these physical activity targets is endless. These recommendations are a minimum and figure 1 below illustrates how more vigorous activity in less time is equivalent to low intensity activity of longer duration. Table 8 in the resource section gives specific day to day examples of low, moderate and vigorous physical activity.

Figure 1. Ways of meeting the moderate physical activity guidelines (in daily life). Adapted from DHB Toolkit: Physical Activity 2003.

• Washing & waxing a car for 45-60 minutes

• Washing windows or floors for 45-60 minutes

• Playing volleyball for 45 minutes

• Playing touch rugby for 30-40 minutes

• Gardening for 30-45 minutes

• Wheeling self in wheelchair for 30-40 minutes

• Walking 2.8km in 35 minutes (12.5 min/km)

• Basketball-shooting baskets for 30 minutes

• Bicycling 8km in 30 minutes

• Dancing fast (social) for 30 minutes

• Pushing stroller for 30 minutes

• Raking leaves for 30 minutes

• Walking 3.2km in 30 minutes (9.5 min/km)

• Water aerobics for 30 minutes

• Swimming laps for 20 minutes

• Skipping for 15 minutes

• Running 2.4km in 15 minutes (6.3 min/km)

• Climbing stairs for 15 minutes

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LESS vigorous, More time

MORE vigorous, LESS time

�0 NPDI Physical Activity Guide

Pacific Specific Benefits

The Sport and Physical Activity Surveys (1997/98, 1998/99, 2000/01) have given us clear messages in relation to Pacific peoples. Only 50% of Pacific youth are active, compared to 68% of national population (SPARC, 2003). There has been a significant increase in sedentary Pacific young people, 6% in 1997 to 33% in 2001 (SPARC, 2003). Only 36% of pacific adults are regularly active i.e. meet the recommended 30 minutes a day, most days of the week, compared with 52% of the national population (SPARC, 2003).

There are no reported data on physical activity patterns of diagnosed Pacific diabetics. However, it seems reasonable to conclude that Pacific people in New Zealand are generally inactive compared with the national population. Anecdotal evidence and clinical experiences would seem to suggest that the physical activity patterns of people who do not have diabetes would be similar (or worse) amongst Pacific people with diabetes.

With the projected rise in numbers of people diagnosed, coupled with the downward trend of physical activity patterns among Pacific people, the need for increased physical activity levels including other interventions for prevention and diabetes management is clear.

Pacific concepts of physical activity and exercise The number of Pacific ethnic groups are vast, comprising of more than 20 ethnic communities, all with there own unique culture, language and history of settlement in New Zealand. Almost 60% of the Pacific population in New Zealand were born in New Zealand (Statistics New Zealand, 2004). Concepts of physical activity and health consequently reflect this diversity. Despite this there are overarching similarities across the Pacific communities. There is qualitative and quantitative evidence to support the view that Pacific constructs of health are holistic and emphasise health as a property of the extended family rather than purely individual (MoH, 2004).

Traditionally Pacific cultures are very physically active. There is currently little evidence of obesity or obesity related diseases (Foliaki and Pearce, 2003, MacPhearson and MacPhearson, 1990). Pacific people are at various transitional stages between their Pacific culture and New Zealand culture (Bell et al, 2001). Gonalevu (cited in Schaaf & Schaaf, 2005) suggested that in terms of diet, younger New Zealand born Pacific people may well have more in common with Europeans than their elders. This may well be the case with attitudes to activity and exercise within the New Zealand setting.

Exercise is often seen as a Papalagi concept. Group activities or recreational games are often viewed in the social context not as physical activity or exercise. Therefore, any reduction in availabity or opportunity for community or group activities may be linked to physical inactivity of Pacific peoples.

SPARC has recognised the reduction in participation rates amongst organised sport within New Zealand (SPARC, 2003). Pacific people do participate in traditional New Zealand organised sport and active leisure pursuits. There are however, some key differences. In the Pacific social context playing an organised sport without your ethnic or cultural peers often doesn’t fulfil all social obligations. This can be seen vividly in our national game, Rugby. The Auckland club rugby competition has 19 clubs, and usually fields two adult teams on any given game day (38 teams with many pacific players). Immediately after the club rugby season ends, the Auckland Samoan Rugby (and Tongan, Cook Island and Niuean) season begins. These competitions run for three months and have in excess of 45 teams (playing every weekend) across the region. It would seem that for a Pacific person, organised sport must be in the correct social and cultural context.

The importance of family, church and community is paramount. It is considered a blessing for children to care for their parents or grandparents once they retire until they die (NZGG, 2003). �0

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Eighty-three percent of Pacific peoples stated an affirmation with a christian denomination (MoH, 2004). Many Pacific people attend several church functions a week. With such strong obligations to family, church and community, time or lack thereof may leave other aspects of life including, physical activity and personal health secondary.

Pacific women have higher prevalence rates of self reported diabetes (NZGG, 2003). Adult Pacific women are less active than their New Zealand European counter-parts (68% versus 58% respectively), while 48% of young Pacific girls are inactive (SPARC, 2003). Pacific peoples are socio-economically disadvantaged (MoH, 2004). Incomes are low and unemployment levels are twice the national average (MoH, 2004). Families are bigger and house occupancies higher. Women and girls are often the family cooks or child carers. Financial pressures and time constraints on Pacific women are immense. This may explain physical inactivity and lower participations rates of Pacific females.

Body size perception of Pacific peoples differs to other New Zealanders (NZGG, 2003). Large body size is often admired and may be perceived as being healthy and / or having wealth and status. While thin people, can be perceived as sickly, or suffering from illness (e.g. cancer).

Acculturation is recognised as integration, assimilation, separation and marginalisation. New Zealand born generations of Pacific peoples have undergone significant acculturation, which is a continuing process. This has both positive and negative impacts on health. Negative impacts may result from loss of identity and social support, as well as changes in dietary, physical activity and substance use (tobacco) patterns (MoH, 2004).

Case Example: ‘Living4Life’ Schools Programme Diabetes Projects Trusts

The Diabetes Projects Trust is situated in Otara, South Auckland. They have a variety of initiatives and programmes aimed specifically at preventing diabetes and its complications in the community. These range from support groups, exercise classes, GP Audit, train the trainers’ programmes and their recent initiative the 3 Schools programme.

The ‘Living4Life’ programme is a specially developed programme aimed at year 9 students. It covers health promotion to prevent diabetes/obesity and make healthy choices, and a motivational physical activity programme. Each school chooses how the programme is set up but essentially there are 10 x 1 hour interactive teaching sessions over the year, and some schools prefer breakfast type activity programmes, or several times a week lunchtime activity sessions.

Currently ‘Living4Life’ is targeted at three AIMHI South Auckland secondary schools - Mangere, Southern Cross and Hillary College. The programme is led by Judy Rowden and Lama Saga. Funding is from CMDHB, under the umbrella of the newly launched ‘Lets Beat Diabetes’, and it is monitored by the NEW (Nutrition, Exercise & Weight) working party.

Judy delivers the teaching sessions, and Lama is the key Activity instructor. Activities range from using activity contractors (e.g.Manukau on the Move - for Kayaking, TV celebrities), resistance classes, playing the more popular sports or games (volleyball, touch rugby,

kilikiti), going for hikes and the very popular Hip Hop dance offs (Mangere College won the Auckland Hip Hop contest! In 2005).

This programme initially started as an unfunded trial in one school but escalated and subsequently gained some direct funding. These activity sessions have proven to be very popular, with some sessions having 50 - 60 kids participating. The essential aspects of the physical activity components are participation, fun and doing activities the young people want to do while reinforcing the overall messages delivered in the health promotion sessions.

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Barriers to Physical Activity for Pacific Peoples

Foliaki and Pearce (2003) view diabetes prevention and control on individual and population based levels. These authors point out some individual barriers consistent with other studies and commentators (Kriska, 2002, Simmons et al, 1998). On the population approach they pointedly refer to the biggest sticking point. They contend that any approach focuses on not only bio-physiological and lifestyle influences but just as importantly the politico-economic environments and social structures we live in. Choice for some, as they put it, is fast becoming choice via no option. This may be illustrated in minimum wage rates, cycle lanes or free access to council facilities such as the Manukau City Council Swimming pools. While this argument is beyond the scope of this paper it is never the less important to consider.

Simmons et al (1998) identified a number of barriers to diabetes care for Pacific peoples (table 3 below). These authors identified thirty barriers from the multi-ethnic South Auckland community, with 50% of respondents being Pacific identified. Despite cultural, acculturation, and socioeconomic status the barriers were similar between ethnic groups. The most important perceived barriers were; that the disadvantages of diabetes care outweighed the benefits; the lack of community based services; and the limited range of services available. They proposed that systematic action to reduce the impact of these barriers would improve patient and population outcomes.

Table 3. Barriers to Diabetes Care. Adapted from Simmons et al, 1998.

Psychological • including beliefs, western vs. spiritual health vs. alternate vs. public beliefs

• motivation & self efficacy

• negative perceptions of time

• no symptom cure

• Emotion

• Pre-contemplative (hard to follow programmes, giving up things they enjoy)

Current general & • Lack of knowledge of diabetes & diabetes services

specific knowledge

of their situation

Internal Physical • Self factors / other health conditions eg. Diabetes (amputation) & non- diabetes related (arthritis)

External Physical • Financial constraints

• Service or physical access (transport)

• access / appropriate staff (levels or ethnic specific)

• appointment or staffing systems

• lack of community based services (no local clinic)

• unhelpful health professionals in the past

Psychosocial barriers • Unsatisfactory / inappropriate diabetes care / education

to care • Group pressures from others not to adhere to advice

• Lack of public awareness

• Lack of family support

• Family demands

• Unsupportive macro environment (eg feeling of lack of support)

• Communication eg language

• Inappropriate cultural messages eg attitude, ethnicity of workers

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The evidence based best practice guidelines also identified specific barriers to diabetes care for Pacific peoples (NZGG, 2003). Specifically this included time, socioeconomic status, language, beliefs about illness and health concepts, trust issues with providers, willingness to change lifestyle and the fact that Pacific peoples are not in fact generic, while there are many cultural similarities there are differences as well.

The LotuMoui Symposium, led by Counties Manukau District Health Board (CMDHB) in December 2004 held workshops which also identified barriers (and solutions) to healthy lifestyles (see Table 4).

Table 4. Perceived Barriers to Healthy Lifestyles: Pacific Participants at the Lotumoui Symposium. Adapted from Schaaf & Schaaf 2005.

• Binge eating

• Lost the basics of nutritional eating

• Lack of Education and awareness

• Lack of resources

• Lower socio-economic status

• Cultural issues

• Fear of making changes (particularly Church environments and cultural practises)

• Thinking not doing

• Pride

Specific barriers to physical activity itself are well recognised. These are listed below (Table 5).

Table 5. Barriers to Physical Activity. Adapted from MoH DHB Toolkit: Physical Activity 2003 & SPARC; Obstacles to Action: A Study of New Zealanders’ Physical Activity and Nutrition 2004

• Time

• Too hard to stick to a routine

• Other responsibilities

• Lack of knowledge (of facilities and opportunities) to be active

• Inadequacy feelings (eg. ‘body beautiful image’)

• Other things they would rather be doing

• Fear of failure

• Language

• Injury or disability

• No-one to be active with

• No motivation

• Poor health

While the Pacific population may differ in terms of barriers to physical activity, it is clear that the

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following factors play important roles in getting in the way of Pacific peoples wanting to begin, maintain or improve their physical activity levels;

• Time

• Financial constraints

• Language

• Other responsibilities (Church, Family)

• Fear of change

• Lack of knowledge (of facilities and opportunities) to be active

• Poor health due to illness, injury or disability

• Motivation

Interventions that are aimed at lifestyle changes in particular increasing Pacific people’s physical activity patterns must acknowledge the above barriers and provide solutions to overcome these barriers.

The role of the family in Physical ActivityFamily is central to the Pacific way of life. Most Pacific peoples’ idea of family can mean ‘extended family’ regardless of living arrangements (MoH, 1997). There is currently little data available examining the specific family roles in relation to physical activity patterns. Much of what we know is specific first hand knowledge of Pacific communities, or has been gathered via symposia or consultation processes.

“For Pacific people, the family is the main unit in which children learn, grow and are enabled to survive the vulnerable years of early childhood. The family has also traditionally been the only support structure for older people. Regardless of actual living arrangements, ‘family’ to Pacific people usually means ‘extended family’ and includes an integration of family networks”

Dr Mesui’s chapter ‘Pacific Perspectives’ in the evidenced based guidelines for type 2 diabetes summarises specific family member roles in terms of diabetes care succinctly (NZGG, 2003). Physical activity can also be viewed in this construct:

• The family leader can play a role in decision making and influence family attitudes towards physical activity.

• Family elders also, can influence decisions on physical activity levels by influencing attitudes towards physical activity.

• Vehicle drivers are often needed by the family to help other family members with family events, such as funerals, weddings or sick relatives. Attending schools sports or going for a walk is often viewed as secondary to such events.

• More fluent English speakers are also needed for what might seem like trivial matters but are vital in terms of the family unit, like opening a bank account or translating some forms for the IRD or WINZ. Time spent dealing with these matters makes it more difficult to spare time for other activities like physical activity.

• The family cook often spends many hours preparing meals, time unavailable for physical activity for these family members.

• Young family members are often the drivers, interpreters or daily task managers, placing high demands on there time also.

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Pacific families, church communities, cultural communities, cultural or community leaders can all have huge influence over attitudes and beliefs surrounding physical activity. Trying to alter physical activity patterns of Pacific people without these people would be doomed to fail.

Case Example: Health Pacifica

Health Pacifica Doctors in Mangere, South Auckland has been instrumental in setting up many Pacific specific targeted health interventions.

Mary Patana leads the ‘Pacifica Aerobics’ activity sessions, which are based in 3 locations around South Auckland, Mangere, Clendon and Otara (above). She has a passion for her peoples’ health and wellbeing.

The ‘Pacific Aerobics’ sessions are held five days a week. Attendances have grown dramatically since the programmes inception. It is not out of the ordinary to have more than 50 participants or any given day. It really is a social gathering with physical activity on the menu.

This programme was set up to get their (Health Pacifica) diabetic population physically active. It proved to be very popular and was rapidly expanding in terms of numbers attending sessions. They have approximately 25 diabetics who regularly attend the physical activity sessions. These patients are managed under the CCM (Chronic Care Management) plan and are reviewed on Health Pacific’s premises. Everyone is encouraged to regularly attend, while educational messages such as nutrition, hydration and diabetes monitoring are conveyed during the activity sessions. People are encouraged to weigh themselves, with around 5- 10% of those attending choosing to do so. The physical activity session itself follows a standard slow warming up phase, some more vigourous aerobics / pacific style dance moves, followed by a slowing down up period.

Mary is undergoing further tertiary education at present to enhance her knowledge around physical activity delivery and sees access and education as some of the bigger barriers that face the Pacific populations.

Places for Physical activity (Who is doing what?)The industrialised world’s trends of increasing obesity and decreased activity levels and their sequalae (diabetes and heart disease being the most prominent) has seen various approaches in tackling the problem. What is very clear however is that lifestyle interventions can prevent or delay the onset of type 2 diabetes in high risk groups, and that modest weight loss through diet and physical activity reduces the incidence of type 2 diabetes in high risk persons by about 40-60% over 3 to 4 years (Williamson et al, 2004).

Physical activity clearly has an important role in improving the health status of pacific diabetics. But who delivers this physical activity in New Zealand to Pacific people and Pacific diabetics. Summarised in the table 6 below are avenues that a Pacific person can take to become more physically active.

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Table 6. Organisations providing physical activity interventions. Adapted from DHB Toolkit: Physical Activity 2003.

Government programmes

SPARC Community-based: Green prescriptions, 0800 Active, KiwiWalks, He Oranga Poutama. For young people: KiwiSport, Sportfit

Te Puni Kokiri Omangia Te Oma Roa

ACC SportSmart: 10 point plan for injury prevention, injury prevention kit for schools (Te Kaupapa Arai Whara) (health resource, through the marae), falls prevention demonstration projects

EECA Walking School Buses, Sustainable Transport

Local government Recreation and sports facilities and a variety of directly provided or funded recreation programmes for all ages, Safer Community Councils, Healthy Cities, design of urban environments in ways that encourage incidental physical activity

Public health services, Healthy Cities, nutrition and physical activity teams have strategies that DHBs include training and workplace programmes, Healthy Schools, Agewell

Ministry of Education/ Health and Physical Recreation Curriculum, tertiary education institutions education (programmes, gym facilities), clubs

Ministry for the Policy Environment

Department of Summer walking programmes Conservation

Ministry of Transport National Road Safety Strategy

Ministry of Women’s Policy, audit functions Affairs

Non-government organisations

National Heart Stroll, Strut, Stride, guidelines for exercise programmes for patients with Foundation heart disease, Pacific Heartbeat

Arthritis Foundation Move It or Lose It, falls prevention programmes

Agencies for Healthy Weight New Zealand, supports SPARC’s programmes for physical Nutrition Action activity promotion

Te Hotu National Maori public health training organisation Manawa Mäori

YMCA, YWCA A range of gym-based and other physical activity programmes, cardiac rehabilitation, physiotherapy etc

Most of these intervention strategies have their place and may be utilised by Pacific peoples. However considerations to the barriers that Pacific peoples face means that many of these interventions may not be appropriate for Pacific populations. Pacific health providers in primary care settings have in recent times been able to directly fund and run Pacific specific activity interventions. This has led to an array of physical activity interventions predominantly Pacific style aerobics in community or church based settings (CMDHB, 2004).

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Physical activity programmes that work for Pacific people The recent comprehensive literature review centred on diabetes and Pacific peoples, commissioned by CMDHB (Schaaf & Schaaf, 2005) has 11 recommendations;

1. Target Pacific specific interventions and services.

2. Pacific services for Pacific people.

3. Community involvement.

4. Culturally tailored interventions and services relevant to Pacific people’s lives.

5. Family centred.

6. Social support (within and outside the family).

7. Creating environments that promote healthy living.

8. Integrated and co-ordinated services.

9. Prioritise reducing obesity.

10. Have long term strategies.

11. The importance of education.

While these authors state that these recommendations may not be new, it has served to collate the multi-factorial aspects of the diabetes epidemic among Pacific people. Much of what has been recommended is actively being pursued or is in place in many Pacific communities already. Some of the more pertinent points include effectively incorporating cultural elements, beliefs and icons, using stories, narrative, ‘myths’ and legends as educational and learning techniques. Utilisation of traditional healing beliefs, ideals and values, particular the ‘holistic’ or ‘balance’ notions as starting points for education. Also actively using videos and DVDs as educational tools. Pacific people have displayed a preference for health promotion featuring Pacific people, speaking Pacific languages.

Primary care providers (health, activity and exercise providers) have many and varied physical activity interventions in place. No less than 12 specific Pacific health providers run (or collaborate physical activity programmes). Some were set up specifically to monitor or promote activity for obese or diabetic Pacific people. However, almost all have grown to include the wider community with most organisations reporting heavy attendances. Commonalities between these programmes are listed below:

1. Lead by Pacific providers or trainers (where possible).

2. They are all Church or Community based.

3. Most are music / dance ‘Pacific Styles’ or ‘Pasifika aerobics’ orientated.

4. Participation and Fun are cornerstones

5. There are some group walking programmes

6. Most are part of lifestyle programmes or do include educational aspects (particularly nutrition).

7. Pacific Youth programmes have focussed on dance and sport (e.g.. volleyball, touch and Kilikiti)

The success (in terms of attendance) of many of these church or community based interventions is a clear starting point in getting Pacific diabetics and communities physically active together. One difficulty that has arisen is the measurement activity of sessions, and setting appropriate sessions for diabetic individuals. Many programmes have a good following many of whom may

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not be diabetic (or even pre-diabetic). It is however important for diabetics that some structure to physical activity remains so that they have predictable physiological responses to physical activity.

Physical Activity, Behavioural Change & Pacific Peoples Clearly behaviour change is what is needed amongst the Pacific diabetic population. Improved nutrition and diet, smoking cessation and increased physical activity are the desired outcomes but how do we get the Pacific diabetic population to these desired outcomes and contribute in the prevention of diabetes and other lifestyle chronic diseases?

Individual level health behaviour change models focussing on physical activity / inactivity have incorporated Social Cognitive Therapy, Health Belief Model and the Transtheoretical Stages of Change Model (Khan et al, 2002). To date there is little evidence that specific use of such models have assisted in improving Pacific peoples physical activity outcomes, although Simmons and Mesui (1999) have suggested the ‘stages of change’ model may be useful in evaluating programmes aimed at prevention of type 2 diabetes. Simmons et al (2004) backed this up by showing a shift from “action stage to “maintenance” stage for readiness to change weight in the “Tale of two churches” study. A summary of Prochaska and Diclemente stages of change model in relation to practical intevetions for improving physical activity is given in the table 7 below.

Table 7. Stages of Change, Stage and Action suggested. Adapted from Duffy & Schnirring, 2000.

Stage of Change Behaviours Action suggested

Precontemplation Surprise or ignorance when exercise Deliver clear physical activity is recommended messages

Education on problem, benefits & support

Contemplation Ambivalence about adopting physical Convince in favour of change

activity, resistance, denial Use community role models & examples

Determination Patient’s statements reflect concern Help patient find an appropriate and desire to change physical activity strategies

Offer tools & set goals, encourage small changes eg. park further away, play with kids, do housework

Action Commitment to exercise Support patients as they become more physically active (use family, elders, olfer siblings & community)

Reinforce achievement, reiterate support, benefits & goal focus

Maintenance Exercise becomes routine Support patients as they remain physically active (use family, elders, olfer siblings & community)

Congratulate, reinforce achievements, goals & benefits

Relapse Lapses into inactivity patterns Help patient avoid staleness / demoralisation, help patients re-evaluate their next physical activity action steps

Ask why, identify barriers & options to overcome, ? motivation

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Making Pacific Physical Activity Delivery BetterPacific people are, if nothing else very practical people. Anyone who has visited any of the Pacific Islands can give you examples of westernised machinery, tools, cars, whiteware, magazines, almost anything being adapted or modified to suit an ‘island purpose’. We must apply the same technologies and practicalities to proven physical activity lifestyle interventions.

Suggestions from the LotuMoui Symposium (2004) ranged from expanding and comprehensively training the Pacific health workforce, changing the church environment, changing mindsets, challenging cultural practices that promote unhealthy lifestyles, and specific media campaigns.

Ideas gleaned from existing Pacific physical activity providers are many and varied:

• Expanding Green Prescriptions to include a Pacific branch or focus (use Pacific branch as follow up agency (not regional sports trusts).

• Expanding Green Prescriptions to include other allied health providers (widening the net).

• IT solutions including Medtech templates or links to specific Pacific programmes or providers (and mainstream options).

• IT solutions for providers discs, IT links, flash screens for providers - who to ring (e.g. on medtech).

• Translating into pacific languages specific diabetic / activity guidelines and information.

• Using more visual images utilising print media, DVDs, videos, CDs.

• Stronger media promotions of physical activity (particularly Pacific channels).

• Improving workforce issues.

• Stronger role modelling and leadership from family, community and church leaders.

Case Example: Dylan Mika

Dylan Mika is Samoan. Dylan is also a Type 1 diabetic, a former Auckland, Blues, All Black and Manu Samoa Rugby Representative. Here he answers various questions about physical activity and the impact diabetes has had on his life. He is now retired and living in Auckland after finishing his rugby career in Japan a few years ago.

Being a rugby player was a huge part of his life, and being a diabetic meant that he had to have very good understanding of his problem, be able to manage his blood sugar levels, and understand the importance and benefits that physical activity had on his health.

Dylan’s concepts of activity are clear, he knows that being physically active is an important part of his diabetes management, “any kind of activity will do” from simply walking to the shops, or not having any TV remotes to doing the house cleaning.

Specific diabetes issues that he confronted being a rugby player were making certain he had eaten correctly before any training, knowing his blood sugar levels before training and having enough sweet drinks at training – just in case!

His family has played a massive role, “if they didn’t have a very good understanding of diabetes and its impact on me I would have been in big trouble”. He doubts he would have been a top rugby player if his family didn’t play such an active role in managing his diabetes with him. Food is especially important, getting everyone in the family (“and that’s a lot of people where talking about”) eating the same food not preparing separate special meals for the diabetic person.

Dylan keeps active these days by playing squash, swimming, walking, housework and he still does weights in the gym every now and again.

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�0 NPDI Physical Activity Guide

Resources Specific Pacific physical activity targeted resources are scarce, with many Pacific providers producing or modifying their own. Examples of some of these are diaries for blood glucose monitoring, nutrition and exercise, information sheets and photos. This section provides links to the NPDI Physical Activity Handbook by outlining the “5 Step Physical Activity Process”, algorithm and physical activity intensity table. In an attempt to help quantifying physical activity a “Pacific Lifestyle Bible” is shown also. Specific physical activity links and resources are also listed.

5 Step Physical Activity Process Step 1. Deliver the key messages:

• Terminology - Physical activity not exercise.• 30 minutes of moderate-intensity physical activity on most if not all days of the week can

produce substantial benefits for diabetics.• Physical Activity may be accumulated in bouts of 8 - 10 minutes.• Those already doing 30 minutes of moderate-intensity physical activity a day should be

encouraged to do a higher level of intensity for longer to increase the benefits of physical activity.

Step 2. Safety considerations:• Diabetic complications are higher amongst Pacific peoples so;• Ensure GP or practice team assess cardiovascular risk.• Those with cardiovascular disease or coronary heart disease should start physical activity

at low intensities and avoid vigorous physical activity.• Best times to be physically active; (to enhance glycaemic control) • Similar times each day.• Between meals e.g. after breakfast but before lunch or after lunch but before dinner.• Food and water; • Always drink lots of water.• Have available a small amount of carbohydrate e.g. fruit juice, a lollie or dried fruit in

case of hypo-glaecemic attack.• Regular feet checks pre / post physical activity.

Step 3. Quantify current Physical Activity level:• Use specific measure tools such as PAR-Q & you (www.csep.ca/forms.asp). • Use specific timed measurements such as 12 minute walk or specific measurable

distances.• Use an activity diary over a set period e.g. 1 week.

Step 4. Set goals, monitor, follow up & progress:• Set goals;

• SMART - Specific, measurable, achievable, relevant and time-based e.g. walk to / from church; attend 2 weekly Pacifica aerobics classes over next 3 months.

• Consider the Stages of change model (see guideline for summary).• Monitor or re-test (see Step 3).• Progress e.g. if doing low intensity increase to moderate, if attending 2 classes increase

to 3 or 4.Step 5. Physical Activity Intensity:

• Use chart on guideline (figure 2 or green prescription pads) to guide prescription for low / moderate / vigorous intensities.

• Use tasks / jobs / activities / hobbies or sports that are relevant to the person

�0


Figure 1.Physical activity guide for Pacific people with type 2 diabetes

Physical Activity / Exercise Key Messages• Be physically active everyday in as many ways as possible• Minimum of 30 minutes moderate intensity physical activity on most if not all days of the week• Can be accumulated in bouts of 8 - 10 minutes

Initial Contact with Diabetes Team (Safety)

• Those with cardiovascular disease should see their GP & begin physical activity at low intensities

• For those on insulin, specific advice should be given by GP (practice team) on dosage, site & time relevant to physical activity

• Quantify Physical Activity - adequate? Use specific measurement tools eg. PAR-Q & YOU, walk or step test, diary

Goal Setting / Stages of Change / Pacific Relevant• Set goals:

• SMART (specific, measurable, achievable, relevant, time-based) e.g. walk with family to / from church, attend 2 pacific aerobics sessions per week over next 2 months

• Stages of change Model: (set goals & advice according to readiness to change behaviour)• Pre-Contemplation - not thinking about changing habits (Action - give more info about

benefits etc & support)• Contemplation - understands need, but not quite ready for action (Action - use community

role models)• Preparation - ready to make changes (Action - set goals, encourage small changes eg.

park further away)• Action - practicing new behaviour changes (Action - reinforce achievement, reiterate

support, goal focus)• Maintenance - has remained physically active (Action - congratulate, reinforce

achievements, goals & benefits)• Relapse - lessening of physical activity (Action - ask why, identify barriers & options to

overcome, ? motivation)• Pacific relevant

• Pacific Community based programmes - church & community physical activity programmes

• Family centred - getting whole families involved• Culturally tailored - language, appropriate settings, accessibility & cost

Physical Activity Intensity (examples)Low Moderate VigorousWalking or cycling slowly Walking briskly Climbing stairsTai Chi Pacific aerobics / Dancing Running / joggingDusting or Vacuuming Cycling medium speed with some hills Swimming lapsStretching Mowing lawn (powered lawn mower) Mowing lawn Golf (powered cart) Washing windows / floors (hand mower)Playing volleyball (> 6 man) Washing car Cycling quickly Bowls Golf (pulling or carrying golf clubs) including hillsKilikiti Gym weights (machines) Playing touch rugbySweeping, Gardening Pushing kids in pushchair Moving or pushing or pruning furniture Gym circuit training

Follow-up, Remeasure & Assess• Goals achieved or not• Relevant pathway? (consider advice given, stages of change model issues)

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Table 8. Types & Intensity of Physical Activity

Activity Intensity

• Walking or Cycling slowly Low

• Taichi Low

• Yoga or Stretching Low

• Bowls or Golf Low

• Dusting or Vacuum Cleaning Low

• Turn the TV off or don’t use the remotes Low

• Play Kilikiti Low - Moderate

• Collect shellfish Low - Moderate

• Get off the bus early and walk, park the car further away from work and walk Low - Moderate

• Play with the kids (as much as possible) Low - Moderate

• Use chores around the house and garden to work up a sweat Low - Moderate

• Do things around the home by hand instead of using machines Low - Moderate

• Get off the bus or train early and walk Low - Moderate

• Encourage the family to walk together Moderate

• Walk the dog, walk to the shops, walk to church Moderate

• Take the stairs instead of the lift Moderate

• Wash the car by hand Moderate

• Go to community ‘Pacifica Aerobics’ classes Moderate

• Walking quickly Moderate

• Mow the lawns and work in the garden Moderate

• Let the backyard or garden help you work up a sweat Moderate - Vigorous

• Play sports with the family, church or community Moderate - Vigorous

• Dance Moderate - Vigorous

• Running, jogging or climbing stairs Vigorous

• Swimming laps Vigorous

• Gym circuit training Vigorous

• Competitive sport (rugby, netball etc) Vigorous

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Information Leaflets1. Green Prescription - Diabetes and Physical Activity http://www.pushplay.org.nz/files/Diabetes%20&%20PA%20leaflet%202004.pdf

2. Green Prescription - Healthy Weight Healthy Life http://www.pushplay.org.nz/files/Healthy_Eat_BRO.pdf

3. Green Prescription - GRx Information Cook Island http://www.pushplay.org.nz/files/Patient_CookIs.pdf

4. Green Prescription - GRx Information Samoan http://www.pushplay.org.nz/files/Patient_Samoan.pdf

5. Green Prescription - GRx Information Tongan http://www.pushplay.org.nz/files/Patient_Tongan.pdf

6. Green Prescription - A Guide to Exercise and Activity Levels http://www.pushplay.org.nz/files/What_Intensity.pdf

7. Push Play http://www.pushplay.org.nz/files/GRX_Medical.pdf

8. Ministry of Health - Keeping Well with Diabetes http://www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/9b6a685407922a32cc256e3d0006224f?OpenDocument

9. National Center for Chronic Disease Prevention and Health Promotion - Be Active Kids (Diabetes) http://www.ndep.nih.gov/diabetes/pubs/Youth_Tips_Active.pdf

10. National Center for Chronic Disease Prevention and Health Promotion - Food and Activity Tracker (Diabetes) http://www.ndep.nih.gov/diabetes/pubs/GP_FoodActTracker.pdf

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Websites or Pages1. Diabetes

a. NZ Homepage - http://www.diabetes.org.nz

b. Living with Type 2 Diabetes http://www.diabetes.org.nz/managing/type2.html#activity

c. Living with Type 1 Diabetes http://www.diabetes.org.nz/managing/type1.html

d. Monitor Diabetes http://www.diabetesmonitor.com/

2. NZ Ministry of Health

a. Pacific Health - http://www.moh.govt.nz/pacific

b. Diabetes in NZ - http://www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/c882d0d59e75c270cc256c46001186bf?OpenDocument

c. Physical Activity http://www.moh.govt.nz/moh.nsf/238fd5fb4fd051844c256669006aed57/03a8bf6f49f41e4ccc256ee300787945?OpenDocument

d. DHB Toolkit Physical Activity http://www.newhealth.govt.nz/toolkits/physicalactivity.htm

e. DHB Toolkit Diabetes http://www.newhealth.govt.nz/toolkits/diabetes/Diabetes.pdf

3. National Center for Chronic Disease Prevention and Health Promotion

a. Diabetes Page, http://www.cdc.gov/diabetes/

b. Diabetes Resources (booklets, leaflets, manuals & video’s) including some in Samoan & Tongan http://www.ndep.nih.gov/diabetes/pubs/catalog.htm

c. Diabetes Prevention Programme http://www.bsc.gwu.edu/dpp/lifestyle/dpp_acor.html

d. Resource Page http://www.cdc.gov/diabetes/pubs/tcyd/resources.htm

e. CDC & ACSM Physical Activity Intensity Levels http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf

4. SPARC

a. Home page http://www.sparc.org.nz/

b. Push Play http://www.pushplay.org.nz/

c. Green Prescription http://www.pushplay.org.nz/page.asp?PageID=24

d. Kiwi Sport http://www.sparc.org.nz/whatwedo/yp/kiwisport.php

e. Sportfit http://www.sparc.org.nz/whatwedo/yp/sportfit.php

f. Kiwi Walks http://www.sport.org.nz/kiwiwalks/Search.asp?Region=Auckland&RegionID=4

g. He Oranga Poutama http://www.pushplay.org.nz/page.asp?pageID=25

5. Regional Sports Trusts http://www.sport.org.nz/rst.html

6. Heart Foundation

a. Home Page http://www.heartfoundation.org.nz/index.asp

b. Pacific Islands Heartbeat Programme http://www.pacificheart.org.nz/

7. National Diabetes Information Clearinghouse (NDIC) - United States ��


http://diabetes.niddk.nih.gov/index.htm

8. Children Resources & Tasks Activity Resource sheets

a. UK Food & Health http://www.food.gov.uk/healthiereating/eatsmartplaysmart/eatsmartlessonplans/playsmartlesson7

b. CDC http://www.nche.org/5functions_infoexchange_eduweek_2003.htm

9. Diaries

a. American Heart Association

http://www.justmove.org/diary/login.cfm

b. National Heart Lung & Blood Institute

http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/diary.htm

c. Diabetes.com

http://www.diabetesmonitor.com/records.htm#glucose

10. USA Resources

a. National Heart Lung & Blood Institute

http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm

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ReferencesBell, AC, Swinburn, Amosa, H and Scragg RK. 2001. A nutrition and exercise intervention program for

controlling weight in Samoan communities in New Zealand. International Journal of Obesity and Related Metabolic Disorders, 2001, 25(6); 920-7.

CMDHB. 2004. National Pacific diabetes initiative progress reports. Appendix 1. June 2004 - December 2004. CMDHB.

Duffy D.F. and Schnirring, L. 2000. How to council patients abut exercise. Physician and Sportsmedicine, 28(10), 627-629.

Foliaki, S. and Pearce, N. 2003. Prevention and control of diabetes in Pacific people. British Medical Journal, 327, 437-439.

Khan, EB, Ramsey LT, Brwonson RC, Heath GW, Howze EH, Powell KE, Stone EJ, Rajab, MW and Corso P. 2002. The effectiveness of interventions to increase physical activity. A systematic review. American journal of Preventative Medicine, 22(4suppl); 73-107

Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. 2002. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6); 393-403.

Kriska, A. 2002. Striving for a more active community. Lessons from the diabetes prevention programme and beyond. American Journal of Preventative Medicine, 22(4S); 6-7.

MacPherson, C & L. 1990 Samoan medical practice and belief. Auckland University Press. Auckland.

Ministry of Health. 1997. Making a Pacific Difference: Strategic initiatives for the health of Pacific people in New Zealand. Ministry of Health: Wellington

Ministry of Health. 2001. DHB Toolkit: Obesity. To reduce the rate of obesity. Ministry of Health: Wellington.

Ministry of Health. 2003. DHB Toolkit: Physical Activity. To increase physical activity. Ministry of Health: Wellington.

Ministry of Health and Ministry of Pacific Island Affairs. 2004. Tupu Ola Moui: Pacific Health Chart Book. Wellington: Ministry of Health.

New Zealand Guidelines. 2003. Evidence-Based Best Practice Guideline. Management of Type 2 Diabetes. Ministry of Health: Wellington.

Schaaf, D & Schaaf, M.K. 2005. National Pacific Diabetes Initiative Literature Review 2005. Unpublished Report. CMDHB: Auckland.

Simmons, D, Fleming, C, Cameron M, and Leakehe, L. 1996. A diabetes awareness and exercise programme in a multiethnic workforce. NZ Medical Journal, 109 (1031); 373-6.

Simmons, D, Fleming, C, Voyle, J, Fou, F, Feo, S and Gatland, B. 1998. A pilot urban church based programme to reduce risk factors for diabetes among Western Samoans in New Zealand. Diabetic Medicine, 15(2); 136-142.

Simmons, D and Mesui, J. 1999. Decisional balance and stage of change in relation to weight loss, exercise and dietary fat reduction among Pacific Islands people. Asia Pacific Journal of Clinical Nutrition, 8 (1), 39-45.

Simmons, D, Voyle, JA, Fou, F, Feo, S and Leakehe, L. 2004. Tale of two churches: differential impact of a church-based diabetes programme among Pacific Islands people in New Zealand. Diabetic Medicine, 21(2); 122-128.

Simmons, D, Weblemoe, T, Voyle, Prichard, J, Leakehe, L and Gatland, B. 1998. Personal barriers to diabetes care: Lessons from a multi-ethnic community in New Zealand. Diabetic Medicine, 15; 958-964.

SPARC. 2003. SPARC Facts: Results of the New Zealanders sport and physical activity surveys (1997 - 2001), Sport and Recreation New Zealand: Wellington.

SPARC. 2004. Obstacles to Action: A Study of New Zealanders’ Physical Activity and Nutrition, Sport and Recreation New Zealand: Wellington.

Statistics New Zealand. 2004. Pacific Progress: A Report on the economic status of Pacific peoples in New Zealand. Wellington: Statistics New Zealand.

Williamson, D.F., Vinicor F & Bowman, B.A. 2004. CDC Primary Prevention Working Group. Primary Prevention of Type 2 Diabetes Mellitus by Lifestyle Intervention: Implications for Health Policy. Annals of Internal Medicine, 140: 951 - 957.

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�� NPDI Physical Activity Guide ��

�� NPDI Physical Activity Guide��


Physical ActivityHandbook

� NPDI Physical Activity Handbook

�

AcknowledgementsNational Pacific Diabetes Initiative (NPDI) steering group wish to acknowledge and thank the following people for their valuable contribution to the development of this lifestyle guide:

• Jordan Salesa, author of this lifestyle guide

• NPDI Lifestyle Guide Team - Linda Mulitalo Tasi, Stephanie Erick-Peleti and Karen Fukofuka for their support, commitment and dedication to working on this project.

• Josephine Samuelu, Project Manager NPDI and Lincoln Papali’i, CMDHB.

• The team from Intra Pacific Development Trust – Yvonne Timaloa and Karyn Ne’emia

• The regional NPDI summit attendees in Christchurch, Wellington and Auckland for their feedback and comments.

• Rob Cook – Project Manager from the New Zealand Guidelines Group

• Diana O’Neill from SPARC for critiquing this work.

• Dave Driscoll from the National Heart Foundation for his input in to the physical activity hand book.

• The Ministry of Health for their vision and commitment to improving health outcomes for Pacific people.


�

ContentsACKNOWLEDGEMENTS 2

CONTENTS 3

EXECUTIVE SUMMARY 4

Purpose 4

Key physical activity messages 4

PHYSICAL ACTIVITY GUIDE 5

Figure 1: Physical activity guide for Pacific people with type 2 diabetes 5

INTRODUCTION 6

SECTION A 6

Background 6

SECTION B 7

Step 1: Deliver the key messages 7

Step 2: Safety considerations 7

Step 3: Quantify current physical activity level 7

Step 4: Set goals, monitor, follow up and progress 8

Step 5: Physical activity intensity 8

RECOMMENDATIONS 9


�

Executive SummaryPurpose:

• To provide information about the physical activity guide, its context and how to use it.

• The guide is intended for use by Pacific Health Professionals involved in the care of people with type 2 diabetes.

Key Physical Activity Messages:• Physical activity not exercise is the vital message to convey to Pacific peoples.

• Physical activity is an integral part of lifestyle advice for Pacific diabetics.

• 30 minutes of moderate-intensity physical activity on most if not all days of the week can produce substantial benefits for diabetics.

• Physical Activity may be accumulated in bouts of 8 – 10 minutes.

• Those already doing 30 minutes of moderate-intensity physical activity a day should be encouraged to do a higher level of intensity for longer to increase the benefits of physical activity.

• Safety is vital, therefore Pacific diabetics should be screened for appropriateness of physical activity level (intensity). Physical activity should be prescribed individually and be diabetes specific.


�

�

Figure 1.Physical activity guide for Pacific people with type 2 diabetes

Physical Activity / Exercise Key Messages• Be physically active everyday in as many ways as possible• Minimum of 30 minutes moderate intensity physical activity on most if not all days of the week• Can be accumulated in bouts of 8 - 10 minutes

Initial Contact with Diabetes Team (Safety)

• Those with cardiovascular disease should see their GP & begin physical activity at low intensities

• For those on insulin, specific advice should be given by GP (practice team) on dosage, site & time relevant to physical activity

• Quantify Physical Activity - adequate? Use specific measurement tools eg. PAR-Q & YOU, walk or step test, diary

Goal Setting / Stages of Change / Pacific Relevant• Set goals:

• SMART (specific, measurable, achievable, relevant, time-based) e.g. walk with family to / from church, attend 2 pacific aerobics sessions per week over next 2 months

• Stages of change Model: (set goals & advice according to readiness to change behaviour)• Pre-Contemplation - not thinking about changing habits (Action - give more info about

benefits etc & support)• Contemplation - understands need, but not quite ready for action (Action - use

community role models)• Preparation - ready to make changes (Action - set goals, encourage small changes eg.

park further away)• Action - practicing new behaviour changes (Action - reinforce achievement, reiterate

support, goal focus)• Maintenance - has remained physically active (Action - congratulate, reinforce

achievements, goals & benefits)• Relapse - lessening of physical activity (Action - ask why, identify barriers & options to

overcome, ? motivation)• Pacific relevant

• Pacific Community based programmes - church & community physical activity programmes

• Family centred - getting whole families involved• Culturally tailored - language, appropriate settings, accessibility & cost

Physical Activity Intensity (examples)Low Moderate VigorousWalking or cycling slowly Walking briskly Climbing stairsTai Chi Pacific aerobics / Dancing Running / joggingDusting or Vacuuming Cycling medium speed with some hills Swimming lapsStretching Mowing lawn (powered lawn mower) Mowing lawn Golf (powered cart) Washing windows / floors (hand mower)Playing volleyball (> 6 man) Washing car Cycling quickly Bowls Golf (pulling or carrying golf clubs) including hillsKilikiti Gym weights (machines) Playing touch rugbySweeping, Gardening Pushing kids in pushchair Moving or pushing or pruning furniture Gym circuit training

Follow-up, Remeasure & Assess• Goals achieved or not• Relevant pathway? (consider advice given, stages of change model issues)

NPDI Physical Activity Handbook

�

IntroductionThe benefits of being physically active for health and well-being are well known. How to achieve this in the Pacific diabetic population and indeed in non or pre-diabetics has perplexed many health professionals and government organisations. This guide was developed using the NPDI Physical Activity Lifestyle handbook document and refined after consultation via three regional summits with Pacific health providers.

A stepwise approach or algorithm is used to assist with consistent decision making advice and information on physical activity (figure 1).

Section A

Background

The background information for the development for the Physical Activity Guideline is contained in the Physical Activity Lifestyle Guide document. Information was gathered from individual interviews with various Pacific Health Professionals and providers around the country. An extensive literature review of current evidence-based Physical Activity recommendations for people with type 2 diabetes was also undertaken. Other sources of information included reports from the stocktaking and mapping exercise undertaken by Lincoln Papali’i and Dr. Catherine Moor.

Adequate Physical activity levels alone will not suffice in the battle against diabetes. The critical components of the NPDI Framework are clinical intervention, integration and lifestyle intervention.

To delay the progression of the disease and the development of diabetic complications, these key physical activity goals need to be addressed:

1. An individual (and or family / community) shift from physical inactivity to one of physical activity.

2. Accumulation of 30 minutes of moderate-intensity physical activity on most if not all days of the week.

3. Setting mutual relevant physical activity goals, monitor, follow up and progress these.

4. Maintenance of Physical activity lifestyle.

This handbook is designed to compliment the Physical Activity Guideline (figure 1) and enable the clinical or practical realisation of the above goals. Underpinning the development of this handbook (and guideline) was:

• Practicality or simplicity of advice.

• Culturally appropriate advice / information.

• Ease of use.

• Evidence-based.


�

Section B

The Guideline

This section describes the stepwise approach to physical activity guidelines for type 2 diabetic Pacific peoples. This is an expanded explanation of figure 1, where the figure is meant as a clinical trigger for the health professional. Again it is important to note that the guideline and this handbook are not stand alone documents. They have derived from the NPDI Physical Activity Guide Stage 1 - Background; the NPDI Literature Review and the Evidence-based Best Practice Guideline: Management of Type 2 Diabetes publications. This handbook must also be applied along side the smoking cessation and dietary handbooks as well.

Step 1. Deliver the key messages:• Terminology - Physical activity not exercise.

• 30 minutes of moderate-intensity physical activity on most if not all days of the week can produce substantial benefits for diabetics.

• Physical Activity may be accumulated in bouts of 8 – 10 minutes.

• Those already doing 30 minutes of moderate-intensity physical activity a day should be encouraged to do a higher level of intensity for longer to increase the benefits of physical activity.

Step 2. Safety considerations:• Diabetic complications are higher amongst Pacific peoples so;

Ensure GP or practice team assess cardiovascular risk.

Those with cardiovascular disease or coronary heart disease should start physical activity at low intensities and avoid vigorous physical activity.

• Best times to be physically active; (to enhance glycaemic control)

Similar times each day.

Between meals e.g. after breakfast but before lunch or after lunch but before dinner.

• Food and water;

Always drink lots of water.

Have available a small amount of carbohydrate e.g. fruit juice, a lollie or dried fruit in case of hypo-glaecemic attack.

• Regular foot checks pre / post physical activity.

Step 3. Quantify current Physical Activity level:• Use specific measure tools such as PAR-Q & you (www.csep.ca/forms.asp).

• Use specific timed measurements such as 12 minute walk or specific measurable distances.

• Use an activity diary over a set period e.g. 1 week.

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»

»

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Step 4. Set goals, monitor, follow up & progress:• Set goals;

SMART - Specific, measurable, achievable, relevant and time-based e.g. walk to / from church; attend 2 weekly Pacifica aerobics classes over next 3 months.

Consider the Stages of change model (see guideline for summary).

• Monitor or re-test (see Step 3).

• Progress e.g. if doing low intensity increase to moderate, if attending 2 classes increase to 3 or 4.

Step 5. Physical Activity Intensity:• Use chart on guideline (figure 1 or green prescription pads) to guide prescription for low

/ moderate / vigorous intensities.

• Use tasks / jobs / activities / hobbies or sports that are relevant to the person

»

»


�

Recommendations• This handbook should be considered in conjunction with the following documents-NPDI

Nutritian and Smoking Cessation Guide, NPDI Document and Evidence-based Best Practice Guideline: Management of Type 2 Diabetes.

• Health Professionals must consider all aspects of the NPDI framework.

• Training should be provided on how to use this handbook and the guide.

• Resource development should be consistent with the recommendations from the NPDI literature review which will support and complement this handbook.

Links

Push Play

http://www.sparc.org.nz/

Diabetes New Zealand

http://www.diabetes.org.nz/

Centers for disease control and prevention (CDC)

http://www.cdc.gov

Diabetes Prevention Program

http://www.bsc.gwu.edu/dpp/lifestyle/dpp_acor.html

Ministry of Health (Diabetes Toolkit)

http://www.newhealth.govt.nz/toolkits/diabetes.htm

New Zealand Guidelines Group

http://www.nzgg.org.nz

Canadian Society for Exercise Physiology

http://www.csep.ca/about.asp (PAR-Q & You forms)


npdi diabetes services physical guidelines

Documents